Post-operative vomiting and nausea

Post-operative vomiting and nausea may be more severe in
1. young female
2. opioids (esp. first time)

management
fluid and eletrolyte supplement
2.5% dextrose in 0.45% NaCl 2.5D-half saline
Ringer

Prolonged chest tube placement

Present illness

A 73 year-old man smokes one pack a day for more than 30 years. His hypertension and type 2 DM. During a health check-up, CXR revealed lung nodule at RUL. Subsequent CT-guided biopsy revealed adenocarcinoma of lung. PET-CT showed a 3.8 cm lesion with soft tissue density and FDG uptake at posterior segment of right upper lobe of lung. Another 1.3 cm lesion was also found at lateral basal segment of LLL of lung. Other lymph node are found normal. The clinical stage is cT2N0M0, stage IB. Due to poor lung function, (FEV1: 1.09L; FEV1/FVC = 53.17%), surgery is postpone. After steroid and bronchodilator administration, his FEV1 imrpoves from 1.49L to 1.92L. FVC becomes 3.75L, FEV1/FVC becomes 51%. After VATS lobetomy, RUL is excised. 7 days after surgery, his lung still can't fully expand. Chest tube has been placed for 7 days because persistant force air leak (pneumothroax). Leg edema has been noted. Subcutaneous emphysema develops and extends.

Order

1. Vital signs measurement, bid prn
2. On diet as tolerable (DM diet)
3. Chest tube (ES -10cm H2O) => Free drain => (ES -10cm H2O)
   Due to extension to subclavicle region
   
4. Wound change dressing, qd
5. Coaching
6. O2 via nasal canula 1~3 L/min, qd prn
7. One touch finger sugar, qd AC check
   
8. Glimepiride (Amaryl): antidiabetic agents: sulfonylurea
   2mg 0.5 tab po qd
   
9. Theophylline
   200mg 1 tab po bid
   
10. Prednisolone
    5mg 2tab po qd
    
11. Bambuterol (Bambec): beta2-agonist
    10mg 1 tab po hs
    
12. Hydrochlorothiazide + Losartan (Hyzarr)
    12.5mg 1 tab pd qd
    Hydrochlorothiazide: diuretics: thiazide
    Losartan: antihypertensive agent: (angiotension antagonist, ARB)
13. Tamsulosin (Flomax): sympatholytics: alpha-blocker
    1 tab po hs
    
14. Pseudoephedrine + Loratadine (Clarinase)
    Pseudoephedrine: Adrenergic agonists: Decongestants
    Loratadine: H1 blocker
    
15. Celebrex
    1 tab po bid prn if pain
    

Past history
1.COPD
2.Hypertension
3.Type 2 DM (HbA1c 7.5%)

Personal history
Tobacco: 1PPD for > 30 years

Discussion

Prolonged chest tube placement

• Infection: wound infection or retrograde infection from the wound (germs enter the thoracic cavity from the cut where chest tube is inserted into thoracic cavity) . Pneumonia may occur.
• Steroid may weaken his immunity and he may predispose to infection. Stop steroid and change to long-acting beta agonist.
• Change wound dressing more frequent
  

COPD exacerbation

• Pneumothroax may occur if his COPD exacerbates.
  

Leg edema

• Fluid status
  

Blood sugar

Hodgkin disease

Clinical presentations
Enlarged, painless, rubbery, nonerythematous, nonotender lymph nodes
Cervical, supraclavicular, and axillary lymphoadenopathy are the most common initial signs.
B symptoms: drenching night sweats, 10% weight loss, fever
Extralymphatic sites are usually enlarged spleen, skin, gastric, lung, and CNS.
Extralymphatic involvements are more common in non-Hodgkinn lymphoma

Pathology
Reed-Sternberg cell

Staging
Stage I: one lymphatic group
Stage II: 2 lymphatic groups on the same side of the diaphragm
Stage III: Involvement on both sides of the diaphragm or involvement of any extralymphatic organ contiguous to the primary nodal site
Stage IV: Widespread disease with involvement of diffuse extralymphatic sites such as the bone marrow or liver

