A 70-year-old man with total hip replacement complains of distention and constipation in the post operative period. Cecal diameter is found to be 10cm on X-ray.
What is the most likely diagnosis?
Correct Answer B: Ogilvie's Syndrome is an acute intestinal pseudo-obstruction associated with massive dilation, usually of the colon, but also of the small intestine. Mechanical obstruction is absent and there is parasympathetic nerve dysfunction. Males are more commonly affected than females. It is more common in the elderly.
Cases are associated with trauma or surgery and prolonged bed rest, as maybe found in nursing homes or on psychiatric units.
Symptoms include abdominal pain, usually cramping or colicky, bloated feeling, nausea and vomiting and intermittent constipation. Physical exam will show massive abdominal distension, normal, reduced or obstructed bowel sounds, minimal tenderness and empty, air-filled rectum on digital rectal examination.
Abdominal X-ray; often shows massive dilation of the colon (megacolon) with cecal diameters measuring 10-14 cm. Treatment included naso-gastric tube to decompress stomach and relieve vomiting and surgical decompression with flexible colonoscope.
A young adult is brought to the hospital 8 hours after a motor vehicle accident. He is in shock and severe respiratory distress. His upper airway is clear. Neck veins are not distended and the trachea is deviated to the right. Breath sounds are absent over the left chest, and the percussion note over the left chest is dull. Breath sounds are normal on the right side. The patient has:
Correct Answer B: In a hemothorax blood from damaged intercostal, pleural, mediastinal, and sometimes lung parenchymal vessels enters the pleural cavity. Depending on the amount of bleeding and the underlying cause, hemothorax may be associated with varying degrees of lung collapse and mediastinal shift. It usually results from blunt or penetrating chest trauma. Hemothorax may result from thoracic surgery, pulmonary infarction, neoplasm, dissecting thoracic aneurysm, or anticoagulant therapy.
Lung percussion reveals dullness, and auscultation reveals decreased to absent breath sounds over the affected side. Symptoms include chest pain, tachypnea, mild to severe dyspnea (difficulty breathing) may be present. If respiratory failure results, the patient may appear anxious, restless, possibly stuporous, and cyanotic. Marked blood loss produces hypotension and shock.
The affected side of the chest expands and stiffens, while the unaffected side rises and falls with the patient's gasping respirations.
A 72-year-old male slipped on a rug in his kitchen and struck his right side against a counter. He presents several days after the fall with a complaint of ongoing pain in his flank. He has a history of chronic atrial fibrillation, which is treated with warfarin (Coumadin). His vital signs are normal. A physical examination reveals tenderness to palpation along the posterior-lateral chest wall and decreased breath sounds in the right base. Radiographs reveal two fractured ribs on the right side and a moderately large pleural effusion in the right hemithorax. Laboratory test results include a hemoglobin of 10.5 mg/dL (baseline 11.0-12.0 mg/dL) and a prothrombin time of 33.5 seconds with an INR of 2.5.
Which one of the following would be the most appropriate management at this time?
Correct Answer A: This patient has been clinically stable despite losing what appears to be a fair amount of blood into his pleural space after fracturing two ribs, a condition referred to as hemothorax. The treatment of choice in this condition is to remove the bloody fluid and re-expand the associated lung. This therapy is felt to decrease any ongoing blood loss by having the lung pleura put a direct barrier over the site that is bleeding. It also prevents the development of empyema or fibrosis, which could occur if the blood were to remain.
Note: Although not contraindicated, drainage of hemothorax or any pleural effusion in an individual with a coagulopathy should be performed with great care.
A man who is a competitive runner has pain when walking. It has increased and is noted in his 2nd and 3rd metatarsal bone of his forefoot.
Correct Answer B: Metatarsal stress fractures involve the metatarsal shafts and are caused by repetitive weight-bearing stress.
Stress fractures do not result from a discrete injury (eg, fall, blow) but occur after repeated stress. Metatarsal stress fractures (march fractures) usually occur in runners and in poorly conditioned patients who walk long distances carrying a load (eg, new recruit soldiers); they most commonly occur in the 2nd metatarsal. Risk factors include a cavus foot (high arch), shoes with inadequate shock-absorbing qualities, and osteoporosis; these fractures also may be a sign of the female athlete triad (amenorrhea, eating disorder, and osteoporosis).
Forefoot pain that occurs after a long or intense workout, then disappears shortly after stopping exercise is the typical initial presentation. With subsequent exercise, onset of pain is progressively earlier, and pain may become so severe that it prohibits exercise and persists even when the patient is not bearing weight.
A 72 year old black male comes to your office for surgical clearance to undergo elective hemicolectomy for recurrent diverticulitis. The patient suffered an uncomplicated acute anterior-wall myocardial infarction approximately 18 months ago. A stress test was normal 2 months after he was discharged from the hospital. Currently, the patient feels well, walks while playing nine holes of golf three times per week, and is able to walk up a flight of stairs without chest pain or significant dyspnea. Findings are normal on a physical examination.
Which one of the following would be most appropriate for this patient prior to surgery?
Correct Answer A: The current recommendations on preoperative clearance for noncardiac surgery state that preoperative intervention is rarely needed to lower surgical risk. Patients who are not currently experiencing unstable coronary syndrome, severe valvular disease, uncompensated congestive heart failure, or a significant arrhythmia are not considered at high risk, and should be evaluated for most surgery primarily on the basis of their functional status. If these patients are capable of moderate activity without cardiac symptoms, they can be cleared with no stress testing or coronary angiography for an elective minor or intermediate-risk operation such as the one this patient is to undergo.
A resting 12-lead EKG is recommended for males over 45, females over 55, and patients with diabetes, symptoms of chest pain, or a previous history of cardiac disease.
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