Patients present with clinical problems, not with defined diseases. This book discusses common clinical problems encountered in surgical practice, how to solve these problems and how to devise a plan to manage them expeditiously and safely. Experienced clinicians approach diagnosis and management in sequential steps. They first try to define the patient’s major clinical problem. This may be expressed as a symptom (back pain, intermittent claudication, dysphagia), a physical sign (goitre, hepatomegaly, swollen leg) or a grouping of symptoms and signs comprising a definable syndrome (renal injury, anaemia, acute abdomen, hyperthyroidism). The problem may seem focal or regional (a lump or an ulcer, nipple discharge, hernia); this often has operative surgical implications but may indicate merely a focal manifestation of a systemic problem.
After defining the main problem, its common causes are considered. If the clinical pattern matches the usual pattern of one of these common causes, a provisional diagnosis is rapidly made on the basis of the clinician’s previous experience and knowledge. If all aspects do not fit the usual pattern of a common cause, it will be necessary to consider other and less common causes or the possibility of more than one disease process. Remember, it is more common to see an unusual presentation of a common disease than a rare disease. While Occam’s razor encourages us to explain all the patient’s problems with a single diagnosis this is not always possible. A differential diagnosis should also be considered, especially if a single diagnosis is not immediately apparent. Also, with the current ageing population having numerous pre-existing condi-tions, it is possible that a given patient may indeed have more than one diagnosis. Assessment often also requires application of biochemical, imaging and other tests to clinch the diagnosis. Identification of one or more major problems comprises the basis of clinical diagnosis.
A systematic history is taken as a secondary exercise. This aims to detect the presence of concurrent diseases that might need treatment or might influence surgical management, and to check for possible complications and predispositions (secondary problems) of the disease causing the main problem. The mature clinical approach is therefore quite different from the systematic ‘questionnaire’ often used by students. It is empirical, eclectic and sharply focused. It is continually audited and refined as one’s clinical experience grows, new knowledge is assimilated and clinical judgement improves. It seeks to discard as rapidly as possible unhelpful clinical ‘noise’ while maintaining sympathetic communication with the patient.
As clinicians seek a recognisable pattern during the clinical history, examination and subsequent investigations, they often build a composite diagnostic picture in a step-wise fashion, using if–then hypotheses (if the lump is in the thyroid then it should move on swallowing) and yes–no answers. Treatment plans often proceed in the same manner in an integrative sequence (if shock is solely hypovolaemic then it will respond to identifying and stopping the volume loss and refilling the vascular tree). In emergency situations, treating the major problem (e.g. cardiac arrest) must precede specific diagnosis of the cause. These processes can be represented by a decision tree or algorithm; the algorithm pathway leads the clinician along correct pathways of management. This method is particularly valuable in formalising clinical practice among doctors working together in a group and often provides protocols to guide medical staff about short segments of management. In practice, the method has limitations when applied to the clinical student who needs to develop the skill of clinical reasoning and to understand the genesis of the algorithm. Each step or branch in the diagnostic and treatment pathway requires weighing of alternatives (which, if any, investigations are required for this patient with acute abdominal pain?). Weighting is influenced by: knowledge of the prevalence, natural history, common presentations and prognosis of various diseases; the patient’s age and the presence of associated diseases or complications; the sensitivity, specificity, predictive value, cost and availability of investigative tests or procedures; and the experience and skill of the clinician. To acquire this database takes time and effort.
Doctors also vary considerably in their sense of comfort and confidence in reaching a diagnosis on the evidence available from history, physical examination and investigations. Ultra-cautious individuals, and those lacking in experience and judgement, tend to continue to accumulate clinical and investigative data in support of a definitive diagnosis even though each additional test will not significantly alter the treatment plan. Medical students need to develop an appreciation of the natural history and prognosis of individual problems and their causative diseases and an ability to accurately define the patient’s problem while maintaining a holistic approach to the unique requirements of the individual patient. This is best achieved by taking every opportunity to see as many patients as possible and by being involved with the treating team. These aspects usually require an in-depth consideration of the various causes of common problems. The learning curve from this exercise progressively improves the student’s ability to derive and shape diagnostic and treatment plans. This book aims to help the medical student answer the questions raised at each branch of the decision tree and to construct an appropriate pathway of management for each clinical problem.
