SILLIMAN UNIVERSITY MEDICAL SCHOOL

SURGERY WORKSHEET
SUBMITTED TO: Dr. Henry Tan
SUBMITTED BY:
Christian Ayrton Palomar
Alvin G. Pasuquin
Edessa E. Reyes

DATE OF SUBMISSION: August 19, 2014

MEDICINE III

REPRESENTATIVE CASE
Identifying Data: a case of a 78 years old, female, Filipino, housewife.
Source of Information: primary source is the patient
Chief Compliant: Right hip pain
MEDICAL HISTORY
History of Present Illness:
Few minutes PTC, the patient experienced right hip pain moments after a fall at the bathroom. The pain was said to be persistent and localized and with a rate of
7/10 in pain rating scale. No associated symptoms and other injuries were stated. The pain is exacerbated when the patient walks. No medications were taken and
no other means were done to alleviate the pain.
The patient stated that she landed with her buttocks on a wet floor and used her arms to pick herself up and went to her bed which is just beside the
bathroom. The pain persisted which prompted her to go to the Out Patient Department for consultation.
PAST MEDICAL HISTORY:
The patient has been diagnosed with Osteoporosis and is taking calcium supplement and Thyroxine 100mcg/day as her maintenance medications. Previous
surgery was done last 2011 due to Cataract. She is G10P10 (10-0-0-10), all delivered vaginally with no complications and had her menopause at 50 years old.
The patient is non-hypertensive and non-diabetic, no asthma, no food and drug allergies.
FAMILY HISTORY:
Patients sister died of breast cancer. There are no other history of heredofamilial diseases, to mention like goiter, ulcer, gallstones, mental illness, seizure disorder,
and asthma. No family history of infectious diseases like hepatitis, tuberculosis, HIV and other sexually transmitted diseases.
PERSONAL AND SOCIAL HISTORY:
The patient is a housewife. She is non-smoker and non-alcoholic beverage drinker. She denies using illicit drugs.
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
General: Conscious, coherent, not in respiratory distress, and in stretcher.
GUT: urine incontinence especially
Weight: 70 kg
during coughing. The rest of the
V/S:normal
systems are unremarkable.
Skin: normal
HEENT: normal
Neck: enlarged, nodular thyroid gland
Chest and Lungs: normal
CVS: normal peripheral pulses, no murmurs
ABD: no organomegaly, no edema
EXT: there is ecchymosis, swelling and tenderness on the R hip, R lower extremity externally rotated, right leg is shorter
than the left.
PRIMARY WORKING IMPRESSION
RULE IN
RULE OUT
Risk Factors: female gender , advancing age, osteoporosis,
CANNOT BE RULED OUT
menopause, environmental hazards (wet floor)
History: low energy fall
Radiologic Feature
Physical Examination: painful, shortened, externally rotated lower -Shentons line disruption: loss of contour
extremity
between normally continuous line from medial
edge of femoral neck and inferior edge of the
superior pubic ramus
-lesser trochanter is more prominent due to
Femoral Neck Fracture; Right
external rotation of femur
Stage III Garden Fracture
-femur often positioned in flexion and external
rotation (due to unopposed iliopsoas)
-asymmetry of lateral femoral neck/head
-sclerosis in fracture plane
-smudgy sclerosis from impaction
bone trabeculae angulated
-nondisplaced fractures may be subtle on x-ray

DIFFERENTIAL DIAGNOSES

Intertrochanteric Fracture; Right

Risk Factor: a low energy fall in elderly, agility and decreased

muscle tone of the muscles in the area secondary to aging,
female:male ratio between 2:1 and 8:1
typically older age than patients with femoral neck fractures
Physical Examination: painful, shortened, externally rotated
lower extremity
Risk Factor: a low energy fall in elderly, agility and decreased
muscle tone of the muscles in the area secondary to aging,
female:male ratio between 2:1 and 8:1
typically older age than patients with femoral neck fractures

Subtrochanteric Fracture; Right

Greater Trochanteric Fracture; Right

Physical Examination:
shortened extremity on the fractured side, significant swelling is
frequently present, with tenderness to palpation, The leg lies in
external rotation.

