NMS Surgery Casebook

Preface vi
Contributors vii
Part I: Foundations
1 Preoperative Care ............................ 1
Bruce E. Jarrell, Molly Buzdon, Eric D. Strauch
Preoperative Care Principles 2
Case 1.1: Routine Surgery in a Healthy Patient 2
Case 1.2: Common Risk Factors Associated with Routine
Surgery 8
Case 1.3: Common Problems in a Patient Waiting to Enter
the Operating Room 10
Case 1.4: Surgery in a Patient with Pulmonary Symptoms 11
Case 1.5: Urgent Surgery in a Patient with Severe, Acute Pulmonary
Function Problems 12
Case 1.6: Cardiac and Neurologic Risk Associated with Surgery for
Peripheral Vascular Disease 14
Case 1.7: Surgery in a Patient with Liver Failure 19
Case 1.8: Surgery in a Patient with Chronic Kidney Problems 23
Case 1.9: Surgery in a Patient with Cardiac Valvular Disease 24
Case 1.10: Endocarditis Prophylaxis in a Surgical Patient with
Valvular Heart Disease 25
Case 1.11: Surgery in a Patient with Cardiomyopathy 26
2 Postoperative Care .......................... 27
Bruce E. Jarrell, Molly Buzdon, Eric D. Strauch
Postoperative Care Principles 28
Case 2.1: Postoperative Fluid and Electrolyte Management 29
Case 2.2: Postoperative Acute Renal Failure 31
Case 2.3: Postoperative Fever 33
Case 2.4: High Fever in the Immediate Postoperative Period 35
ContentsCase 2.5: Postoperative Cardiopulmonary Problems 35
Case 2.6: Management of a Small Bowel Fistula 37
3 Wound Healing .................................... 38
Bruce E. Jarrell, Eric D. Strauch
Principles of Wound Healing 38
Case 3.1: Wound Management and Complications 39
Case 3.2: Wound Infection 42
Case 3.3: Wound Classification Based on Risk of Subsequent Infection 44
Part II: Specific Disorders
4 Thoracic and Cardiothoracic Disorders ............... 49
Bruce E. Jarrell, Eric D. Strauch
Lung Disease 50
Case 4.1: Asymptomatic Abnormality Seen on Chest Radiography 51
Case 4.2: Symptomatic Abnormality Seen on Chest Radiography 55
Case 4.3: Symptomatic Abnormality Located in the Hilum on Chest
Radiography 57
Case 4.4: Lung Mass with Possible Metastases 60
Case 4.5: Symptomatic Superior Sulcus Tumor 61
Case 4.6: Hemoptysis and Atelectasis in a Y oung Patient 63
Case 4.7: New-Onset Pleural Effusion without Heart Failure 64
Case 4.8: Sudden Chest Pain and Shortness of Breath in a
Y oung Patient 67
Cardiac Disease 72
Case 4.9: Pleural-Based Chest Pain, Fever, and Pleural Effusion 72
Case 4.10: Progressively Increasing Substernal Chest Pain 73
Case 4.11: Mitral Valve Disease that Requires Surgery 77
Case 4.12: Aortic Valve Disease that Requires Surgery 78
Case 4.13: Congestive Heart Failure with Normal
Coronary Arteries 80
Esophageal Disease 81
Case 4.14: Recurrent Regurgitation of Undigested Food 81
Case 4.15: Dysphagia with Weight Loss 83
Case 4.16: Dysphagia with Esophageal Defect 84
Case 4.17: Severe Dysphagia with Coughing 90
Mediastinal Masses 92
Case 4.18: Muscular Weakness and a Mediastinal Mass 925 Vascular Disorders ................................ 95
Bruce E. Jarrell, Molly Buzdon, Marshall Benjamin, Eric D. Strauch
Peripheral Arterial Disease 96
Case 5.1: Brief Neurologic Event 97
Case 5.2: Other Transient Neurologic Events 102
Case 5.3: Asymptomatic Carotid Bruit 103
Case 5.4: Acute Vascular Event in the Leg 104
Case 5.5: Claudication 108