Identifying the main problem can be quite difficult. Defining major problems and eliminating distracting elements demands accurate knowledge of the probable significance of various symptoms and signs – which are important and which are not. Therefore, dysphagia is always likely to be a significant major problem, backache much less commonly so. Difficulties in obtaining a coherent picture may be due to the ques-tioner’s inexperience, to language problems or to the patient’s abnormal mental state. Symptoms such as pain can often by best categorised by using the site of the pain and the mode of onset to define the problem (e.g. acute right iliac fossa pain). A major problem in one clinical circumstance can be a secondary complication in another situation. Two examples follow.
1. Iron deficiency anaemia, discovered in a patient who is otherwise asymptomatic or suffers from vague deterioration in health, is a very significant clinical problem. Anaemia found in a patient presenting with increasing constipation is secondary to the main problem of altered bowel habit. Anaemia in this instance suggests that the main problem is caused by a colonic cancer (Fig 1) and that preoperative preparation needs to include correction of anaemia to improve the safety of surgery.
2. The symptom of weight loss is relatively uncom-mon as a sole clinical problem. In community practice, weight loss may be a presentation of endogenous depression, but may be an early sign of organic disease. In hospital practice weight loss is commonly associated with major clinical problems and again has important diagnostic and therapeutic connotations. Unexplained weight loss requires a thorough clinical search for the underlying cause, which may not always require a surgical solution. Marked weight loss associated with jaundice suggests a malignant cause. Under these circumstances it may either be an indication for preoperative nutrition in preparation forsurgery or a sign of advanced disease and potentially a contraindication to surgery. Many problems may increase the risk of surgical procedures and will need assessment by a careful systems review and the appropriate investigations.
Figure 1 Iron deficiency anaemia may be A: the primary presentation of an occult carcinoma of the caecum; B: a secondary problem when carcinoma of the sigmoid presents with altered bowel habit
Broadly similar problems often have strikingly different causes. A patient bleeding from the gastro-intestinal tract per anum may either: present merely with symptoms of anaemia (occult bleeding); have passed a large tarry stool (melaena); have had several bowel actions consisting almost entirely of copious fresh blood (acute colonic haemorrhage); or merely have noted blood on the paper or pan, with or without pain, during a bowel motion (defaecatory bleeding). The common causes (and treatments) of these various presentations are quite different. Once gastrointestinal bleeding via the anus is recognised to comprise at least four different syndromes (problems), diagnosis of the most likely cause is considerably enhanced as are treatment plans for each problem (Fig 2).
Figure 2 Forms of presentation of gastrointestinal blood loss A: melaena from a duodenal ulcer; B: occult blood loss and anaemia from a caecal carcinoma; C: acute colonic haemorrhage from diverticular disease; D: defaecatory bleeding from haemorrhoids
Students usually begin clinical medicine by taking complete case histories. The initial objective is not primarily to make a diagnosis but to establish communication and rapport with the patient and to learn the basic skills of interview and examination. Many textbooks concentrate on these skills while others are encyclopaedias of disease with detailed descriptions of potential diagnoses. Both are essential educational aids for students, but experienced clinicians prefer to adopt a semi-automatic process of problem definition and interpretation derived from the history and physical examination, aided by a few investigations. This book aims to help the student to achieve this. The various forms of disease presentation may be difficult to derive from reference texts. An account of a specific disease such as duodenal ulcer certainly will include a description of clinical features and complications. Duodenal ulcer can present as chronic dyspepsia or with various complications – an acute exacerbation, perforation, stenosis or haemor-rhage (Fig 3). This text will discuss, not duodenal ulcer as such, but rather the problems of acute and chronic epigastric pain, the acute surgical abdomen, haematemesis and melaena, and vomiting. For each of these presentations duodenal ulcer is discussed as a possible cause, but the disease is considered secondarily – as one of the common causes of these forms of presentation – and with the perspective and weighting appropriate to the likelihood that duodenal ulcer is causing the problem. The clinical problem with which a disease presents largely determines the approach to management.
Figure 3 Forms of presentation of duodenal ulcer A: haemorrhage presenting as haematemesis and melaena; B: pyloric stenosis presenting as vomiting; C: perforation presenting as an acute abdomen. Duodenal ulcer most commonly presents as chronic epigastric pain.
Defining the major problem (e.g. haematemesis with shock) is often the most critical step to be made in planning early diagnosis and effective treatment. Associated shock is a major determinant of the likely need for early surgery in the patient presenting with upper gastrointestinal bleeding. Over a time interval varying with the urgency of the case, optimal resus-citation is achieved, the cause is diagnosed as rapidly as possible, concurrent medical illness is controlled and the correct surgical procedure is performed for the pathology found. The patient must always be made as safe as possible for surgery: we have therefore included discussion of common and important medical dis-orders that influence surgical management and determine surgical risk.
