Writing Question
Part 1
CASE STUDY 1
(Required) Select the tabs to review the patient medical report. Detailed discussion questions follow below.
Identify one or two medical terms in this report. Deconstruct the components of specific medical terms to identify their meanings. In addition, please pay attention to the spelling and pronunciation of the words.
Operative Report
- The patient, Stephen Mulberry, is the subject of this case study.
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Acute cholecystitis
- Acute cholecystitis with partially gangrenous gallbladder
- Laparoscopic converted to open cholecystectomy
General
150 cc
100 cc
2500 cc of lactated Ringer’s
None
A partially gangrenous but mostly inflamed gallbladder with up to 1 cm thick gallbladder wall and multiple (greater than 50-100) small stones, each measuring approximately 2-4 mm
The patient was brought into the OR and placed in the supine position on the operating table. After successful endotracheal intubation, general anesthesia was safely achieved. His entire abdomen was prepped with Betadine and draped in a sterile fashion. A 2.5-cm supraumbilical transverse incision was made for placement of a Verres needle to achieve pneumoperitoneum and the intra-abdominal cavity was insufflated with CO2 with difficulty. After the fascia on each side of the midline was secured with stay sutures, a knife blade was used to open the fascia and the 10-mm trocar was placed at this site. Upon insertion of the laparoscopic camera, no bowel injury was detected. A 10-mm trocar was then placed in the epigastric position at the midline. Two 5-mm ports were placed in the right upper quadrant, one around the nipple line just below the costal margin and the other around the anterior axillary line again below the costal margin. Through one of the 5-mm ports, an endoscopic needle attached to a 60-cc syringe was inserted in order to aspirate the content within the lumen of the gallbladder, which appeared to be extremely inflamed with what appeared to be a very thick peritoneal layer around the gallbladder.
Further dissection was made with a dissector introduced through the epigastric port. When the dissection was carried out down to the level of the gallbladder neck/cystic duct junction, the inflammation of the tissue around this region was so severe that it precluded a safe dissection of this area. The operation was therefore converted from laparoscopic to open cholecystectomy.
After the instruments and trocars, as well as the camera, were withdrawn from the incision sites, a skin incision was made between the epigastric site and the superior right upper quadrant 5-mm port site. The peritoneum was safely entered through this right subcostal incision. A Michotte retractor was placed cranially in order to retract the superior part of the operative field. Prior to opening the subcostal incision, the umbilical port site was closed at the fascial layer using a figure-of-eight suture. With the Michotte retractor in place, the superior portion of the wound was retracted open and several Mikulicz pads were placed within the abdomen to push the small bowel, colon, and stomach away from the operative field. A Kelly clamp was then placed over the fundus of the gallbladder and the peritoneum was scored with electrocautery. The gallbladder was then dissected off of the liver bed using electrocautery from the fundus down toward the neck. Portions of the peritoneal layer were approximately 1-cm thick. Several neovascularizations were noted within this thickened, inflammatory layer of tissue. Hemostasis was achieved using electrocautery. Several larger vessels from the neovascularization were ligated off with suture ties. Much of the gallbladder was shelled off of this inflammatory layer on the liver bed. The cystic artery was identified and ligated and divided between sutures. The cystic duct was also identified. The cystic duct/gallbladder neck junction was clearly identified in a retrograde fashion. The bottom of the gallbladder neck was clamped with a right-angle clamp, and the cystic duct/gallbladder neck junction was ligated with 2-0 silk tie. An additional 2-0 silk tie was placed to reinforce the ligature. The gallbladder was then resected and opened on the back table and sent to pathology. After successful resection of the gallbladder, the liver bed was inspected for any site of hemorrhage. The operative field was irrigated with antibiotic-soaked solution. A JP drain was then placed within the liver bed and brought out through the inferior right upper quadrant trocar site and secured to the skin with a suture.
After adequate hemostasis was achieved and confirmed, the irrigation fluid was aspirated from the abdominal cavity and the surgical wound was closed using PDS sutures. The skin was approximated using a skin stapler. All of the wounds were dressed with sterile gauze and secured with Tegaderm dressing. The patient tolerated the procedure well and there were no complications. The patient was extubated at the end of the case. All sponge and instrument counts were correct at the end of the case.
