Minor Surgery Case (NPLEX Board Review packet)

Case #1
A 25-year-old female complains of painful swelling in her left axilla that first began as a pimple 4
days ago. She has no prior history of these symptoms, and she has no known allergies to drugs or
medications. She denies fever, chills, or excessive perspiration, and her vital signs are all within
normal limits. Physcial examination reveals a recently shaved axillary region that is swollen, red,
and exquisitely painful.
1. Based on this presentation, you would diagnose ________ if physical examination revealed
________.

A. ripe abscess; a soft fluctuant mass
B. ripe abscess; an indurated nodular mass
C. sebaceous cyst; a palpable fixed mass
D. sebaceous cyst; a discreet palpable nodule

2. Which procedure would you use to treat her, and what would be the best technique for
administering anesthesia?

A. incision and drainage; field block
B. excision and removal; nerve block
C. incision and drainage; a topical anesthetic
D. excision and removal; direct injection into the lesion

3. Which surgical instruments would be most appropriate?

A. a #11 scalpel and forceps
B. a #11 scalpel and hemostat
C. a #15 scalpel and hemostat
D. a #15 scalpel and iris scissors

4. Post-surgically, the physician should:

A. close the wound with steri-strips.
B. pack the site with iodoform gauze.
C. close the wound with cutaneous removable sutures.
D. close the wound with subcutaneous absorbable sutures.

5. The patient returns 1 week post-op with a purulent drainage at the operative site. What is
the most likely reason for this?

A. There was trauma to the wound site.
B. The drainage is part of the normal healing response.
C. The surgical wound became infected from an extraneous source.
D. The original lesion was multilocular and was not drained completely.


Answers:
1. A 2. A 3. B 4. B 5. D

Scalpels

The No.11 is an elongated triangular blade sharpened along the hypotenuse edge and with a strong pointed tip making it ideal for stab incisions. Used in various procedures such as the creation of incisions for chest drains, opening coronary arteries, opening the aorta and removing calcifications in the aortic or mitral valves. The No.11 blades fit Handles 3, 3L, 3 Graduated, 5B, 7, 9, B3 and B3L.

The No.15 blade has a small curved cutting edge and is the most popular blade shape ideal for making short and precise incisions. It is utilised in a variety of surgical procedures including the excision of a skin lesion or recurrent sebaceous cyst and for opening coronary arteries. The No.15 fits Handles 3, 3L, 3 Graduated, 5B, 7, 9, B3 and B3L.

Forceps and Hemostats

Link: http://www.ehow.com/info_8143345_differences-between-forceps-hemostats.html#ixzz2m3NFh3KY

1. Haemostatic Forceps

   • This instrument which has a catch for locking its blades is utilized for clamping a blood vessel in order to control hemorrhage. Also termed artery forceps, these instruments are classically used by paramedics to prevent massive blood loss in seriously injured patients who are waiting to be transported to hospital.

   Kelly Forceps

   • Kelly forceps, also termed Rochester forceps, resemble a pair of household scissors, in which the blade has been replaced with a blunt grip. The Rochester forceps, which are available as either a curved or straight instrument, incorporate a locking feature, so as to function as a clamp. This forceps was designed for gripping and holding tightly onto tissue, including ruptured blood vessels.
   • Dressing Forceps
   • These forceps, which are most commonly used to hold and manipulate gauze and similar dressing material, are also used during autopsies. Dressing forceps may be curved or straight, and select models have the appearance of tweezers. The point or tip of these forceps is blunt, with a rough working surface, to offer grip. The dressing forceps are also used for debriding wounds (removing dying tissue and foreign matter) and when working with sutures (stitches).

   Alligator Forceps

   • These forceps, with their long shaft, are utilized for retrieving objects from within and between cavities in the patient's body. The shaft of these forceps is set at an angle to the grip, and they are designed to have a serrated tip, reminiscent of an alligator's mouth, from where the common name is derived. The tip of these forceps remains open until the grip (handles) are closed, which allows for efficient gripping of objects, even in difficult to access areas within a body undergoing surgery. Of interest, the serrated tips of this forceps do not damage living tissue, as one might imagine they would.