These examples indicate that definition of clinical problems is not just a matter of identification. Their diagnostic and therapeutic significance must be recognised and weighed (and often qualified by associated problems influencing the degree of surgical risk).
Focusing on the problem rather than the disease demands six main steps.
1. Identify and define the clinical problem(s). Begin emergency treatment of life-threatening complications.
2. Consider common causes.
3. Compare the patient’s problem with the usual clinical pattern of the common causes.
4. Review less common causes.
5. Check for associated problems, predisposing causes and determinants of surgical risk.
6. Choose diagnostic and treatment plans.
The book follows this format. Individual chapters describe methods of diagnosis and treatment for each presenting problem. Individual diseases are discussed in detail when the problem under question represents the most common presentation of that disease. Selective guides to history-taking and examination, relevant to a region or system, introduce related problem groups. In our medical curriculum, an introductory period – concentrating on the clinical skills of com-munication methods, history-taking and physical examination – is accompanied by and integrated with the introduction of concepts of clinical problem solving evolving to a progressive appreciation of disease processes and their management and prevention, with the senior students becoming members of the surgical team during clinical rotations. These techniques formed the basis of surgical teaching and clinical clerking within surgical rotations in the previous six-year medical course at Monash University. With the advent of integrated medical teaching at Monash University and other medical schools the benefits of discipline-specific teaching have come into question. The presentation of clinical problems in surgery serves as a tool to develop clinical reasoning that will be applicable to other areas of practice and experience, and ensures that important principles of practice best illustrated in a surgical context are maintained, such as the acute abdomen. There is also ample confirmation of the need to integrate basic surgical science into clinical practice, particularly anatomy, physiology and pathology.
The problem-oriented clinical approach
Identifying patients’ clinical problems is integral to helping them. Accurate documentation is important in clarifying a clinician’s diagnosis and in management planning and communicating with other staff in the health care team. It aids clinical reasoning, at least in part, by making it explicit.
The problem-oriented clinical approach (POCA) is a useful tool, helping to organise clinical data in a logical manner by identifying problems that need to be solved in a format that makes problem solving easier. A POCA records the data and the problem-solving process in a coherent and readily retrievable way.
Like many tools, the POCA is potentially cum-bersome; one must ensure that the system remains subservient to its purpose of aiding communication and patient care, data-recording and education. Its purpose is served if information is gathered such that the active major problem is correctly identified, a prompt diagnosis is made and the best and safest solution of the problem is chosen.
The active major problem may be associated with a complication or subsidiary disorder that in itself often requires attention before definitive surgery. Therefore, a secondary problem of cholangitis in a patient presenting with jaundice will modify management significantly (Ch 7.15). Patients frequently have associated medical problems (Ch 10) that, although inactive, influence treatment. In the surgical patient these are of great relevance to the safety of surgery. For example, chronic obstructive pulmonary disease (COPD) is a frequent contributor to morbidity and mortality after surgery.
The POCA begins with a list of major clinical problems derived from the database as follows.
1 Collect and record the database
Take a history and examine the patient
A good history and examination are obtained by a combination of:
• logical interpretation of the gathered data as it emerges and following up leads
• a thorough ‘screening’ of areas not included in the preceding information.
Adequate screening requires a full systems review, family history, past history, social history and recent medications. The past history may reveal antecedent symptoms that are harbingers of the current illness; these thereafter will be considered as part of the history of the present illness. Additional data may be obtained from relatives, from previous records or other treating practitioners, or from laboratory or imaging investigations.
Record the data in a systematic manner
This will minimise omissions, aid in the retrieval of data and help to emphasise important aspects.
The following student POCA exemplifies the system (headings bolded):
1. Record the main complaint.
Severe, generalised abdominal pain for the past eight hours.
2. Write a patient profile. This should be a brief pen portrait of the patient, setting the problem(s) in a socioeconomic context. Such things as cultural heritage, occupation, marital status and housing may be relevant.
Mrs S, a 64-year-old pensioner, lives alone in her own house in South Melbourne. Her husband, a carpenter, died six years ago. She has a supportive family of three grown children all living in Melbourne.
3. Record all the subjective data (S) relating to the present illness or illnesses. This should be arranged chronologically and should note any subsidiary problems complicating the major active problem – particularly any demanding immediate attention. Subjective (S) can be used as a synonym for history and objective (O) for the physical examination and the laboratory, radiological or other objective findings. A flowchart can be a very useful way of documenting a long and complicated illness with frequent admissions.