Workup

1. confirm the diagnosis: excisional lymph node biopsy
   
2. determine the extend of the disease: CXR, chest CT, abdominal CT, or MRI=> to determine if the disease is localized to supraclavicular region
3. If all the tests are not revealing and local radiotherapy is done, a staging laparotomy is used to definitely to exclude more widespread disease
   
4. Bone marrow biopsy
   

CXR, chest Ct

Spells (nonspecific)

CC: Faintness
Focus: neurologic, cardiovascular, pulmonary system, mental health
onset: yesterday when standing up from supine position, after TURBT
accompanied symptoms: diaphoresis

cardiovascular:

• History of hypertension, TIA, myocardial infraction, or arrhythmia: denied
• Accompanied tachycardia, palpation: none
• Normal heart sound
  
• BP measure: 120/90
• Pitting edema, jugular vein distention: none
• Blood loss: gross hematuria, blood loss during cystoscopy
• RBC 4.47*10^6, Hb 14.4 g/dL, Hct: 41.2%, all within normal range (exam date: 2008/1/9)
  

pulmonary:

• History of COPD, chronic cough: denied
• Accompanied tachypnea, palpation: none
• Normal breathing sound

neurologic:

• Visual deficit, blurred vision, numbness, tingling, weakness on one side: none
• Headache: denied

medication:

• Unremarkable

other:

• Sodium: 133 (exam date 2008/1/9)
• BUN:30 (exam date 2008/1/9)

Summary:

• Rule out TIA: history of TIA(-), neurologic deficit(-)
• Rule out hypertension: history of hypertension(-), normal BP, headache(-), vomiting or nausea(-)
• Rule out arrhythmia: history of arrhythmia(-), tachycardia(-), palpation(-) (should check EKG)
• Rule out heart failure: history of heart failure (-), pitting edema(-), jugular distention
• Rule out MVP: normal heart sound
  
• Rule out pulmonary relation origin (pulmonary embolism) : history of SOB, COPD, chronic cough(-), tachypnea(-), normal breathing sound, symmetric chest wall expansion, normal oxygen saturation
• Rule out dehydration: moist oral mucosa, good capillary refill, normal BP, no thirst
  

Assumption
1. Postural hypotension, rule in blood loss-related (after TURBT, raise the possibility of blood loss)

Plan
CBC
Because he concerns about the possibility of anemia and has poor feeding recent days, he asks for additional nutrition supplement through IV (self-pay).
Check BUN, Cre (reason: previous high level of BUN and to rule out hypovolemia)

2. Possible hyponatremia (may cause altered consciousness). Surgery of TURBT, possible dilutional effect

Plan
Check sodium level

Abdominal mass/nodule

abdominal Sonography: an accidental spleen nodule (1cm)
=>to confirm the finding
Repeat abdominal sonography

Abdominal sonography: a hetrogenous hypoechoic mass (8*9 cm) at left upper abdominal area, between the spleen and the pancreas, associated with increased vascularity.
=>to determine the nature of the mass, to rule out malignancy
abdominal CT
CEA, AFP level
Abdominal sonography: fatty liver
=>to determine the liver function
ALT AST level

Abdominal CT: a 9cm heterogenous enhancing space-occupying lesion in left upper abdomen, between teh spleen, pancreatic body, and left adrenal gland. No enlarged lymph nodes were noted.
=>to determine the nature of the mass, possible primary adrenal tumor

Deal with post-op bloody drainage from chest tube

Questions to think:

Does bloody fluid stand for bleeding?

If answer is yes...
How much blood has lost? => How to correct?
(check vital signs first. Blood pressure? Tachycardia? Tachypnea?)
What causes bleeding? =>How to stop bleeding?
(check CBC, PTT, aPTT)

Mitral Regurgitation

Fatigue, exertional dyspnea, and orthopnea are the most prominent complaints in patients with chronic, severe MR. Systemic embolism occurs less frequently than in MS. Right-sided heart failure, with painful hepatic congestion, ankle edema, distended neck veins, ascites, and TR, occur in patients with MR who have associated pulmonary vascular disease and marked pulmonary hypertension. In patients with acute, severe MR, LV failure with acute pulmonary edema is common.

