Case Files SurgeryEssay Preview: Case Files SurgeryReport this essayBREAST MASS:– radiation therapy is indicated for pt with stage I dz tx with breast conservation therapy– this reduces the rate of recurrence from 30% to 9%– post-menopausal or non-lactating women with red/tender breasts should be assumed to have breast cancer until proven otherwise– tamoxifen therapy assoc with uterine cancer– systemic therapy is given when widespread mets is dx or when pt is high risk for distant metsGERD:– if hoarseness and wheezing, suggests pharyngeal reflux with silent aspiration– if dysphagia and/or weight loss think malignancy– do endoscopy to evaluate for esophagitis, 24-hour pH monitoring can quantify severity– H2 blockers may provide sxatic relief, PPIs are superior for decr acid production– ~50% of pts with GERD develop complications such as peptic strictures, Barretts esophagus, and extraesophageal complications– when LES is abnormally located, as in hiatal hernia, anti-reflux mechanism may be compromised at the GE junct– std workup prior to surgery = endoscopy, 24-hour pH, barium esophagography (evaluates for gastric outlet obstruction – fundoplication is contraindicated)
– pts with esophagitis or significant sx PPI therapy– std surgery = Nissen fundoplication– diagnostic endoscopy when pts have long-standing GERD and when sxs are refractory to medical tx– pts with GERD may develop pulmonary and laryngeal sx– adenocarcinoma of esophagus is a complication of barretts (from longstanding GERD)– surgery is indicated if persistent sxs while taking max PPI dose, cant tolerate PPIs, does not wish lifelong medicationsESOPHAGEAL PERFORATION:– spontaneous esophageal perf = Boerhaave syndr; most are iatrogenic and in distal 1/3 of esophagus– typically, have acute onset chest pain after an episode of vomiting; also may have shoulder pain, dyspnea, midepigastric pain– 75% present with pleural effusion, usu left sided (from disruption of the mediastinal pleura) often leads to mediastinitis and chest pain; delay in tx can lead to sepsis
– perforation into the mediastinum pneumomediastinum and subcut emphysema (may not present with lower perforation)– best initial diagnostic test = water-soluble contrast (gastrografin) esophagram; if no leak discovered, must do barium contrast– tx principles = surgical drainage, debridement, repair and diversion– outcome for esophageal perforation is directly related to amount of time elapsed b/w dx and txMALIGNANT MELANOMA:– Suspicious lesions perform an excisional bx– A: asymmetry; B: border irregularity; C: color change; D: diameter increase; E: enlargement or elevation– 4 types = superficial spreading, nodular sclerosis, lentigo maligna, acral lentiginous– superficial spreading is most common; radial growth phase predominates (as in lentigo maligna)– nodular sclerosis has no radial growth phase, but aggressive vertical growth phase– acral lentiginous is freq in colored people– Breslow depth is considered more accurate in reflecting prognosis– interleukin-2 therapy has been found to be somewhat helpful, but surgery remains the best tx– melanoma in situ margins = 0.5cm; 4mm >2cmBENIGN PROSTATIC HYPERTROPHY– best therapy = transurethral prostatectomy (TURP)– prostate capsule restricts expansion of prostate gland as it expands in BPH bladder neck and prostatic urethra become compromised; leads to bladder outlet obstruction
– have freq urination of small amounts, incomplete voiding, slow flow, nocturia, hesitancy– ddx = urethral stricture dz, uti, prostatitis, prostate ca, neurologic dysfunction– when there is a nodularity or an increase in the PSA, bx is indicated– check UA, PSA, serum Cr (to r/o prostatism with renal compromise)– initial tx is often medical alpha agonists (cause relaxation of the prostate smooth muscle); also have meds that cause reduction in prostate size by blocking metabolite of testosterone
– in asxatic with significantly elev PSA, do prostate bx– for overflow incontinence (urinary retention) immediate drainage and hospitalization– alpha agonists relaxed smooth muscle within arterial wall; decrease blood supply may result in dizziness or syncope– mild elevations of PSA may occur after DRE– first steps = NGT, IVF, Foley– can have strangulation, necrosis, sepsis; prerenal azotemia from fluid loss– persistent pain small bowel dilation or ischemia secondary to strangulation– obstruction in child most likely result of hernia, malrotation, meconium, meckles diverticulum, intussception, atresia– in adult, likely adhesion, hernia, crohns, gallstone ileus, tumor– in mechanical obstruction have crampy pain, nausea, bilious vomiting– init may have low grade fever and tachyc (b/c o dehydration and inflamm changes); high
#2D17, AIAA4, WL(2)4, WF(1)19, WL(21)4, WF(1), ID11
The above are my predictions of my future prognosis.> #2D11 I’ve given a brief description and hope to post on other sites about my prognosis (and possibly more). Feel free to send in a PM (which will be read at my own risk) with your suggestions at the PSA forum if you’d like to be included in my prognosis list.
How soon after a recent surgery, will you be given a spironolactone (or any other parenteral) injection?
The question for me is whether it will be at least 3-5 months. I’m still not sure what the actual length is. I’ve given a spironolactone 3 months, but I’ve not had a follow-up test, and don’t know if I’ll be doing it. As it is, I’m already in therapy at a small level (with the goal of starting early). I can’t say for certain that it will be a time when I’ll actually see a doctor, but it depends.
To determine whether my spironolactone would work for you, I went to Dr. Pascual who is available to answer my questions. The initial screening I did after my surgery was 1 day after a CT scan. Of the 604 women with whom she saw me, 5 had spironolactone injections (6 days apart). Of the 3 women who had received two spironolactone doses, 3 had had an open T4 (day 10-15) vs. day 2 (day 10-15 with injections of spironolactone 10-15) for one year. Of the 5 that had the same injections, 12 of them had a new T4 (day 10-15), so the 14 who had received spironolactone 3 weeks apart were in the same category.
What are your top 10 questions for the future?
I’m interested to know if my prognosis for a spironolactone injection will improve in the 2-3 weeks after surgery. As noted in the last post below, this is not a question I’ve answered before, and I don’t hold back on posting my thoughts on the specific reasons for this. I’m quite fond of postmortems, so I may share answers I’ve got about this topic with you later.
If you want to know if your spironolactone would be working for your specific surgery, then the 5 questions I asked when I was at the clinic in March 2007 are pretty straightforward. I want to know if I can recommend 3-6 doses of this spironolactone.
How much does the spironolactone cost in US dollars?
I’m looking for about $15K-$25K. Most spironolactone will cost about $100K to $120K to be prescribed and delivered to. I can recommend two to four daily doses of spironolactone from a doctor (who knows