4. Record risk factors, systems review, past history and family and social history under separate headings.
Certain diseases have characteristic risk factors (e.g. vascular disease – smoking, diabetes). It is often helpful to list whether the patient in question has one or more of the known risk factors for the disease, both prospectively and after a clinical diagnosis has been made.
5. Objective data (O): record the physical examination findings of systems relevant to the presenting problem, including important associated problems as well as findings in other systems of importance in management (e.g. those relevant to safe anaesthesia and surgery, such as cardiovascular status).
6. Record any other objective data from laboratory investigations and previous records.
The data on Mrs S is developed (with parenthesised explanatory notes) as follows.
History of the presenting complaint
Subjective data (S)
Mrs S has been admitted because of severe periumbilical pain of sudden onset, which then spread to involve the whole abdomen over the next several hours. She noticed pain also in the left shoulder. Any movement made the pain worse. Her local doctor was called (LMO – Dr T) and referred her to hospital. She has no previous history of abdominal pain.
Systems review has arthritis affecting hands and feet; moderate hand deformities cause some disability and pain requiring active treatment (this seems to warrant a place as a separate, active problem). No other relevant symptoms on systems review.
(An analysis of the past history might have revealed that the present illness manifested itself years in the past; previous symptoms suggestive of a longstanding history of duodenal ulcer would have become part of the history of the presenting complaint.)
Past history
(a) Rheumatoid arthritis for eight years – mainly hands and wrists (this will be discussed in the current problem list). On analgesics and nonsteroidal anti-inflammatory agents (this fact could be a risk factor for the main problem).
(b) In hospital last year with a myocardial infarct, there were no complications or sequelae (this may, however, be relevant to her current problem, especially if surgery is needed).
(c) Tonsillectomy as a child (this seems both inactive and irrelevant to the main problem; leave it as past history).
Risk factors – takes anti-inflammatory agents for rheumatoid arthritis; no history of cigarette smoking.
Family and social history – parents both dead: mother stroke, father old age; social history, as above.
Medications (agents, indications, dosage and side effects) – ibuprofen (‘Brufen’) 400 mg tds: nonsteroidal anti-inflammatory drug; aspirin i-ii qid prn: analgesic.
Objective data (O)
Now (six hours after onset): in severe pain. On exami-nation: generalised, marked abdominal tenderness and board-like guarding and rigidity. Silent abdomen with absent bowel sounds. Rectal exami-nation normal. Not shocked, BP 120/70, P 90, regular, T 37.1 C.
(At this point in the record a brief account can be given of the examination findings of other systems relevant to the surgical management of the current problem. These aspects appear subsequently in the record as separate problems where discussion concentrates on their management and significance in the longer term. In this instance the past history of myocardial infarction indicates that protection of cardiovascular function is of particular relevance to safe and successful surgical treatment.)
Cardiovascular assessment: no hypertension, heart not enlarged, no signs of heart failure, heart sounds normal, no murmurs.
(A brief summary of the remainder of the physical examination can also be set down at this point in the record – see later.)
Investigations to date: A plain X-ray of the chest and abdomen showed free gas under both sides of diaphragm.
(Other radiological studies and additional inves-tigations will appear under a subsequent assessment and diagnostic plan unless they are immediately available.)
2 Constructing a problem list
Constructing a problem list is the key to a good problem-orientated medical record (POMR). Identifying problems is the most important step in analysing the database so that a diagnosis can be made and the correct treatment chosen.
First, there will be the presenting problem that may, by this stage, be a precise diagnosis (e.g. perforated duodenal ulcer) or may be a symptom (e.g. acute upper abdominal pain) or a sign or a sign/syndrome/symptom complex (e.g. ‘acute abdomen’, shock, ‘peritonitis’). This depends on the stage at which the patient is assessed. The problem recorded should be the most specific statement that can be made about the clinical state or diagnosis at that time.
Then, any other significant problems derived from the database should be listed, all with a number and a title. Problems may be active (A) or inactive (IA) and this should be recorded on the problem list along with the date of onset. Other problems judged to be of little current significance may be left noted in the past history.
Mrs S’s problem list at the end of the history and examination, before investigations, was outlined as:
Some useful hints on making a problem list are:
The list must be flexible enough to take account of changing situations; however, stability is desirable because subsequent records will relate to the established list.
