Incarcerated Incisional Hernia

Incarcerated Incisional Hernia - Abdominal Pain/Abdominal...

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Abdominal Pain/Abdominal Mass Abdominal Pain/Abdominal Mass Melissa L. Hughes Scott Q. Nguyen, M.D. Celia M. Divino, M.D. Department of Surgery Mount Sinai School of Medicine
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HPI Mrs.Masseo HPI Mrs.Masseo Mrs. Masseo is a 63-year-old female with PMH of HTN, DM, s/p laparotomy for peptic ulcer disease seven years ago Presents to ER with one day history of sudden, worsening abdominal pain associated with nausea, two episodes of vomiting, and abdominal distension
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What other information would you want regarding this patient’s history?
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Other Pertinent HPI Other Pertinent HPI Patient had noticed a bulging from her mid abdomen beneath the surgical scar for the past several months. It was not initially painful, became larger when she coughed, and would go away when she was lying down After an acute coughing episode the morning prior to admission, patient reported that she suddenly experienced severe pain in her mid abdomen that was constant and accompanied by an increase in size of the midline bulge which did not go away when she tried to lie down No flatus or bowel movement over the past day, several episodes of vomiting, and subjective fevers
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Other Pertinent History Other Pertinent History PMH : Poorly controlled HTN and DM for the past 20 years PSH : Appendectomy at age 35, laparotomy 7 years ago for PUD Meds : lisinopril, insulin, nexium, aspirin Allergies : NKDA Social history : 1.5 packs of cigarettes a day for the past 40 years
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What would you look for on physical exam?
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Physical Exam Physical Exam Ill-appearing, obese woman in severe pain BP 100/60 HR 115 Temp 38.2 C RR 24 HEENT: oral mucosa dry Heart: tachycardic, regular rhythm Lungs: clear to auscultation bilaterally Abdomen: obese abdomen, healed midline laparotomy and RLQ scars, hypoactive bowel sounds, moderate distension, firm, tender softball size mass at midline scar with erythema of the overlying skin. No rebound or guarding in remaining abdomen Guaiac positive stool
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What is your differential diagnosis?
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Differential Diagnosis Differential Diagnosis Incarcerated ventral hernia Small/large bowel obstruction- secondary to adhesions, volvulus, neoplasm Abdominal wall tumor Abdominal wall abscess
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What labs would you order?
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15 10 30.1 350 134 3.3 94 40 20 1.7 190                 n% 89    LFTs, amylase, lipase, and coags- WNL Lab results, Mrs. Masseo
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Lab Findings Lab Findings Pre-renal azotemia secondary to dehydration Leukocytosis from infection/inflammatory process
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What imaging would you like to obtain?
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Obstructive Series Obstructive Series
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Obstructive Series Obstructive Series Describe the X-ray findings
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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Incarcerated Incisional Hernia - Abdominal Pain/Abdominal...

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