Case 5.6: Claudication and Absence of a Femoral Pulse 112
Case 5.7: Toe Ulceration in Peripheral Vascular Disease 113
Case 5.8: Aortoiliac Occlusive Disease 116
Case 5.9: Cardiac Risk in Major Vascular Reconstruction 119
Case 5.10: Pulsatile Mass in the Abdomen 121
Case 5.11: Ruptured Abdominal Aortic Aneurysm 124
Case 5.12: Complications of Abdominal Aortic Replacement 126
Case 5.13: Chronic Postprandial Abdominal Pain and Weight Loss 128
Case 5.14: Tearing Chest and Back Pain 130
Venous Disease 131
Case 5.15: Postoperative Leg Swelling 132
Case 5.16: Prevention of Deep Venous Thrombosis 133
Case 5.17: Postoperative Shortness of Breath 136
Case 5.18: Confounding Findings in Pulmonary Embolism 137
Case 5.19: Recurrent Pulmonary Embolism on Anticoagulation
Therapy 138
Case 5.20: Gastrointestinal Bleeding as a Complication of Anticoagulation
Therapy 138
Case 5.21: Severe Deep Venous Thrombosis 140
6 Upper Gastrointestinal Tract Disorders ............... 141
Bruce E. Jarrell, John L. Flowers, Molly Buzdon, Eric D. Strauch
Case 6.1: Acute Epigastric Pain 144
Case 6.2: Acute Epigastric Pain with Regurgitation and Coughing 145
Case 6.3: Acute Epigastric Pain with Hiatal Hernia 148
Case 6.4: Acute Epigastric Pain with Pyloric Channel Ulcer 150
Case 6.5: Acute Epigastric Pain with Gastric Ulcer 153
Case 6.6: Acute Epigastric Pain with Early Gastric Cancer 156
Case 6.7: Acute Epigastric Pain with a Rigid Abdomen 158
Case 6.8: Upper Gastrointestinal Bleeding 161
Case 6.9: Upper Gastrointestinal Bleeding with Esophageal Varices 168
Case 6.10: Acute Epigastric Pain with Gastric Lymphoma 1707 Pancreatic and Hepatic Disorders ................... 172
Bruce E. Jarrell, Eric D. Strauch
Common Pancreaticobiliary Disorders 173
Case 7.1: Asymptomatic Gallstones 173
Case 7.2: Right Upper Quadrant Pain 174
Case 7.3: Right Upper Quadrant Pain with Gallstones and Signs of
Infection 177
Case 7.4: Right Upper Quadrant Pain with Gallstones and Jaundice 178
Case 7.5: Right Upper Quadrant Pain in Pregnancy 179
Case 7.6: Right Upper Quadrant Pain with Cholelithiasis and Elevated
Amylase 179
Case 7.7: Right Upper Quadrant Pain with High Fever 180
Case 7.8: Right Upper Quadrant Pain in an Extremely Ill Older Adult 183
Case 7.9: Right Upper Quadrant Pain, Fever, and Jaundice 184
Case 7.10: Complications of Laparoscopic Cholecystectomy 186
Case 7.11: Painless Jaundice 188
Case 7.12: Painless Jaundice due to Obstruction at the Common Bile Duct
Bifurcation 193
Case 7.13: Other Biliary Tract Cancers 196
Case 7.14: Acute Epigastric Pain with High Serum Amylase and Lipase 197
Case 7.15: Acute Epigastric Pain in Severely Ill Patient 198
Case 7.16: Acute Epigastric Pain with Continued Pain 201
Common Hepatic Disorders 204
Case 7.17: Hepatic Mass 205
Case 7.18: Fever and Pain in the Right Upper Quadrant 210
8 Lower Gastrointestinal Disorders ................... 213
Bruce E. Jarrell, Molly Buzdon, Eric D. Strauch
Small Intestinal Disorders 214
Case 8.1: Crampy Abdominal Pain 214
Case 8.2: Crampy Abdominal Pain with Partial Improvement 221
Case 8.3: Crampy Abdominal Pain with Signs of Small Bowel
Obstruction 222
Case 8.4: Injury to the Bowel during Lysis of Adhesions 223
Case 8.5: Crampy Abdominal Pain following Pneumonia 224
Case 8.6: Abdominal Pain in an Older Adult 224
Case 8.7: Abdominal Pain with Suspected Mesenteric Ischemia 226