If possible, make the problem list simple. Only list major or significant problems; do not fragment the list by dividing one problem into many problems when they are time-related and clearly all likely to be the symptoms or complications of one disease. If several problems can be grouped into one major problem with several manifestations or presentations, use this approach. The various manifestations of malignancies or vascular or metabolic diseases often lend themselves to this approach. For example:
Carcinoma of the left breast with metastases
• left pleural effusion A
• cerebral metastases – increased intracranial pressure A
• pathological fracture of right femoral neck A
or
Atherosclerotic vascular disease
• ischaemic heart disease
• congestive heart failure (presenting problem) A
• previous myocardial infarct (2008) IA
• left cerebral haemorrhage (2008): residual right hemiplegia
or
Insulin-dependent (type 1) diabetes mellitus
• presenting problem
• ketoacidosis A
• associated urinary tract infection A
• retinopathy
• peripheral neuropathy IA
If the nature of a problem becomes clearer, change the title but keep the number.
If the problem list is unhelpful or becomes incoherent as the real story unfolds, it should be changed.
3 Assessment and plan
The next step is to record the initial assessment (A) and plan (P) for each active problem. The plan combines diagnostic and treatment components. Returning to the sample case:
# 1 Acute abdomen
A. Acute abdomen with generalised peritonitis. Free gas under the diaphragm indicates a perforated viscus. Perforated duodenal ulcer is the most likely diagnosis. No signs of severe dehydration or shock.
P. Requires urgent laparotomy after preoperative preparation by IV fluid replacement, nasogastric intubation, prophylactic antibiotics and subcutaneous heparin.
The treatment plan in a surgical patient can be organised as follows:
• the preparation necessary before any planned operation
• the control of concurrent medical illness
• the operative procedure and findings.
Measures used to control concurrent medical illness should be briefly detailed and the clinical response of the patient noted. For example, Mrs S might have been on long-term steroid treatment for her arthritis. Consideration of possible side effects of such treatment would then be needed. Temporarily increasing steroid dosage and route of administration while fasting during the perioperative period might be recommended to diminish the risk of a postoperative addisonian crisis.
Operations and their dates (naming the responsible consultant surgeon) or other key events should be recorded on the problem list. The example problem list is shown in the next column.
Once the problem list has been constructed, subsequent entries in the record should refer to a specific problem (identified by number and title). Postoperative complications are similarly oriented unless of long-term significance, when they could become a major problem.
The operative incision, procedure and findings should be briefly described.
Operation 20.07.2009 (Dr M)
Upper midline incision: Findings: perforation of chronic duodenal ulcer. Procedure: truncal vagotomy and pyloroplasty. Abdominal lavage. Primary wound closure, drain tubes to site of perforation and to subcutaneous tissues.
Now document the other problems.
# 2 Rheumatoid arthritis
A Chronic, active disease. Joints involved and degree of disability are noted.
P Nil at present
(Note that problem # 3 does not appear here because it is inactive.)
4 Progress notes
Record these under the number and title of the relevant problem with the date and the time under recorded or assumed headings:
Subjective
Objective
Assessment
Plan
A simple routine can be followed when assessing progress in the straightforward postoperative case. Most of the negative observations need not be recorded and, if no significant complication has occurred, then only brief notes about normal progress are necessary. The subjective assessment is most important; a patient who feels well and has little pain is nearly always doing well. The next step is to observe the nursing charts and note the values and trends in the temperature, pulse rate, respiratory rate and blood pressure. Fluid balance is checked by noting inputs and outputs since surgery. A raised temperature early after surgery is usually due to atelectasis. The common sources of postoperative fever provide a useful guide to those aspects of physical examination that need regular attention. These sites are the chest, the intravenous drip site, the wound, the urine (particularly in patients who have been catheterised during surgery) and the calves for evidence of deep venous thrombosis. If a wound complication is suspected, the dressing will usually need to be removed and the wound carefully inspected.
Write succinct progress notes; for example:
# 1 Perforated duodenal ulcer: postoperative course 20.07.2009, 10.00 am
S Complains of increased pain in abdominal wound
O T38.4, P 100 Wound is reddened and oedematous, with purulent discharge and surrounding cellulitis
A Wound infection
P Remove sutures, swab of pus for culture
The complication of postoperative wound infection and abscess is then added to the problem list under heading # 1.
5 Discharge summaries
The discharge summary should clearly and concisely convey the essential features of the patient’s illness. One copy is sent to the patient’s general practitioner and another remains in the front of the hospital record for easy reference by clinicians reviewing the patient post-discharge or on subsequent admissions.