Diagnostic Confirmartion:
AP pelvic view, an AP view of the involved hip,
and either a cross-table lateral view of the hip or a
frog lateral view of the hip, as well as a traction
AP hip radiograph if the surgeon does not fully
understand the fracture pattern. A full-length
radiograph of the involved femur is necessary to
rule out any pathologic process or deformity that
may exist distal to the fracture.
Physical Examination:
(-) Hemorrhage may be substantial
Diagnostic Confirmation:
Biplanar plain radiography is the basic and
essential imaging study for the diagnosis of
subtrochanteric femur fractures.
Full-length anteroposterior
A cross-table lateral view of the
AP view of the pelvis and of the ipsilateral knee

Risk Factor: occurs most commonly as a component of

intertrochanteric fractures; fall

Physical Examination: ; With this fracture, no

deformity may be apparent

Physical Examination: pain, difficulty walking, weight bearing is

possible, tenderness over the area,

Diagnostic Confirmation:
MRI defined the actual geographic extent of
greater trochanteric fractures more accurately
than other imaging techniques.

Risk Factor: Occurs commonly as a component of

intertrochanteric fracture; fall

isolated fracture of the lesser trochanter is quite

rare; because of the anatomical location of the
lesser trochanter which is protected anteriorly and
posteriorly by large muscular masses, superiorly
by the head and the neck of the femur, laterally by
the femur itself, and medially by the ilio- and
ischio-public branches of the pelvis

Physical Examination: pain, difficulty walking, weight bearing is

possible, tenderness over the area,
Lesser Trochanteric Fracture; Right

Diagnostic Confirmation:
Standard X-ray is enough to diagnose lesser
trochanter fracture, but requires AP and lateral
views if non-displaced forms are not to be missed.

LABORATORY TESTS TO ORDER

TESTS

TEST NECESSITY

PRICE

LABORATORY STUDIES
These tests are done to determine the patients medical condition before surgery to allow correction of any abnormalities before surgical interventions.
Complete Blood Count

Electrolytes (Na, K)
Prothrombin Time
Activated Partial Thromboplastin
Time

This test is ordered to document any blood loss, to help diagnose disorders that affect blood cells such
as anemia, infection, inflammation, and bleeding disorder due to thrombocytopenia. Additional blood
typing and crossmatching will be ordered in case the patients haemoglobin and haematocrit are low in
preparation for surgery.
Electrolyte tests are used to identify an electrolyte or acid-base imbalance and to monitor the effect of
treatment on a known imbalance that is affecting bodily organ function. It can also detect possible
hemolysis.
Prothrombin measures the extrinsic factors of coagulation. This is ordered to detect possibilities of
having bleeding disorders.
APTT measures the intrinsic factors of coagulation. This is ordered to detect possibilities of having
bleeding disorders.

250

580
360
350

IMAGING MODALITIES
Hip X-ray

This test is always indicated to determine which type of fracture, if any, is present. AP views of the
pelvis and hip and cross-table lateral x-ray films are usually sufficient to evaluate potential fractures.
Rotating the affected leg internally or externally can increase the sensitivity of these radiographs.

310

THERAPEUTICS
Problem List
1.
2.
3.
4.

Therapeutic Objectives

Pain in the right hip with ecchymosis and swelling

Osteoporosis
Nodular goiter
Urine incontinence when coughing

1.
2.
3.

