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Category: General Surgery

FINGER TEST FOR NECROTIZING FASCIITIS

FINGER TEST FOR NECROTIZING FASCIITIS

A patient presents with a deep muscle abscess. Is this necrotizing fasciitis? All too often I see the deliberation focus on things like the laboratory score or the imaging. The role of those things are being debated but what is beyond debate is to have the bedside skills for recognizing necrotizing infections.   Childers in 2001 and 2002 described the finger test as a diagnostic intervention at the bedside. It does not get enough attention. The instructions are to make…

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HERNIA TAXIS: DECOMPRESS BEFORE REDUCTION

HERNIA TAXIS: DECOMPRESS BEFORE REDUCTION

I remember in residency calling general surgery for a hernia that could not be reduced. The surgeon was irritated and determined to prove it could be reduced. After about 30 minutes of sweat and tears the hernia was reduced and he instructed me to send the patient home. I later learned that his approach is generally frowned upon in the surgical literature, as forceful reduction can result in reduction en masse as well as perforation. In the days before emergency…

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STRANGULATED SMALL BOWEL OBSTRUCTION

STRANGULATED SMALL BOWEL OBSTRUCTION

STRANGULATED SMALL BOWEL OBSTRUCTION A patient presents with nausea and vomiting, is found to have small bowel obstruction, and is to be admitted to the hospital. The hospitalist and general surgeon disagree over whether strangulation is present. Can we recognize strangulated small bowel obstruction at the bedside? Strangulation means intestinal ischemia. Most of the time this is caused by a “closed loop obstruction,” meaning there is obstruction not only distally but also proximally, preventing the release of pressure. Small intestinal…

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PHYSICAL DIAGNOSIS OF SMALL BOWEL OBSTRUCTION

PHYSICAL DIAGNOSIS OF SMALL BOWEL OBSTRUCTION

A middle aged man presented with worsening bloating, cramping abdominal pain, nausea, and vomiting. He had been in the ED the day before for similar symptoms, his x-rays were normal, and he had been diagnosed with gastroenteritis. With vomiting and cramping pain, you wonder about a bowel obstruction. Can physical diagnosis help? LIMITATIONS OF RADIOGRAPHS This is a very important topic because plain films have a sensitivity for small bowel obstruction approximately 50% and even noncontrast CT scan has limitations…

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INCARCERATED HERNIA

INCARCERATED HERNIA

A patient presents with pain in his ventral hernia.  You wonder whether it could be strangulated. Does the bedside examination help?  Sure. Check for tenderness, localized peritoneal signs, assess appetite, ability to eat and drink, bowel habits.  Does this answer the question as to whether there is strangulation?  Probably not.   There is no question that strangulated hernias need immediate surgery.  And there is no question that reducible hernias, if there is no concern for infarction, do not need admission…

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