   Biopsy forceps

   • These forceps, which resemble domestic scissors, are available in both a locking and non-locking model and can be purchased with either a straight or angled shaft. Biopsy forceps were designed to grip and hold living tissue and are chosen when delicate and precision work is to be performed.

Tiotropium bromide (Spiriva)

Today's med: Tiotropium bromide (ty oh TRO pee um)  
(brand name: Spiriva HandiHaler) 

Snapshot:   

Use: COPD

·         Action:  long-acting, 24 hour, anticholinergic bronchodilator (Inhibits smooth muscle receptors, 

                     leading to bronchodilation)

·          SE: antimuscarinic effects; urinary retention, constipation, acute angle closure glaucoma, palpitations

·         CI: narrow-angle glaucoma, prostatic hyperplasia, urinaryretention, or bladder-neck obstruction.

Drug Class: Anticholinergic agent

Other Drugs in this class: Ipratropium bromide, Ipratropium bromide/albuterol, Glycopyrronium bromide, Atropine, Benzatropine, Tropicamide, Doxylamine, Dicycloverine, Tiotropium bromide monohydrate, Diphenoxylate/Atropine, Propantheline bromide, Dicyclomine hydrochloride, Benztropine mesylate, Methylscopolamine bromide, Mepenzolate, Mepenzolate bromide, Atropine/Hyoscyamine/Scopolamine/Phenobarbital, Difenoxin/Atropine, Propantheline, Chlorpheniramine/Methscopolamine/Pseudoephedrine, Pseudoephedrine/Methscopolamine, Phenylephrine/Methscopolamine/Chlorpheniramine, Chlorpheniramine/Methscopolamine, Atropine Sulfate, Edrophonium/Atropine

Indications: Maintenance treatment of bronchospasm associated with COPD (including bronchitis and emphysema); reduction of COPD exacerbations

Action:  Competitively and reversibly inhibits the action of acetylcholine at type 3 muscarinic (M₃) receptors in bronchial smooth muscle causing bronchodilation.  Poorly absorbed from GI tract, systemic absorption may occur from lung.

Contraindications: Hypersensitivity to tiotropium or ipratropium, or any component of the formulation (contains lactose)

Adverse Effects:>10%:

Gastrointestinal: Xerostomia (5% to 16%)

Respiratory: Upper respiratory tract infection (41%), pharyngitis (9% to 13%), sinusitis (7% to 11%)

1% to 10%:

Cardiovascular: Chest pain (1% to 7%), edema (dependent, 5%)

Central nervous system: Headache (6%), insomnia (4%), depression (1% to 4%), dysphonia (1% to 3%)

Dermatologic: Rash (4%)

Endocrine & metabolic: Hypercholesterolemia (1% to 3%), hyperglycemia (1% to 3%)

Gastrointestinal: Dyspepsia (6%), abdominal pain (5%), constipation (4% to 5%), vomiting (4%), gastroesophageal reflux (1% to 3%), stomatitis (including ulcerative; 1% to 3%)

Genitourinary: Urinary tract infection (7%)

Neuromuscular & skeletal: Arthralgia (4%), myalgia (4%), arthritis (≥3%), leg pain (1% to 3%), paresthesia (1% to 3%), skeletal pain (1% to 3%)

Ocular: Cataract (1% to 3%)

Respiratory: Rhinitis (6%), epistaxis (4%), cough (≥3%), laryngitis (1% to 3%)

Miscellaneous: Infection (4%), moniliasis (4%), flu-like syndrome (≥3%), allergic reaction (1% to 3%), herpes zoster (1% to 3%)

<1% (Limited to important or life-threatening): Angioedema; application site irritation (glossitis, mouth ulceration, pharyngolaryngeal pain); atrial fibrillation, blurred vision, candidiasis (oral), dizziness, dehydration, dry skin, dysphagia, gingivitis, glaucoma, hoarseness, hypersensitivity reactions, ileus (paralytic), intestinal obstruction, intraocular pressure increased, joint swelling, palpitation, paradoxical bronchospasm, pruritus, pupil dilation (if powder comes in contact with eyes), skin infection, skin ulcer, supraventricular tachycardia, tachycardia, throat irritation, urinary difficulty, urinary retention, urticaria

Concerns related to adverse effects:

• Bronchospasm: Rarely, paradoxical bronchospasm may occur with use of inhaled bronchodilating agents; discontinue use and consider other therapy if bronchospasm occurs.