Inflammatory Bowel Disease 229
Case 8.8: Crampy Abdominal Pain in Patient with Crohn Disease 230
Case 8.9: Perianal Disease in a Patient with Crohn Disease 232Case 8.10: Management of Crohn Colitis 233
Case 8.11: Complications of Long-Standing Ulcerative Colitis 233
Case 8.12: Complications of Acute Colitis 235
Disorders of the Colon 237
Case 8.13: Right Lower Quadrant Pain 237
Case 8.14: Right Lower Quadrant Pain with Dysuria and Increased
WBCs 238
Case 8.15: Worsening Right Lower Quadrant Pain 243
Case 8.16: Right Lower Quadrant Pain with Mass on Appendix 244
Case 8.17: Complications of a Ruptured Appendix 245
Malignant Disorders of the Colon, Rectum, and Anus 247
Case 8.18: Screening for Colorectal Cancer 247
Case 8.19: Heme-Positive Stool 248
Case 8.20: Heme-Positive Stool in Patient with Polyp 250
Case 8.21: Heme-Positive Stool with Fatigue and Weight Loss 253
Case 8.22: Heme-Positive Stool with Suspected Colon Cancer 256
Case 8.23: Operative Findings in Colon Cancer 257
Case 8.24: Complications of Postoperative Colectomy 258
Case 8.25: Heme-Positive Stool in Patient with Rectal Adenocarcinoma 259
Case 8.26: Heme-Positive Stool in Patient with Rectal Cancer 262
Case 8.27: Metastasis in Colorectal Cancer 267
Case 8.28: Heme-Positive Stool with a Hard Lesion 268
Lower Abdominal Pain 269
Case 8.29: Left Lower Quadrant Pain and Fever 270
Case 8.30: Recurrence of Left Lower Quadrant Pain 272
Case 8.31: Left Lower Quadrant Pain in a Deteriorating Patient 273
Case 8.32: History of Left Lower Quadrant Pain with Sensation
of Voided Air 274
Lower Gastrointestinal Bleeding 275
Case 8.33: Massive Lower Gastrointestinal Bleeding 275
Case 8.34: Persistent Bleeding with a Massive Lower Gastrointestinal
Bleed 279
Other Benign Lower Gastrointestinal Tract Disorders 282
Case 8.35: Syndromes of Acute Colonic Dilation and Obstruction 282
Case 8.36: Rectal Prolapse 286
Case 8.37: Perianal Problems 287
Case 8.38: Persistent Perianal Drainage 288
Case 8.39: Severe Anal Pain with Perianal Mass 289
Case 8.40: Need for Colostomy 2899 Endocrine Disorders .............................. 291
Bruce E. Jarrell, W . Bradford Carter, Eric D. Strauch
Endocrine Disorders 291
Case 9.1: Thyroid Nodule Found on Examination 292
Case 9.2: Symptomatic Hypercalcemia 299
Case 9.3: Medical Management of Acute Hypercalcemia 303
Case 9.4: Secondary Hyperparathyroidism 305
Case 9.5: Hyperparathyroidism and Severe Hypertension in the Same
Patient 305
Case 9.6: Acute Development of a Tender Neck Mass 306
Case 9.7: History of Hyperparathyroidism and Intractable Duodenal
Ulcers 308
Case 9.8: Medullary Carcinoma of the Thyroid 311
Case 9.9: Incidentally Discovered Adrenal Mass 311
10 Skin and Soft Tissue Disorders and Hernias .......... 313
Bruce E. Jarrell, Eric D. Strauch
Malignant Melanoma 313
Case 10.1: Evaluation of a Skin Lesion 313
Case 10.2: Diagnosis of Malignant Melanoma in a Skin Lesion 315
Case 10.3: Malignant Melanoma with a Palpable Lymph Node 323
Case 10.4: Malignant Melanoma with Distant Metastasis 323
Case 10.5: Malignant Melanoma on the Cheek 324
Case 10.6: Malignant Melanomas in Other Areas 325
Case 10.7: Small Bowel Obstruction and History
of Malignant Melanoma 326
Sarcoma 326
Case 10.8: Sarcoma of the Lower Extremity 326
Case 10.9: Metastatic Sarcoma to the Lung 331
