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???. Dr Tom Hardy SHO General Surgery. 85 yo male. Patient referred from GP – concerned about this gentleman’s pain, ?appendicitis 4/7 increasing RIF Over last 24 hours has developed Nausea and 1 x vomiting Starting to feel unwell PMH – HTN, AF, Angina. Differentials??. Appendicitis

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  1. ??? Dr Tom Hardy SHO General Surgery

  2. 85 yo male • Patient referred from GP – concerned about this gentleman’s pain, ?appendicitis • 4/7 increasing RIF • Over last 24 hours has developed Nausea and 1 x vomiting • Starting to feel unwell • PMH – HTN, AF, Angina

  3. Differentials?? • Appendicitis • Bowel Obstruction due to • Hernia • Ca • Adhesions • Perforation • Renal Colic

  4. Plan? • Airway – is it patent? • Breathing - • RR 24 • O2 saturations 99% on 5litres O2 • Circulation – • BP 95/54 • P 102 • Disability – • AVPU • Everything else – • T 37.1 • U/O ?? • BM – 6.9

  5. On examination • Cardio – • I + II + O • Respiratory - • Good air entry • Abdo – • V tender RIF, small lump in R groin, red, tender, no cough impulse, non-reducible • Rest of abdomen soft, bowel sounds not present • PR – empty rectum

  6. Initial Management • Groups please • Initial investigations/beside • Scans/secondary investigations • Other considerations

  7. Initial Management 1 • Bedside – • Vital signs • Bloods • FBC, LFT, U&E, CRP, Amy, G&S/X-match • ABG • BM • Catheterise/NG Tube • IVI • NBM

  8. ABG

  9. Initial Management 1 • Scans • AXR? • CXR? • CT abdo/pelvis

  10. Extras • Inform theatres • Inform anaesthetist • Booking and consenting • ECG

  11. Bloods

  12. Hernias! • Definition - • Protrusion of a tissue through the wall of the cavity which normally contains it

  13. Reducible – • you can put it back in • Irreducible – • you can’t • Incarcerated – • you can’t put it back in • Strangulated – • blood supply cut off

  14. 1) Risk factors for developing hernia • Smoking, chronic cough, female, heavy lifting, previous surgery • 2) Hernia develops, initially reducible and of no concern • 3) If increases in size, may become irreducible • 4) Part of bowel/tissue gets trapped leading to irritation, swelling, oedema • 5) Increasing size leads to further issues which may compromise blood supply • 6) Hernia becomes strangulated, can lead to necrosis as no blood supply and peritonism

  15. Types of Hernia • Inguinal • Direct vs Indirect • Femoral • Incisional – ummm...through an incision • Richter’s Hernia – one side of bowel wall, may not be an obstruction • Umbilical/paraumbilical • Littre’s hernia

  16. Up-to-date webite, viewed 3/1/12, http://www.uptodate.com/contents/image?imageKey=SURG/27585&topicKey=SURG/3686&source=outline_link&search=femoral hernia&utdPopup=true

  17. Up-to-date webiste, http://www.uptodate.com/contents/image?imageKey=SURG/27584&topicKey=SURG/3686&source=outline_link&search=femoral hernia&utdPopup=true, viewed 3/1/12, hernia anatomy

  18. Surface Anatomy • A: Inferior epigastric artery • B: Femoral nerve • C: Femoral artery • D: Femoral vein • E is the most important … • THE PUBIC TUBERCLE

  19. Examination of a Hernia • Examine standing and sitting • How do you assess a lump?? • SCRoTum • 3 x S – Size, Shape, Surface • 3 x C – Cough impulse, Colour, Consistency • Reducibility • 3 x T – Tenderness, Transillumination, Temperature • External genetalia!!!

  20. IPE Questions 1 • This gentleman has a swelling in his groin, please take a history... • Risk factors • Features of a hernia • Differential diagnosis • Don’t forget lymphadenopathy

  21. IPE Questions 2 • Examination... • Hernia or Abdomen?? • Probably Hernia first, if time/to finish abdomen

  22. IPE Questions • What is a hernia? • How to differentiate between direct and indirect • How to differentiate between inguinal and femoral • How would you identify the deep inguinal ring? • Treatment options • Complications of hernia surgery

  23. Communication in Surgery Happy Sad Angry Hmmmm Get out of my theatre Good job Your only fit for psych PR not PV!

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