• Hypersensitivity reactions: Immediate hypersensitivity reactions (urticaria, angioedema, rash, bronchospasm) have been reported. Discontinue immediately if signs/symptoms occur. Use with caution in patients with a history of hypersensitivity to atropine.

Disease-related concerns:

• Glaucoma: Tiotropium may worsen symptoms of narrow-angle glaucoma; use with caution.

• Myasthenia gravis: Tiotropium may worsen symptoms of myasthenia gravis; use with caution.

• Prostatic hyperplasia/bladder neck obstruction: Tiotropium may worsen the symptoms of prostatic hyperplasia and/or bladder neck obstruction; use with caution.

• Renal impairment: Use with caution in patients with moderate-to-severe renal impairment (Cl_cr ≤50 mL/minute); monitor closely for anticholinergic adverse events.

Other warnings/precautions:

• Appropriate administration: Not indicated for the initial (rescue) treatment of acute episodes of bronchospasm.

• Appropriate use: The contents of Spiriva® capsules are for inhalation only via the HandiHaler® device. Capsules should not be swallowed; there have been reports of incorrect administration (swallowing of the capsules).

• Avoid ocular contact: Avoid inadvertent instillation of powder into the eyes; may dilate pupils and/or cause blurred vision. 

Pregnancy Risk Factor C 

Standard Dosing:  Oral inhalation: Adults: Contents of 1 capsule (18 mcg) inhaled once daily using HandiHaler® device. Note: To ensure drug delivery the contents of each capsule should be inhaled twice.

 
Administration

Administer once daily at the same time each day. Remove capsule from foil blister immediately before use. Capsule should not be swallowed. Place capsule in the capsule-chamber in the base of the HandiHaler® Inhaler. Must only use the HandiHaler® Inhaler. Close mouthpiece until a click is heard, leaving dustcap open. Exhale fully. Do not exhale into inhaler. Tilt head slightly back and inhale (rapidly, steadily and deeply); the capsule vibration may be heard within the device. Hold breath as long as possible. If any powder remains in capsule, exhale and inhale again. Repeat until capsule is empty. Throw away empty capsule; do not leave in inhaler. Do not use a spacer with the HandiHaler® Inhaler. Do not use HandiHaler® device for other medications. Always keep capsules and inhaler dry.

Delivery of dose: Instruct patient to place mouthpiece gently between teeth, closing lips around inhaler. Instruct patient to inhale deeply and hold breath for 5-10 seconds. The amount of drug delivered is small, and the individual will not sense the medication as it is inhaled. Remove mouthpiece prior to exhalation. Patient should not breathe out through the mouthpiece.

Drug interactions:  Drug interactions Link

A total of 342 drugs (2481 brand and generic names) are known to interact with tiotropium.

• 340 moderate drug interactions (2475 brand and generic names)
• 2 minor drug interactions (6 brand and generic names)

Show all medications in the database that may interact with tiotropium.

DO NOT USE in cases of urinary retention, Myesthenia gravis, Prostatic hyperplasia/bladder neck obstruction, Glaucoma or renal impairment.

COPD: need to 'Tiotrate' your breathing (not for acute episodes)

Valsartan (ARB)

Snapshot from Phun Pharm facts
Angiotensin II receptor antagonist (ARB)
  Use: htn, safe in pts with impaired glucose intolerance

·         Action: blocking the binding of angiotensin II to the AT ₁ receptor in vascular smooth muscle and the adrenal gland, producing decreased BP.