CASE STUDY 2
Bernard Collins is a 75-year-old male who has a long history of trouble urinating, along with frequent urinary tract infections. One month ago, an IVP done on February 2, 2010 showed a distended urinary bladder with a large postvoid residual. His symptoms include hesitancy and a decrease in the strength and force of his urinary stream. Physical exam reveals the prostate to be smooth, benign, and approximately 50 g in weight. We will discuss treatment options with the patient, including a TURP, when he returns in 1 week for follow-up.
Question 1
After reviewing the Operative Report of Stephen Mulberry (Case Study 1) and provide the following in your post.
Please make a short summary of the case. What procedure was intended? Why did it have to be converted? What were the abnormal findings? Be sure to explain any medical terms used in your response.
Reviewing the operative report, identify some key diagnosis and organs investigated during the procedure.
Question 2
Review the Outpatient Office Encounter for Bernard Collins (Case Study 2) and provide the following in your post.
Explain to Bernard in a way that he can understand what has happened to his prostate gland as a result of aging.
Question 3
General questions:
Describe the primary functions performed by digestive and urinary systems.
What are the structures of the digestive system?
What are the structures of the urinary system?
Part 2
CASE STUDY 1
Outpatient Office Encounter
The patient, Mrs. Elaine Markus, is a 37-year-old woman with a history of migraine headaches and visual field disturbances.
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Mrs. Elaine Markus is a 37-year-old woman with a history of migraine headaches and visual field disturbances. She has a left medial lower quadrant defect (an area of reduced visual function) that was noted in December of 2014 and has been stable. She recently developed a right temporal lower quadrant defect, which was first noted in September of 2019 and has had worsening symptoms in October.
An MRI in November showed a normal study of the brain including visual cortex and periventricular white matter, with a normal study of the orbits, optic nerves, and extra ocular muscles. A pituitary microadenoma (small benign tumor of the pituitary gland) of approximately 3 mm on the left side of the gland was found with no compromise of the optic chiasm. Mrs. Markus underwent further evaluation by MRI with pituitary cuts and the microadenoma was again noted left of midline causing no compression of the optic nerves nor invasion of the cavernous sinus. The microadenoma is approximately 5 mm.
Past medical history is also significant for depression, asthma, and a hiatal hernia. Her current medications include Prozac, Imitrex, and Azmacort MDI.
In summary, Mrs. Markus is a patient with an incidentally noted pituitary microadenoma on MRI. This is reportedly new when compared with prior studies. We cannot explain the new visual field disturbances except for the adenoma. A pituitary workup has been initiated and her prolactin level is mildly elevated, but this can be secondary to her medications, especially Prozac, which can cause hyperprolactinemia. Thyroid function is normal, and a growth hormone test level is pending. I will proceed to rule out hypercortisolemia and Cushing’s disease.
CASE STUDY 2
Outpatient Office Encounter
Howard Solo is a 65-year-old patient and a retired airline ground maintenance technician. He worked for 40 years for American Airlines. He complains of tinnitus and hearing loss that have worsened over the past year. An audiogram was obtained on July 24, 2009 at the time of the patient’s initial visit. This audiogram revealed an average 75 dB (decibel) hearing loss through the speech frequencies in the right ear with an average loss of 80 dB loss in the left ear.
Question 1
After reviewing the Outpatient Office Encounter of Elaine Markus (Case Study 1) and provide the following in your post.
Perform a quality assessment of the medical terminology used by identifying one or two terms that may be inaccurate or confusing within the context of the case presented.
Question 2
After reviewing the Outpatient Office Encounter of Howard Solo (Case Study 2) accomplish the following and report in your findings and comments in your post.
Discuss how you would classify the type of hearing loss that Howard has experienced. Include the degree of severity of hearing loss based on the results of the audiometry. What kind of treatment would you recommend?
Question 3
General questions:
Define the parts of the brain.
Name and define the cranial nerves I-XII.
Part 3
Your next writing assignment is a paragraph that is due at the end of this week. For this assignment, you will have an opportunity to tap into your creative side and write about something you enjoy that takes place in an imaginary world. To begin with, please read the following three selections from Chapter 14 of Common Ground (pp. 273–278).
“Escaping the Fact-Filled World”
“Why I’m a Gamer”
“With Fantasy, Opportunities are Endless”
Let’s begin this week’s discussion by sharing our impressions of these three readings with a goal that further conversation will help us determine the best approach for our own paragraph. Of the three reading selections, which one did you find yourself relating to more closely? Did any of them inspire your own memories or experiences of a fantasy activity?
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