1. A MORTALITY FOR GENERAL
SURGERY – YELLOW TEAM
DR BASSEY AE

2. BIODATA
• P.O.
• 50 YO
• MALE
• DRIVER
• IDOMA

3. P.C.
• ABDOMINAL PAIN x 4/7
• ABDOMINAL SWELLING x 2/7

4. HxPC
• 4/7 PRIOR TO PRESENTATION DEVELOPED
ABDOMINAL PAIN, UMBILICAL, ACHING, NON-
RADIATING, NO KNOWN AGGRAVATING
FACTOR, RELIEVED BY VOMITING
• VOMIT – NON-PROJECTILE, NON-BILOUS,
NON-BLOODY, OCCURRED AFTER INGESTING
FOOD OR FLUID

5. HxPC (CONT’D)
• ASSOCIATED FREQUENT LOOSE STOOL,
WATERY, NON-MUCOID, NON-BLOODY

6. HxPC (CONT’D)
• 2/7 AFTER ONSET OF THESE PROBLEMS,
STARTED HAVING PROGRESSIVE ABDOMINAL
SWELLING ASSOCIATED WITH THIRST AND
↓URINE AND STOOL OUTPUT

7. HxPC (CONT’D)
• NO PRIOR HX OF ABD TRAUMA
• NO HX OF ILLNESS XTISED BY HI GRADE FEVER,
HEADACHES, DIARRHOEA
• NO HX OF ABD SURGERY
• PRIOR TO ONSET, NO HX OF CHANGE IN BOWEL
HABITS, WT LOSS OR HAEMATOCHEZIA
• NO HX OSF SWELLINGS IN GROIN OR ANY OTHER
PART OF ABDOMEN THAT APPEAR ON STRAINING
OR COUGHING

8. HxPC (CONT’D)
• PT TOOK HERBAL MEDICATION FOR HIS
PROBLEM BUT HAD NO RESPITE

9. SYS REVIEW
• N A D

10. PMHX
• KNOWN RVD ON HAART, OFF MEDICATION
FOR 2 MONTHS PRIOR TO PRESENTATION
• DGXED 2YRS AGO

11. FSHX
• DOESN’T SMOKE OR TAKE ALCOHOL

12. EXAMINATION - GENERAL
• MIDDLE AGED MALE
• RESTLESS
• PALE
• DEHYDRATED
• ANICTERIC
• ACYANOTIC
• FEBRILE (T – 38.8C)
• NO PEDAL OEDEMA

13. ABDOMEN
• DISTENDED
• MWR
• TENSE
• TENDER
• PN – TYMPANITIC
• BS – HYPOACTIVE
• 6x4 CM SWELLING IN RT INGUINAL REGION, NO
COUGH IMPULSE, FIRM, TENDER, IRREDUCIBLE
• HAD REDUCIBLE SWELLING WITH POSITIVE
COUGH IMPULSE ON LT INGUINAL REGION

14. RECTAL EXAM
• EMPTY RECTUM
• SLIGHTLY ENLARGED PROSTATE

15. CVS
• PR – 124B/M, SMALL VOL
• BP – 100/60 MMHG

16. CHEST
• DYSPNOIEC
• RR – 48C/M

17. CNS
• N A D

18. PROBLEMS
• SEPSIS
• ACUTE INTESTINAL OBSTRUCTION
• OBSTRUCTED RIH
• REDUCIBLE LIH

19. MGT PLAN
• RESUSCITATION WITH R/L VIA 2 WIDE BORE
CANNULAE. PT BECAME CALM, VITALS
IMPROVED TO PR-90B/M, BP-120/70MMHG
• ANTIBIOTICS – ROCEPHIN, FLAGYL
• NG TUBE – 2L BILOUS FLUID
• URETHRAL CATHETER PASSED – CONC URINE
INITIALLY THEN DILUTE URINE
• NPO

