Dr.

Muhammad Muzzammil Postgraduate traniee Surgical ward 3

 25 yrs old male patient with no co morbids presented with H/O: Blunt trauma to chest due to RTA ------> 12 hour back

As per ATLS (primary survey)

Airway: Intact Breathing:
32 b /m with use of accessory muscle Decrease breath sound on left side of chest, with surgical

emphysema on left side of chest extended upto neck.

Circulation: Pulse = 99 B/ min, B.P = 100/70 mmHg

Two large I/V bore cannula, Crystalloids given.blood sample sent for cross match .

Disability:
GCS 15/15 .

Exposure: No wound or bruises observed on the body

 Adjuncts:

Foleys catheter was passed (concentrated urine 200 ml)

History:

A no allergy
M not significant. P not significant. L 3 hrs back.

E fall from bike .

Secondary survey:

Abdomen: soft and non tender.

DRE: fecal stain finger

Chest: decrease breath sound on left side with surgical emphysema on left side of chest extended upto neck.

 Chest x-ray shows 3rd , 4th and 5th rib fracture on left

side of chest Pneumothorax on left side.

 Pt. was kept N.P.O. 100 % oxygen inhalation. I/V line maintained. IV fluids, IV antibiotics, IV analgesics.

 Chest intubation done.

PostOp:
Kept NPO.

100% oxygen inhalation.

I/V fluids,I/V antibiotics ,I/V analgesics and i/v proton

pump inhibitor. Nebulization. Input output charting.

 Patient extubated on post intubation day. Plan : discharge

25 years old male patient with no known co-morbids came with c/o: Abdominal pain.8 days. Constipation. 2 days Abdominal distention2 days Fever.... .1 day

 insignificant

A middle aged male of average built,dehydrated lying on bed,well oriented in time, place and person. Vitals:Pulse BP Temp. RR = 150 beats/min = 80/40 mm Hg = A/F = 22 b/min

 Tenderness on all over abdomen. Gut sounds absent.

P/R: fecal stained finger.

 Hb. TLC Plt Na. K+ Cl Urea

Creatinine
Sugar

= = = = = = = = =

10.7 g/dl 17.2 539000 139 meq/lt 4.04 meq/lt 102 meq/lt 41 mg/dl 1.0 mg/dl 102 mg/dl

x.ray:
Shows distended bowel loops with multiple air fluid levels

Diagnostic tap:

Shows bowel secretions

 Intestinal perforation secondary to typhoid/perforated

appendix??.

 Patient was kept N.P.O. I/V line maintained. IV fluids, IV antibiotics, IV analgesics and IV PPI.

Input Output charting.

 500 ml purulent fluid aspirated.

perforation at tip of appendix found with omentum wrapped around it.

Omentum removed from appendix and appendectomy

done.

PostOp:
Kept NPO. I/V fluids,I/V antibiotics ,I/V analgesics and i/v proton

pump inhibitor.
Nebulization.
Input output charting.

 Patient discharged yesterday

30 years old male with no comorbids came with c/o:

Fever.. 7 days Abdominal pain ...4 days. Vomiting.3 days. Absolute constipation.....3 days

 Not significant

Young male of average built lying on bed, dehydrated well oriented in time, place and person. Vitals:-

Pulse BP Temp. RR

= 120 beats/min = 80/50 mm Hg = A/F = 40 b/min

 Tenderness all over abdomen Gut sounds inaudible.

P/R: fecal staining fingure.

 Hb. TLC Plt Na. K+ Cl Urea Creatinine

Sugar

= = = = = = = = =

11.2 g/dl 13900 292000 123 meq/lt 5.00 meq/lt 86.5 meq/lt 54 mg/dl 0.9 mg/dl 94 mg/dl

x.ray:
Dilated large and small bowel loop.
Ultrasound abdomen: Distended bowel loops with fluid containing echos in the

upper abdomen noticed Gases in lower abdomen noticed Hypoechoic 4.7 cm *7.8 cm area containing echoes of fine septa consistent with collection in right side of pelvis Minimal ascitis noticed

 Peritonitis sec to hollow viscus perforation .(sec to

typhoid??)

 Patient was kept N.P.O. I/V line maintained. IV fluids, IV antibiotics, IV analgesics.

NG passed (dark colour fluid 300 ml).

Catheter passed ( concentrated urine 150ml).

Drain placement under local anesthesia as patient was vitally unstable two drains were placed under LA Findings were 200 ml fecal staining fluid aspirated from right drain 200 ml of fecal staining fluid aspirated from left drain Per-op findings: on 3rd post admission day exploratory laparotomy done findings were: 1*1 cm perforation 4 cm proximal to IC junction Repair done and loop ileostomy made.

Anesthesia Progress:
Smooth recovery from anesthesia.

PostOp:
Kept NPO. I/V fluids, I/V antibiotics I/V analgesics I/V PPI Nebulization. Chest physiotherapy Input output monitoring

 Subjective
Objective

: No active complaints.
ileostomy working.

: vitally stable.
Abdomen: gut sound audible Labs: Normal limits.

Lines Plan

: NG out.
: .

70 years old female with known case of HTN came with

c/o:

swelling on abdomen5 years constipation....7 days Abdominal pain ....2 days. Abdominal distention.2 days

 History of operated for paraumblical hernia 7 years

ago

Old aged female of average built lying on bed, dehydrated well oriented in time, place and person. Vitals:-

Pulse BP Temp. RR

= 88 beats/min = 110/70 mm Hg = A/F = 24 b/min

 tender swelling on umblical region.cough impules positive No skin changes.

Gut sounds inaudible.

P/R: fecal stain fingure.

 Hb. TLC Plt Na. K+ Cl Urea Creatinine

Sugar

= = = = = = = = =

12.8 g/dl 6300 242000 138 meq/lt 4.1 meq/lt 100.5 meq/lt 50 mg/dl 0.9 mg/dl 114 mg/dl

x.ray:
Dilated large and small bowel loop. Ultasound abdomen: Defect seen in ant abdominal wall measuring 3 cm.

 Acute intestinal obstruction sec to recurrent

paraumblical hernia.

 Patient was kept N.P.O. I/V line maintained. IV fluids, IV antibiotics, IV analgesics.

NG passed (dark colour fluid 150 ml).

Catheter passed ( concentrated urine 100ml).

Per-op findings:

Exploratory laparotomy done. .

Multiple adhesions between sac and bowel loops Sac contained discoloured ileum

Iatrogenic perforation 4 feet from IC junction ,primary repair

done.
1.5 feet discoloured ileum 1 feet from IC junction ,right limited

hemicolectomy with ileocolic anastomosis done

Anesthesia Progress:
Smooth recovery from anesthesia.

PostOp:
Kept NPO. I/V fluids, I/V antibiotics I/V analgesics I/V PPI Nebulization. Chest physiotherapy Input output monitoring

 Subjective
Objective

: No active complaints.
Flatus passed.

: vitally stable.
Abdomen: gut sound audible Labs: Normal limits.

Lines Plan

: NG out.
: Discharge.