The source of referral of the patient and the name of the patient’s community practitioner should always be checked and recorded. It is essential that the doctor of first contact, the patient’s local practitioner and the operating surgeon receive full information (including a copy of the discharge summary) at the time of discharge. Prior telephone communication should have been made by the consultant or registrar if the discharge summary is likely to be delayed for any reason, such as waiting for histology or other results.
Particularly with chronic illnesses such as cancer and degenerative or metabolic diseases, the discharge summary should also state what the patient has been told of the disease and prognosis and what has been told to relatives.
The completed record at discharge should contain the following items.
1. Problem list
2. Discharge and problem summary: a narrative of the course of events during the current admission including details of operative dates, findings, procedures done, histopathology and surgeon’s name; a concise note is written under each problem to indicate the current status, future plans and, if relevant, the prognosis
3. Medications on discharge
4. The patient’s and relatives’ knowledge of disease (when relevant)
5. Follow-up
6. Details of the patient’s family doctor and other consultants to whom copies of the summary should be sent
7. The completed POMR and discharge summary for Mrs S can now be detailed.
Medical record
Introduction: Mrs S was admitted because of severe periumbilical pain of sudden onset that then spread to involve the whole abdomen. Her local MO was called (Dr T) and she was referred to hospital.
Patient profile: Mrs S, a 64-year-old pensioner, lives alone in her own house in South Melbourne. Her husband, a carpenter, died six years ago. She has a supportive family of three grown children all living in Melbourne.
Systems review: Rheumatoid arthritis affecting hands and feet for eight years; moderate deformities of hands cause disability and pain requiring active treatment with analgesics and nonsteroidal anti-inflammatory agents. No other relevant symptoms on systems review.
Risk factors: Anti-inflammatory agents for rheumatoid arthritis – no history of cigarette smoking.
Past history: (i) Myocardial infarct: last year. No complications or sequelae, no angina since, no current medications. (ii) Tonsillectomy when a child.
Family and social history: Parents both dead: mother stroke, father old age.
Current medications: ‘Brufen’400 mg tds, aspirin i-ii qid prn.
Presenting complaint: # 1 Acute abdomen. Sudden onset of very severe periumbilical pain six hours before admission on 20.07.2009. Pain remained severe and spread to involve whole abdomen over next three hours. She also noted pain in the left shoulder. On admission to ward still in severe pain. On examination generalised, marked abdominal tenderness and board-like guarding and rigidity. Silent abdomen with absent bowel sounds. Rectal examination normal.
Not shocked, BP 120/70, P90, regular, T 37.1 C.
Cardiovascular assessment: heart not enlarged, no signs of heart failure, heart sounds normal, no murmurs.
Systems review: no other abnormal findings except for arthritis.
A plain X-ray of the chest and abdomen showed free gas under both sides of diaphragm. Assessment: Acute abdomen – generalised peritonitis. Free gas under the diaphragm indicates the diagnosis of perforated viscus, probably perforated duodenal ulcer.
Plan: Urgent laparotomy after preoperative preparation by IV fluid replacement, nasogastric intu-bation, prophylactic antibiotics (‘Keflin’ 1 Gm IV) and subcutaneous heparin (5000 u). Operation20.07.2009 (Dr M) Findings: perforation of chronic duodenal ulcer. Upper midline incision. Procedure: truncal vagotomy and pyloroplasty, abdominal lavage. Primary wound closure, drain tubes to site of perforation and to subcutaneous tissues.
# 1 Perforated duodenal ulcer: postoperative course 21.07.2009 Satisfactory, intravenous fluids and nasogastric aspiration continuing
22.07.2009 Oral fluids commenced, nasogastric tube and IV line removed
23.07.2009 Normal diet, progress satisfactory
25.07.2009, 10.00 am
Complains of increased pain in abdominal wound, T 38.4, P 110. Wound is reddened and oedematous with purulent discharge and surrounding cellulitis
Assessment: Wound infection: remove sutures, swab of pus for culture
26.07.2009 Much improved, drainage less
27.07.2009 Full diet, wound stable, for discharge soon
# 2 Rheumatoid arthritis
A Chronic, active disease. Wrists and meta-car-pophalangeal joints most involved, moderate flexion deformity of metacarpophalangeal joints with ulnar deviation. Moderate disability, causing difficulty with dressing and handling utensils.