Choose between exams

Case study:

A 38-year-old female has had a fully movable, firm, and well-circumscribed mass for 5 years. During the past 5 years, the size of the mass remained approximately the same. The mammography showed a shadow with slightly irregular border. Nothing else is remarkable. What exam should be done to determine the nature of the mass? (The options here are fine needle aspiration, cone biopsy, incisional biopsy, and excisional biopsy.)

Opinion:

Ask her attitude toward the mass.

• She wants it out even if the tumor is benign.

Do a fine needle aspiration.

Reason
If the cytology result turns out to be benign, a fine needle aspiration dealt a minimal injury and preserves the possibility to have a conservation surgery.

Do not do a excisional biopsy.

Reason
If the biopsy result shows malignancy, the excision border may not sufficient to provide a tumor cell-free margin.

• She wants it out only if the tumor is malignant.

Do a cone biopsy

Methods to prevent atelectasis

1. deep breathing
2. cough
3. incentive spirometery
4. postural drainage
5. negative pressure suction
   

Post-operation wound pain usually hinder method 1, 2, and 3 to be performed.

Indications of post-op pain:

1. a rapid shallow breathing pattern of the patient
   
2. pain accompanied with cough, breathing, hand-raising
3. statements of the patient

Method 5 is contraindicated during the first day after surgery.
Negative pressure suction will peel down clots of micro-injuries resulted from the process of the surgery itself. The sequela is bleeding.

Actinomycosis

Actinomycosis

Essentials of Diagnosis

History of recent dental infection or abdominal trauma

Chronic pneumonia or indolent intra-abdominal or cervicofacial abscess

Sinus tract formation

General Considerations

Anaerobic, gram-positive, branching filamentous bacteria

Anaerobic organisms are not easily identified in regular culture. When biopsy or drainage samples from the infection site are exposed to room air, the anaerobic organisms die. Thus, the culture finding will be negative. Anaerobic organisms are usually identified by pathology/morphology finding of the biopsy samples.

Normal flora of the mouth and tonsillar crypts

Lesions may develop in the gastrointestinal tract or lungs following ingestion or aspiration of the organism from its endogenous source in the mouth

Because actinmycete is a normal flora of the mouth and tonsillar crypts, the most frequent infection site of actinomycyte is cervical and facial region. People with peri0d0ntal diseases, whose sliva has higher concentration of actinomycte, are predisposed to pulmonary actinomycosis.

Infection typically follows extraction of a tooth or other trauma

Symptoms and Signs in Pulmonary Infections

Fever, cough, sputum production

Night sweats, weight loss

Pleuritic pain

Multiple sinuses may extend through the chest wall to the heart or abdomen

Differential Diagnosis

Lung cancer

Tuberculous lymphadenitis (scrofula)

Other cause of cervical lymphadenopathy

Nocardiosis

Crohn's disease

Pelvic inflammatory disease from another cause

Treatment

Penicillin G (drug of the choice) 10 to 20 million units IV for 4–6 weeks followed by penecillin V, 500 mg PO four times daily for 4-6 months

Ampicillin 12 g/d IV for 4–6 weeks followed by amoxicillin 500 mg PO three times a day for 4-6 months, are alternatives

Actinomyocte may form abcesses, sinuses, and/or fistulas where antibiotics have poor penetration. Therefore, higher concentration of antibiotics are required. IV route to administer antibiotics I & D and antibiotics administration should be done simultaneously if any abcesses, sinuses, and/or fistulas are found. If medical managements failed, consider surgical excision.

Sulfonamides such as sulfamethoxazole may be an alternative regimen at a total daily dosage of 2–4 g

When to Admit
All patients with thoracic or abdominal actinomycosis

Patients with cervicofacial actinomycosis if the diagnosis is in question, to control symptoms, or initiate IV antibiotics

Sudhakar SS et al: Short-term treatment of actinomycosis: two cases and a review. Clin Infect Dis 2004;38:444.