Surgery Top 10 OnCall Scenarios

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SurgeryTop 10 On-Call Scenarios
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Case 1a

• You are the on-call intern covering the very busy
  general surgery service. At 2 am, the nurse pages
  you and informs you that Mr. Smith, who is POD1
  from a subtotal colectomy has a fever of 38.8.
  What is your approach to this patient and the
  workup?

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Case 1b

• You are on-call again 5 nights later. At 2 am,
  the nurse pages you to inform you that Mr. Smith,
  who is not POD6 from his colectomy has a fever
  of 39.6 and has rigors. He is also sweating
  profusely and his oxygen requirement has
  increased from 2L to 4L NC. What is the most
  likely problem and how should you, the intern,
  approach this situation?

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Case 2

• You have just completed your first uneventful
  appendectomy on a 12 yo boy. The attending
  informs you that she will speak to the family.
  Four hours later, you are doing a post-op check
  on your patient. His family is irate that no one
  came to speak with them and are demanding
  immediate audience with the attending surgeon and
  the hospital manager. What is your approach to
  this situation?

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Case 3

• You are on-call at a busy trauma hospital. During
  evening rounds, you note that a 25 yo man, HD2
  after sustaining multiple rib fractures, has a
  low BP and has saturations of only 80 on 5L NC.
  What should be your initial workup including what
  PE findings are you most interested in? What is
  the next step in management?

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Case 4

• You are asked by your chief resident, who is
  scrubbed in the OR, to evaluate the first patient
  who had a complicated Whipple earlier in the day.
  The patient is now 4 hours out from surgery. Her
  vitals appear normal, but you note that he has
  made only 30 cc of urine since leaving the OR.
  What is your workup and initial management?

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Case 5

• A 65 yo woman is POD5 from an extensive
  laparotomy for a large gastric tumor. At 2 am,
  the nurse calls you stating she is feeling short
  of breath. On evaulation, she is tachypnic, has a
  somewhat diminished BP and hypoxic with sats in
  the 60s on RA. The CT scanner is currently down
  and unavailable until 2 days from now. What is
  the next step in management?

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Case 6

• A 23 yo male undergoes an X-lap for a stab wound.
  During the case, he is found to have only a small
  bowel injury which is repaired. On POD2, he has
  a coughing fit and develops a small leak of clear
  fluid from his midline wound. Later that
  afternoon, you get called that after another
  coughing spell, there is a substantial amount of
  drainage from under the dressing and the dressing
  looks bulkier. What has happened and what is the
  management?

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Case 7

• A 75 yo man presents to the ED with perforated
  diverticulitis. Post-op, he is in the ICU for 4
  days and then transferred to your service. For
  the next 3 days, he is awake every night and has
  not taken much to eat despite having normal BMs
  and stopping IVFs. Now, on POD8 he is confused
  and aggitated. He alternates between being awake
  and asleep and is confused. What are the next
  steps in management?

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Case 8

• A 63 yo woman undergoes a Nissen fundoplication
  for reflux. Intra-op, she has some mild
  hypotension but not EKG findings. The next
  morning, she complains of sudden onset chest pain
  that started 5 minutes before you walked in. What
  is your differential and what is the workup?

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Case 9

• A 27 yo man is involved in a high-speed MVA and
  sustains a R femur fx, grade III liver laceration
  and large laceration to right leg. He is now
  POD6 after his femur repair and has yet to
  receive any blood products. On morning rounds, a
  routine labs demonstrate a Hct of 21. His nurse
  approaches you frantically telling you that she
  is drawing blood for a TC and that you should
  give him 2 units of blood. His VS are stable and
  feels well. What is your next move?

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Case 10

• A 52 yo woman undergoes a completion proctectomy
  for medically refractory Crohns colitis.
  Intra-op, she has a small serosal-only injury in
  the small bowel that is repaired without
  incident. Over the next 4 days she does great.
  The morning of POD5, she is about to be
  discharged when her O2 requirement increases to
  4L. The chief decides to keep her for an extra
  day. During the course of the day, her O2
  requirement continues to climb and she begins to
  have N/V. At noon she is 88 on a NRB and she is
  febrile to 40. What is your differential and plan.

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Extra Case

• A 42 yo man is admitted to the hospital for a SBO
  after a large GIST tumor resection 2 weeks
  earlier. His labs are noteful for a hct of 38.
  The next morning, he begins vomitting blood.
  Later that afternoon, he begins having projectile
  vomiting of bright red blood. He has a HR of 140
  and SBP 100. What is the next steps in management?

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