Discharge summary
Name: Mrs S, aged 64 years, dob 16.03.1945, Hospital Record No 1234
Inpatient dates: 20.07.2009 – 28.07.2009
# 1 Perforated duodenal ulcer
Mrs S, a 64-year-old pensioner, has been taking anti-inflammatory drugs for rheumatoid arthritis diagnosed in 2006 and has a past history of myocardial infarction in 2008 with no sequelae. There was no past history of peptic ulcer or smoking. She was admitted eight hours after the sudden onset of severe generalised abdominal pain associated with pain in the left shoulder. Examination revealed generalised peritonitis; an erect chest X-ray showed free gas under the diaphragm. Laparotomy that evening confirmed the clinical diagnosis of a perforated duodenal ulcer. A truncal vagotomy and pyloroplasty with peritoneal toilet were performed and the wound closed with drain tubes to the pyloroplasty and to the subcutaneous layer of the abdominal wall. Recovery was complicated by a subcutaneous wound abscess that required suture removal and drainage. At the time of discharge the wound was not completely healed, requiring daily dressings to a small granulating area.
Owing to the associated risk factors of arthritis requiring anti-inflammatory agents and the need to continue treatment of her arthritis, the prognosis must be guarded and long-term follow-up is recommended. The patient is aware of her diagnosis and associated risk factors.
# 2 Rheumatoid arthritis
Rheumatoid arthritis since 2006 affecting mainly the hands and wrist. Significantly disabled by pain, stiffness and deformity of wrists and painful hip joints. Requires moderately high doses of anti-inflammatory drugs. Referred to rheumatology outpatient clinic for continuing management of this problem.
Medications on discharge. Digesic tablets (paracetamol/dextroprapoxyphrene) two four-hourly prn.
Follow-up
Surgical outpatients (Dr M) 10.09.2007
Rheumatology clinic 10.09.2007
Local MO: Dr T
Student case presentations
Verbal case presentation is a fundamental part of clinical medicine. It may consist of an informal exchange of information between colleagues on a ward round or it may be a more formal presentation before an audience. Whatever the circumstances, it is essential that the listener’s interest and attention are kept. The best way to achieve this is to convey all the relevant data in a brief, concise and systematic form that highlights the presenting problem. Visual aids help make the presentation coherent. All the points mentioned previously in compiling a POMR are relevant to a case presentation. Some aspects particu-larly relevant to a verbal case presentation are outlined below.
Suggested format
1. Introduction: patient identification, date of admission, referral route, reason for admission (preferably a succinct paragraph).
2. Problem list.
3. Patient profile.
4. Presentation of the admitting problem incorporating all relevant information, some of which might be considered in more detail in relation to later problems. Present the data and its assessment, any relevant risk factors and the initial plan of management. Continue the narrative about the course of the illness, highlighting significant major events (such as operations) and avoiding irrelevant detail.
5. It may be appropriate to present additional problems separately.
6. Relevant investigations and their results should be available to present and to discuss (e.g. X-rays and other imaging results). Investigations done in private are often retrievable from the patient, referring general practitioner or surgeon, or from the private laboratory by telephone.
7. Summary: this should be comprehensive but concise.
What to put on visual aids such as computer presentation packages
Introduction, patient profile and summary should be fully written out in correct prose. The problem list (2) should also be written down in full. Write down the key events and findings relating to items 4, 5 and 6 including clear diagrams where relevant. Do not write the presentation out word for word – the presentation should be spoken rather than read. Abbreviations are widely used in clinical medicine. Some are fairly standard (e.g. NAD) and are acceptable as written shorthand, but others are less so. When giving a verbal presentation, however, abbreviations should be ‘translated’ into words (e.g. ‘PR’ should become ‘rectal examination’; ‘JVP’ should become ‘jugular venous pressure’). The summary should bring together the whole story, in particular the main problem and its outcome. All parts of the presentation require careful preparation, but the introduction and sum-mary perhaps most of all, for maximum impact and message.
Suggestions
1. Do not be undone by a fragmented problem list. If the list is against you, change it.
2. Do not omit relevant findings from the presentation of the admitting problem because you think they fit under a separate problem. The importance of concurrent medical illness and associated disorders of homeostasis in relation to the safety of surgery must be remembered and emphasised when relevant. Measures taken to control these disorders should be described. These data are usually best located under item 4, as well as in item 5 where future rather than current management is stressed. Risk factors in relation to particular problems and disease often involve other systems and may be usefully mentioned under item 4 as well.
