Case Synopses Gravitational Pressure Gradient of 10.0 cm H 2 O During a repeat L4–L5 lumbar laminectomy in the prone position, a 43-year-old woman arrested 45 minutes after onset of surgery with an unrecordable blood pressure (BP) and end-tidal CO 2 (ETCO 2 ) of 15 mm Hg. Rapid resuscitation efforts were successful, with ETCO 2 rising to 36 mm Hg, BP to 82/60 mm Hg,…
Case Synopsis A 35-year-old woman is scheduled for a partial colectomy due to complications from her ulcerative colitis. She has a history of migraine headaches, endometriosis, fibromyalgia, and nonspecific low back pain. She is currently on a high-dose oral opioid regimen. She is nervous, having catastrophizing thoughts about not surviving, and having chronic and difficult-to-treat pain after her surgery. Problem Analysis Definition Pain is defined by…
Case Synopsis A 45-year-old woman, body mass index (BMI) 24, American Society of Anesthesiologists (ASA) physical status 2, underwent left eye orbitotomy for the correction of thyrotoxic exophthalmos under general anesthesia in a freestanding ambulatory surgical center. The patient tolerated the procedure well without anesthetic complications. However, the surgery was unexpectedly difficult and lasted more than 2 hours. The estimated blood loss (EBL) was about 50…
Case Synopsis A 53-year-old man underwent posterior spinal fusion with instrumentation, involving segments L1–L4. His past medical history included protein S deficiency, for which he received warfarin therapy. He discontinued his warfarin therapy 2 weeks before surgery without telling his health care providers. His uneventful surgery lasted 8 hours. One hour postoperatively he became tachypneic, his blood pressure dropped from 130/80 to 88/50 mm Hg, and…
Case Synopsis A 14-year-old boy with an established diagnosis of autistic spectrum disorder is scheduled for a semielective release of hand contracture that he suffered as a sequela to a burn injury at age 5. He has had three prior surgeries and is known to have difficult emergence. Currently he is in the holding area obsessively playing a computer game on his tablet and ignoring requests…
Case Synopsis A healthy 32-year-old woman is scheduled for elective myomectomy. General endotracheal anesthesia is induced, and the surgeon requests a dose of prophylactic cefazolin. The anesthesiologist administers the contents of a 10-mL syringe but realizes immediately that he has given phenylephrine instead. He administers incremental doses of nitroglycerin to reduce the anticipated hypertension from the syringe swap. The patient suffers no apparent ill consequences. Problem…
Case Synopsis A 42-year-old man complains of shortness of breath and mild right-sided chest pain in the outpatient recovery area, shortly after a right wrist fusion. A preoperative ultrasound-guided brachial plexus block was placed using the supraclavicular approach. On examination, the patient’s respiratory rate is 20 breaths per minute, and his room-air saturation is 94%. His blood pressure and heart rate are normal. A chest radiograph…
Case Synopsis A 69-year-old man underwent open abdominal aortic aneurysm repair under general anesthesia. An epidural catheter was inserted before induction for postoperative pain control. The anesthesiologist successfully placed the epidural catheter after the third attempt. Aspiration after insertion of the catheter yielded a blood-tinged column that cleared when the catheter was pulled out by 2 cm. Despite using a relatively diluted mixture of local anesthetics…
Case Synopsis A 25-year-old woman undergoes spinal anesthesia with a 25-gauge Quincke needle for outpatient hysteroscopy. The following day, she complains of a severe headache. Her headache is worse when she is in the upright position and resolves when she is supine. Acknowledgment The author wishes to thank Dr. Matthew P. Feuer and Dr. Spencer S. Liu for their contributions to the previous edition of this…
Case Synopsis A 32-year-old woman, gravida 2, para 1, with a full-term pregnancy, undergoes general anesthesia for emergency cesarean delivery owing to prolonged fetal bradycardia. The patient receives a rapid-sequence induction using propofol and succinylcholine. The trachea is intubated using a 3.0 MacIntosh blade, cricoid pressure, and a styletted 6.5 endotracheal tube. After cesarean delivery, the patient is extubated and transferred to the postanesthesia care unit.…
Case Synopsis A hypertensive 76-year-old woman presents for total hip arthroplasty after sustaining a fractured neck of femur during a mechanical fall. After uneventful intravenous induction, anesthesia is maintained by spontaneous ventilation of a volatile anesthetic via a supraglottic airway device. Soon after positioning on the operating table, the patient becomes tachypneic. A few minutes after surgery commences, the patient develops hypoxemia, respiration becomes noisy, and…
Case Synopsis A 68-year-old man with a history of atrial fibrillation was scheduled for left total hip arthroplasty. He was chronically anticoagulated with 10 mg of rivaroxaban (Xarelto) daily to decrease his risk of stroke and thromboembolism, and this medication was stopped 72 hours before his arrival for surgery. Preoperative laboratory studies demonstrated a hemoglobin of 13 g/dL, a platelet count of 175 × 10 3…
Case Synopsis A 24-year-old primigravida underwent cesarean section for breech presentation under uncomplicated spinal anesthesia performed with a 27-gauge Whitacre needle. On the second postpartum day, she complained of a severe, diffuse headache. On the third postpartum day, she suffered a grand mal seizure. The obstetrician believes the headache is a spinal headache, and the anesthesiologist is consulted. Problem Analysis Definition Postpartum headache has been defined…
Case Synopsis A 49-year-old man weighing 125 kg is scheduled for decompression laminectomy and instrumented fusion of the lumbar spine at multiple levels for lumbar stenosis. General anesthesia proceeds uneventfully with prone positioning, and the patient’s face and eyes are protected from direct pressure with a horseshoe headrest. Somatosensory evoked potentials are monitored intraoperatively. The surgery lasts 8 hours with an estimated blood loss of 2.5…
Case Synopsis A 73-year-old man undergoes total hip arthroplasty performed under spinal anesthesia using 1.5 mL of 0.75% bupivacaine (11.25 mg) with 100 μg of morphine. The patient receives approximately 1500 mL of intravenous fluids during the 2-hour procedure. After 3 hours in the recovery room, he complains of moderate bladder fullness and strains to void 150 mL of urine. A postvoid ultrasound evaluation reveals a…
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Learning Objectives Learn the common causes of finger pain. Develop an understanding of the anatomy of the digital nerves. Develop an understanding of the unique clinical presentation of glomus tumor of the finger. Develop an understanding of the differential diagnosis of finger pain. Learn how to use physical examination to identify glomus tumor of the hand. Develop an understanding of the treatment options for glomus tumor.…
Learning Objectives Learn the common causes of finger pain. Learn the common causes of finger numbness. Develop an understanding of the unique relationship of the digital nerve to the bones of the fingers. Develop an understanding of the anatomy of the digital nerves. Develop an understanding of the causes of plastic bag palsy. Develop an understanding of the differential diagnosis of plastic bag palsy. Learn the…
Learning Objectives Learn the common causes of trigger finger. Develop an understanding of the unique anatomy of the flexor apparatus of the finger. Develop an understanding of the causes of trigger finger. Develop an understanding of the differential diagnosis of trigger finger. Learn the clinical presentation of trigger finger. Learn how to examine the finger and associated tendons. Learn how to use physical examination to identify…
Learning Objectives Learn the common causes of hand pain. Learn the common causes of hand deformity. Develop an understanding of the unique anatomy of the palmar fascia. Develop an understanding of the differential diagnosis of Dupuytren contracture. Learn to identify the underlying diseases associated with Dupuytren contracture. Learn the clinical presentation of Dupuytren contracture. Learn how to examine the hand to identify Dupuytren contracture. Learn how…