·         SE:  headache and dizziness

·         CI: preg/lact

·          Interactions: Lithium, Potassium-sparing diuretics (eg, spironolactone), potassium supplements

Today's med: Valsartan (val SAR tan) 
(brand name: Diovan)

Drug Class: Angiotensin II receptor antagonist

Other Drugs in this class: Valsartan/hydrochlorothiazide, Losartan,Olmesartan, Irbesartan, 
Candesartan,Telmisartan, Losartan/hydrochlorothiazide,Azilsartan, Eprosartan,Telmisartan/hydrochlorothiazide, 
Losartan Potassium, Aliskiren/Valsartan,Candesartan cilexetil,Amlodipine/Valsartan/Hydrochlorothiazide,
Telmisartan/Amlodipine,Candesartan/Hydrochlorothiazide,Irbesartan/Hydrochlorothiazide,Amlodipine/Olmesartan,Olmesartan/Hydrochlorothiazide,Olmesartan/Amlodipine/Hydrochlorothiazide,Eprosartan mesylate, Amlodipine/Valsartan,Azilsartan kamedoxomil,Azilsartan/Chlorthalidone,Eprosartan/Hydrochlorothiazide, 
Olmesartan medoxomil

Indications: Alone or in combination with other antihypertensive agents in the treatment of essential hypertension; reduction of cardiovascular mortality in patients with left ventricular dysfunction postmyocardial infarction; treatment of heart failure (NYHA Class II-IV)

Action: Valsartan produces direct antagonism of the angiotensin II (AT2) receptors, unlike the ACE inhibitors. It displaces angiotensin II from the AT1 receptor and produces its blood pressure-lowering effects by antagonizing AT1-induced vasoconstriction, aldosterone release, catecholamine release, arginine vasopressin release, water intake, and hypertrophic responses. This action results in more efficient blockade of the cardiovascular effects of angiotensin II and fewer side effects than the ACE inhibitors.

Contraindications: Hypersensitivity to valsartan or any component of the formulation; concomitant use with aliskiren in patients with diabetes mellitus

Adverse Effects: >10%:Central nervous system: Dizziness (heart failure trials 17%)

Renal: BUN increased >50% (heart failure trials 17%)

1% to 10%:

Cardiovascular: Hypotension (heart failure trials 7%; MI trial 1%), orthostatic hypotension (heart failure trials 2%), syncope (up to >1%)

Central nervous system: Dizziness (hypertension trial 2% to 8%), fatigue (heart failure trials 3%; hypertension trial 2%), postural dizziness (heart failure trials 2%), headache (heart failure trials >1%), vertigo (up to >1%)

Endocrine & metabolic: Serum potassium increased by >20% (4% to 10%), hyperkalemia (heart failure trials 2%)

Gastrointestinal: Diarrhea (heart failure trials 5%), abdominal pain (2%), nausea (heart failure trials >1%), upper abdominal pain (heart failure trials >1%)

Hematologic: Neutropenia (2%)

Neuromuscular & skeletal: Arthralgia (heart failure trials 3%), back pain (up to 3%)

Ocular: Blurred vision (heart failure trials >1%)

Renal: Creatinine doubled (MI trial 4%), creatinine increased >50% (heart failure trials 4%), renal dysfunction (up to >1%)

Respiratory: Cough (1% to 3%)

Miscellaneous: Viral infection (3%)

All indications: <1% (Limited to important or life-threatening): Allergic reactions, alopecia, anaphylaxis, anemia, angioedema, anorexia, anxiety, chest pain, constipation, dyspepsia, dyspnea, flatulence, hematocrit/hemoglobin decreased, hepatitis (rare), impotence, insomnia, liver function tests increased, microcytic anemia, muscle cramps, myalgia, palpitation, paresthesia, photosensitivity, pruritus, rash, renal failure, rhabdomyolysis, somnolence, taste disorder, thrombocytopenia (very rare), vasculitis, vomiting, weakness, xerostomia

Concerns related to adverse effects:

• Hyperkalemia: May occur; risk factors include renal dysfunction, diabetes mellitus, concomitant use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salts. Use with caution with these agents; monitor potassium closely.

• Hypotension: During the initiation of therapy, hypotension may occur, particularly in patients with heart failure or post-MI patients. Symptomatic hypotension may occur upon initiation in patients who are salt- or volume-depleted (eg, those treated with high-dose diuretics); correct volume depletion prior to administration. This transient hypotensive response is not a contraindication to further treatment with valsartan.