20. MGT PLAN (CONT’D)
• FLUID CHART FOR I/O MONITORING
• VITAL SIGNS MONITORING
• URGENT PCV, E/U/CR, URINALYSIS, CXR, PLAIN
ABD XRAY
• SR INFORMED – GXM 2UNITS, FOR
EMERGENCY EXLAP AS SOON AS STABLE

21. 2ND
DAY OF ADMISSION
• PT OBJECTED TO SURGERY AND PREFERRED
MEDICATION DESPITE BEING EDUCATED ON THE
NATURE OF HIS PROBLEM, THE NEED FOR
SURGERY AND THE PERILS OF FURTHER DELAY
• MEANWHILE, INVX RESULTS:
• PCV : 17%
• E/U/CR : Na – 152, Cl – 127, HCO3 – 12
• NG TUBE EFFLUENCE: 6500ML OVER PAST 17HRS
• URINE BAG – DILUTE URINE

22. 2ND
DAY
• RECEIVED 1 UNIT OF BLOOD
• 5 UNITS OF BLOOD REQUESTED FOR PRE-OP
TRANSFUSION AND SURGERY
• PT STILL REFUSED SURGERY

23. 3RD
DAY
• NG TUBE EFFLUENCE – 800ML OF FAECULENT
FLUID
• RECEIVED 2ND
UNIT AND HAD 2 EXTRA
• PT ALSO CONSENTED TO SURGERY AND WAS
BOOKED FOR EMERGENCY EX-LAP

24. INTRA-OP
• RIGHT DIRECT RICHTER HERNIA WITH HERNIATED
SMALL BOWEL SEGMENT ISCHAEMIC
• ON APPLICATION OF WARM SALINE PERFUSION
IMPROVED AND BOWEL WAS RETURNED
• LEFT SLIDING HERNIA WITH SIGMOID COLON
FORMING PART OF HERNIA SAC
• HERNIORRHAPHY WAS PERFORMED ON BOTH
SIDES

25. POST OP ORDER
• NPO
• 3L/DAY, ALT R/L AND D/W
• ANTIBIOTICS – LEVOFLOXACIN, FLAGYL
• ANALGESIA – PENTAZOCINE
• FLUID I/O MONITORING
• VITALS MONITORING
• TRANSFUSE 2 UNITS IN FIRST 24HRS POST OP

26. 12HRS PO
• NG TUBE – BILOUS
• URINE BAG – DIL URINE
• FEBRILE – 38.3-39.7C
• PLAN – CT POST OP CARE

27. POD 1
• NG TUBE – BILOUS
• FEBRILE – 38.3-40C
• DEHYDRATED
• PR – 82, BP – 110/70
• BOWEL SOUNDS – HYPOACTIVE
• PLAN: INCREASE FLUID INPUT TO 4L/DAY,
URGENT E/U/CR

28. POD 2
• BOWEL MOTIONS RESUMED
• FEBRILE – 39.4-40.3C
• STARTED TALKING IRRATIONALLY
• POST OP PCV – 33%
• YET TO DO E/U/CR
• PR – 84, BP – 110/60
• PLAN – TEPID SPONGING, IM PCM, CHANGE
FLAGYL BRAND, TO RECEIVE 50MMOL KCL/DAY

29. POD 3
• STILL FEBRILE: 39.8-40.8C
• NG TUBE – SLIGHTLY BILOUS
• URINE BAG – DILUTE URINE
• NO E/U/CR YET
• PR – 100, BP – 110/60
• PLAN – URINE M/C/S, BLOOD M/C/S, CT IV
ANTIBIOTICS FOR ANOTHER 48HRS

30. POD 3(CONT’D)
• STILL FEBRILE: 40.8C
• PLAN – INVITE PHYSICIAN IN CHARGE OF RVD
MGT, FOR POSSIBLE EX-LAP
• PATIENT PASSED AWAY 7HRS AFTER ABOVE
REVIEW

31. THANK YOU