MANAGEMENT
Advice and Information
1. Teach the patient about the condition, self-care activities, lifestyle
changes, nutritional needs, and medication information necessary to
achieve compliance.
2. Teach the basics of good nutrition.
3. Educate the patient the importance of exercise in the process of
rehabilitation.
SURGICAL MANAGEMENT
Fracture
Indications
FEMORAL NECK FRACTURE
Femoral Neck Fracture Nondisplaced femoral neck fracture of
Cannulated
Screws both young and elderly patients
(Garden I and II)
Displaced femoral neck fracture in
young, active patient

To relieve pain in the Emergency Department

To provide appropriate Pre, Intra, and Post-op medications
To prevent any complications

Non-pharmacologic Management
1. Admit patient to surgical ward post-op.
2. Monitor V/S post-op.
3. Monitor input and output every shift.
4. Early ambulation to prevent DVT.

Contraindications

Complications

Displaced femoral neck fracture in elderly,

inactive patient, rheumatoid arthritis,
moderate osteoarthritis, poor bone density,
limited life expectancy, pathologic fracture.

Nonunion ,infection, decubitus ulcers,

urinary tract infections, DVT

Primary Hip Replacement Displaced femoral neck fracture in and Preexisting sepsis, young patient, failure of Fracture of the femur, dislocation,
or Hemiarthroplasty of the elderly patient
internal fixation devices, pre-existing septicemia, pain.
Hip (Garden III and IV)
disease of the acetabulum
PHARMACOLOGIC MANAGEMENT
Drug Name
Efficacy
Safety
Suitability
ANALGESICS
Opioid analgesic agonist; blocks Contraindications
Relief of moderate to severe pain; for pre-op
pain perception in the cerebral Hypersensitivity, CNS depression, severe analgesia, supplement to balanced anesthesia,
cortex;
decreases
synaptic respiratory depression
surgical anesthesia, obstetrical anesthesia
chemical transmission throughout Cautions
the CNS, which in turn inhibits pain Use caution in Addison's disease, chronic
OPIOID
sensation into higher centers
alcohol use, debilitated patients, drug abuse
history, elderly patients, G6PD deficiency, head
injury, hepatic dysfunction, hypothyroidism,
impaired pulmonary function, increased
intracranial pressure, toxic psychosis, prostatic
hypertrophy, renal dysfunction, urethral stricture
ANTIBIOTICS
First-generation
semisynthetic Contraindications
Infections of skin and soft tissues, pre- and
cephalosporin that binds to 1 or Hypersensitivity
post-op wound and trauma, billiary, and
more penicillin-binding proteins, Cautions
gynecological infections, RTI, UTI, subacute
thereby arresting bacterial cell-wall Prolonged use is associated with fungal or bacterial endocarditis. Septicemia.
1st
Generation
synthesis and inhibiting bacterial bacterial superinfection
Cephalosporins
replication; has poor capacity to Use with caution in patients with seizure disorder
cross blood-brain barrier; primarily (high levels are associated with increased risk of
active against skin flora, including seizures)
S aureus

Patient:
Address:

Christian Ayrton Palomar, MD

Christian Ayrton Palomar, MD

Silliman Medical Center

0915-HEAL-YOU

Silliman Medical Center

0915-HEAL-YOU

Date:
Age/Sex:

Patient:
Address:

Date:
Age/Sex:

Christian Ayrton Palomar

Lic. No. 012596

Christian Ayrton Palomar

Lic. No. 012596

REFERENCES:
Braunwaldet. al. 2008.Harrisons Principles of Internal Medicine.18th ed. McGraw Hill Companies, USA.
Bruntonet.al. 2008.Goodman & Gilmans Manual of Pharmacology and Therapeutics. McGraw Hill Companies, USA
Kumar et. al. (2010) Robbins and Cotran: Pathologic Basis of Disease. 8th ed., Saunders-Elsevier, Philadelphia, USA
MIMS Philippines (2012)
eORIF. August 18, 2014. www.eorif.com
Philippine Pharmaceutical Directory.5th Ed. (2005) Philippines.
Pincuset. Al (2010).Henrys clinical diagnosis and management by laboratory methods. 10 th Ed, Saunders-Elsevier, Philadelphia, USA
Strandell.C. et.al.(2000). Manual of Laboratory and Diagnostic Tests.6th ed. Lippincott Williams and Wilkins. Philadelphia