3. The presentation of the database may often be shortened with advantage. For example, negative findings in an unaffected systems review history can be dismissed briefly by simply stating ‘no relevant abnormalities emerged in the remaining systems on questioning’. Negative findings on physical examination can also be dismissed by saying, for example, ‘no abnormalities were found in the genito-urinary or neurological systems’. Important negatives, however, should be stated, for example, if the patient has diabetes ‘there was no evidence of diabetic neuropathy, retinopathy or vascular complications of the disease’.
4. During the admission, make sure you understand what has happened to the patient and why. For example, the details of any operation(s) and what the patient understands about the illness. If in doubt, ask.
Example case presentation
Mrs JR, aged 27. Admitted on 6 June 2009 from the emergency department with acute abdominal pain after being assaulted.
Problem list
# 1 Abdominal trauma: ruptured spleen
– Splenorrhaphy (Dr RM) 6.6.2009 A
# 2 Marital problems 2003 A
Patient profile
Mrs JR is a 27-year-old waitress who has recently remarried. She has one son aged seven from her first marriage, the child being in the custody of his father. Her second marriage has been marred by quarrels and her husband has beaten her several times in the past and on the occasion of this presentation.
# 1 Abdominal trauma – Ruptured spleen
S At about 2.30 on the afternoon of her admission, Mrs JR was hit several times with a closed fist to the left side of her upper abdomen and over the lower ribs. She immediately felt pain over this area extending up into her left shoulder and arm.
Mrs JR drove to her father’s house and then, feeling thirsty, drove to a milk bar where she collapsed. She was taken to her local GP who referred her to hospital. She arrived at 8.00 pm. In hospital she complained of generalised abdominal pain radiating to both shoulders (L > R). The pain was aggravated by movement and was associated with nausea and thirst. Her period was one week overdue; she was not taking contraceptive measures.
O Pale, distressed young woman, lying with both hips flexed. Shivering. Cold hands and feet. Dry tongue. BP 100/60 lying; 80/50 sitting. Pulse 110. RR 25 – shallow, rapid breathing.
Abdomen. Not moving with respiration. Generalised guarding and release tenderness.
Bowel sounds present. Pelvic examination – tender. No blood in the vagina.
Investigations. CXR; AXR – NAD. FBE – Hb 10.8. RTG – normal. Has not passed urine.
A
• Haemoperitoneum – probably ruptured spleen.
• Possible associated visceral injuries.
P Resuscitate – normal saline – 1 litre started in ED; x-match six units blood.
Urgent investigation. CT scan of the abdomen with contrast was done prior to theatre because of possibility of associated left renal injury. This showed no evidence of renal injury.
Urgent laparotomy – theatre booked for operation as soon as possible (9.00 pm).
At operation. 6.6.2009 (RM) upper midline incision.
Findings. Haemoperitoneum (about 1.5 L), two lacerations on medial surface of spleen (one 5 cm long anterior to hilum, the other 2 cm long at the attachment of the gastrosplenic ligament that contained haematoma). No other abnormality found (pelvic organs normal, kidneys normal, no evidence bowel injury).
Procedure. The gastrosplenic ligament was divided, the spleen mobilised and the two lacerations sutured with 2/0 chromic catgut. Gelfoam was applied to the site of the lacerations and two large suction drains placed behind the spleen and anterior to the hilum of the spleen, respectively. The peritoneal cavity was lavaged with isotonic saline. Four units of blood were given.
Postoperative course. Uneventful. Discharged for regular follow up by LMO and in surgical OP until risk of delayed haemorrhage minimises. The patient knows of the diagnosis and that her spleen has not been removed, and to seek medical help urgently if severe abdominal pain recurs.
# 2 Marital problems
Both marriages marred by violence. Remarried six months ago.
Summary: A previously well 27-year-old woman who sustained a lacerated spleen after being beaten. Details of the history and findings on examination and at operation are outlined in the narrative. At operation (RM), the spleen was repaired. She made an uneventful recovery and was discharged 10 days later. She has serious marital problems that might result in a second failed marriage. Counselling will be arranged by the local MO as required following her discharge.
Local MO: Dr AR (notified of progress by telephone prior to discharge).
Follow up: Local MO, surgical OP (RM) in one week.
Format of bedside presentations
Presentation of a summary of the clinical record at the bedside during a ward round can be a difficult exercise that requires a good understanding of your patient’s progress and management. The points best emphasised are patient identification and portrait, the presenting problem and any significant concurrent medical diseases that affect that problem’s management, the eventual diagnosis (if known), the operation, progress and prognosis.