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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recommend appropriate antimicrobial prophylaxis for a given surgical procedure.

  • Discuss the timing of antimicrobial prophylaxis for surgery, including doses prior to surgery and dosing after surgery.

  • Describe the controversy regarding mechanical bowel preparation prior to colorectal surgery.

  • Identify the pros and cons to using oral antimicrobial decontamination prior to colorectal surgery.

  • Evaluate the need for perioperative β-blocker therapy in a specific surgical patient.

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PATIENT PRESENTATION

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Chief Complaint

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“I have colon cancer and I’m here for surgery.”

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HPI

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Edward Adler is a 72-year-old man who was recently diagnosed with anemia and generalized weakness. The workup for anemia included a colonoscopy, which showed a malignant neoplasm of the proximal ascending colon. The neoplasm was identified, and the biopsy revealed moderately-differentiated adenocarcinoma. The patient denies any current abdominal pain or change in bowel habits, but reports a 20-lb weight loss over the past several months. He is eating but has less of an appetite than normal.

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PMH

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Positive for HTN, CAD, TIA, and chronic rhinitis; also mild osteoarthritis, for which he has required no regularly scheduled medications in the past. History of gastritis and anemia.

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PSH

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Tonsillectomy, left inguinal hernia repair, colonoscopy with biopsy.

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SH

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Positive for smoking history of one half of a pack daily; quit 20 years ago.

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Meds

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  • Atenolol 100 mg PO daily

  • Hydrochlorothiazide 12.5 mg PO daily

  • Atorvastatin 40 mg PO daily

  • Sertraline 100 mg PO daily

  • Omeprazole 20 mg PO daily

  • Aspirin 81 mg PO daily

  • Triamcinolone nasal spray, two sprays in the morning

  • Ferrous sulfate 325 mg PO TID

  • Multivitamin one PO once daily

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All

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None

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ROS

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  • Cardiopulmonary: Denies chest pain, shortness of breath, or wheezing.

  • Gastrointestinal: Denies history of hepatitis, ulcers, or jaundice.

  • Genitourinary: He has no history of hematuria or renal calculi.

  • Musculoskeletal: Positive for arthritis of both wrists and hands.

  • Psychiatric: Positive for some depression.

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Physical Examination

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Gen
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He has the appearance of a normally developed white man who appears his stated age. He is alert, awake, and in no obvious distress.

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VS
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BP 132/86 mm Hg, P 68 bpm, RR 11, T 37.1°C; Wt 69 kg, Ht 172.7 cm

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Skin
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Warm and dry. Multiple seborrheic dermatomes over the abdomen and chest.

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HEENT
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Face reveals no asymmetry. Pupils are equal. Eyes have no icterus or exophthalmus, extraocular muscles intact. He is wearing corrective lenses.

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Neck/Lymph Nodes
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