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 AMC Clinical exam-recalls

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sue



Points : 42144
Join date : 2013-12-26

PostSubject: AMC Clinical exam-recalls   Thu Dec 26, 2013 11:07 pm

You are the covering surgical resident in a suburban hospital. The ICU charge nurse calls you to talk to the son of a 65 year old Mr. Franzke who underwent an elective repair of an infrarenal abdominal aortic aneurysm. Mr. Franzke had no other preoperative medical problems and the surgery was successful although as routine measurement he is now postoperatively in ICU and the plan is to extubate him later this afternoon. 
The son, Brian, is rather concerned about his father, that he is in ICU.


YOUR TASK IS TO: explain the current management and further care of the patient and to answer the son’s questions. 


 
Discussion:

Brian seems to be quite upset about finding his father in ICU and he acts quite aggressively  and angry although at the same time concerned about how sick his father looks with all the tubes and electrodes on his body incl. in his mouth (ETT).
He wants to know if things have gone wrong, why all this is happening, what happens from now on, will he ever get out of hospital, was the operation really necessary and is there a chance that he himself might develop an aneurysm in the future.

1. Provide reassurance that ICU is a routine postoperative measure for monitoring and advanced support if necessary for breathing, fluid management and heart function following such a big abdominal operation which often affects the breathing etc.! 
2. Explain the nature of abdominal aneurysm (dilation of weakened wall of the artery due to atherosclerosis), the risk of not operating it (rupture 
if > 5 cm,  thrombosis, embolism, exertion of pressure of adjacent structures like sciatic nerve or infections). Draw a picture!
3. Describe the operation, draw a picture!
4. Outline the plan to remove the breathing tube today and to then transfer the patient back to a surgical ward within 1 or 2 days.. Pain relief and DVT prophylaxis should be explained including the involvement of allied health teams like physio, occupational therapist etc.
5. Make sure that Brian understands that you are available anytime for further questions or if another family member wants to ask questions. There is also always the possibility to talk to the surgeon, the registrar or the nurses. 

Brian wants to know what causes an aneurysm, what are the first signs and can he get one (he probably should have regular examinations and investigations from age 50 onwards)..
AAA is common in older males, especially with a family history! Other risk factors are arteriosclerosis, hypertension, diabetes, smoking and hypercholesterolaemia.

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