Hernias and Related Conditions 332
Case 10.10: Pain in the Groin 332
Case 10.11: Inguinal Hernia 335
Case 10.12: Additional Hernia-Related Problems 342
Case 10.13: Ventral Hernia 343
11 Breast Disorders ................................. 345
Julia H. Terhune, Bruce E. Jarrell, Emily Bellavance, Michelle
Townsend Day, Katherine Tkaczuk, Eric D. Strauch
Case 11.1: Screening for Breast Cancer 346
Case 11.2: Evaluation of a Mammographic Abnormality 349Case 11.3: Evaluation of Mammographic Microcalcifications 350
Case 11.4: Biopsy Results in Lesions Visible on Mammography 352
Case 11.5: Palpable Breast Mass 355
Case 11.6: “Lumpy” Breasts 356
Case 11.7: Breast Mass in a Y oung Woman 357
Case 11.8: Nipple Discharge 357
Case 11.9: Staging and Prognosis in Infiltrating Ductal Carcinoma 359
Case 11.10: Select Clinical Factors that Affect Prognosis 360
Case 11.11: Nipple Lesion 362
Case 11.12: Surgical Management of Breast Cancer 363
Case 11.13: Treatment Options for Stage I and II Breast Cancer 366
Case 11.14: Breast Reconstruction 368
Case 11.15: Medical Management of Breast Cancer 369
Case 11.16: Treatment of Stage III and IV Breast Cancer 370
Case 11.17: Breast Mass with Cellulitis and Edema 371
Case 11.18: Events that Occur Later in Patients with Breast Cancer 372
Case 11.19: Breast Problems in Pregnancy and the Peripartum Period 373
Case 11.20: Breast Cancer in Patients of Advanced Age and Decreased
Function 374
Case 11.21: Breast Mass in a Man 375
Case 11.22: Gynecomastia 375
Part III: Special Issues
12 Trauma, Burns, and Sepsis ......................... 377
Bruce E. Jarrell, Thomas Scalea, Molly Buzdon
Case 12.1: Primary and Secondary Assessment of Injuries 378
Case 12.2: Initial Airway Management 378
Case 12.3: Initial Pulmonary Management 380
Case 12.4: Pneumothorax in a Patient with Hypotension 385
Case 12.5: Hypotension and Neck Vein Distention
with Normal Breath Sounds 386
Case 12.6: Hypotension with Normal Breath Sounds
and No Neck Vein Distention 387
Case 12.7: Initial Cervical Spine Management 390
Case 12.8: Initial Assessment of Thoracic Injury 393
Case 12.9: Indistinct or Widened Mediastinum 396
Case 12.10: Initial Abdominal Assessment Based on the Mechanism
of Injury 397
Case 12.11: Initial Assessment of Abdominal Injury 401
Case 12.12: Abdominal Injuries Visible on CT Scan 406
Case 12.13: Operative Findings with Abdominal Trauma 413
Case 12.14: Initial Neurologic Injury Assessment and Management 415Case 12.15: Other Neurologic Problems 416
Case 12.16: Continuing Hemorrhage 418
Case 12.17: Postoperative Problems in Trauma Patients 419
Case 12.18: Traumatic Arteriovenous Fistula 423
Case 12.19: Continuing Pulmonary Problems 425
Case 12.20: Respiratory Distress 426
Case 12.21: Stab Wound to the Neck 428
Case 12.22: Other Injuries to the Neck 430
Case 12.23: B ur n 431
Case 12.24: Total Parenteral Nutrition 437
13 Pediatric Surgical Disorders ........................ 442
Clint D. Cappiello, Eric D. Strauch, Bruce E. Jarrell
Case 13.1: Acute Respiratory Distress 443
Case 13.2: Respiratory Distress with Oral Intake 445
Case 13.3: Bilious Emesis 448
Case 13.4: Imperforate Anus 456
Case 13.5: Vomiting in a 2-Week-Old Infant 457
Case 13.6: Abdominal Wall Defects 459
Case 13.7: Abdominal Pain in a 7-Month-Old Child 463
Index 465