• Renal function deterioration: May be associated with deterioration of renal function and/or increases in serum creatinine, particularly in patients with low renal blood flow (eg, renal artery stenosis, heart failure) whose glomerular filtration rate (GFR) is dependent on efferent arteriolar vasoconstriction by angiotensin II; deterioration may result in oliguria, acute renal failure, and progressive azotemia. Small increases in serum creatinine may occur following initiation; consider discontinuation only in patients with progressive and/or significant deterioration in renal function.

Disease-related concerns:

• Aortic/mitral stenosis: Use with caution in patients with significant aortic/mitral stenosis.

• Heart failure: Use caution when initiating in heart failure; may need to adjust dose, and/or concurrent diuretic therapy, because of valsartan-induced hypotension. Careful monitoring of BUN, serum creatinine, and potassium is necessary especially if preexisting renal disease exists.

• Hepatic impairment: Use caution in patients with significant hepatic impairment since clearance is significantly reduced.

• Renal artery stenosis: Use valsartan with caution in patients with unstented unilateral/bilateral renal artery stenosis. When unstented bilateral renal artery stenosis is present, use is generally avoided due to the elevated risk of deterioration in renal function unless possible benefits outweigh risks.

• Renal impairment: Use with caution with pre-existing renal insufficiency and severe renal impairment.

Concurrent drug therapy issues:

• Angiotensin-converting enzyme (ACE) inhibitors and renin inhibitors: Concomitant use of an ACE-inhibitor or renin inhibitor (eg, aliskiren) is associated with an increased risk of hypotension, hyperkalemia, and renal dysfunction. Concomitant use with aliskiren should be avoided in patients with GFR <60 mL/minute and is contraindicated in patients with diabetes mellitus (regardless of GFR).

Special populations:

• Pediatrics: Canadian labeling: Use is not approved in patients <18 years of age.

• Pregnancy: [U.S. Boxed Warning]: Drugs that act on the renin-angiotensin system can cause injury and death to the developing fetus. Discontinue as soon as possible once pregnancy is detected.

Pregnancy Risk Factor D

Standard Dosing: Oral:  Hypertension:

Children 6-16 years: Initial: 1.3 mg/kg once daily (maximum: 40 mg/day); dose may be increased to achieve desired effect; doses >2.7 mg/kg (maximum: 160 mg) have not been studied

Adults: Initial: 80 mg or 160 mg once daily (in patients who are not volume depleted); dose may be increased to achieve desired effect; maximum recommended dose: 320 mg daily

Heart failure: Adults: Initial: 40 mg twice daily; titrate dose to 80-160 mg twice daily, as tolerated; maximum daily dose: 320 mg

Left ventricular dysfunction after MI: Adults: Initial: 20 mg twice daily; titrate dose to target of 160 mg twice daily as tolerated; may initiate ≥12 hours following MI

Administer with or without food.

Drug interactions: http://www.drugs.com/drug-interactions/valsartan.html

A total of 376 drugs (1787 brand and generic names) are known to interact with valsartan.

• 43 major drug interactions (196 brand and generic names)
• 331 moderate drug interactions (1586 brand and generic names)
• 2 minor drug interactions (5 brand and generic names)

Show all medications in the database that may interact with valsartan.

ACE Inhibitors: Angiotensin II Receptor Blockers may enhance the adverse/toxic effect of ACE Inhibitors. Monitor therapy

Herbs (Hypertensive Properties): May diminish the antihypertensive effect of Antihypertensives. Monitor therapy

Herbs (Hypotensive Properties): May enhance the hypotensive effect of Antihypertensives. Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: Angiotensin II Receptor Blockers may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Nonsteroidal Anti-Inflammatory Agents may diminish the therapeutic effect of Angiotensin II Receptor Blockers. The combination of these two agents may also significantly decrease glomerular filtration and renal function.Monitor therapy

Yohimbine: May diminish the antihypertensive effect of Antihypertensives. Monitor therapy

Val's-ARB-tan.