Clinical Surgery Made Easy

A companion to problem-based learning

de Silva, Mohan

• Publisher: tfm Publishing Ltd
• Year: 2008
• Print ISBN: 9781903378656
• eBook ISBN: 9781908986306
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This book aims to supplement the reader's clinical experience with a carefully designed series of commonly encountered clinical problems in general surgery to simulate the clinical decision-making approach. Each clinical topic includes: a problem-solving approach; system-based essential core knowledge; concise explanations of relevant basic sciences; management pathways (based on the most up-to-date guidelines); FAQs; self-assessment (EMQs, SBAs, T/F). This book, primarily aimed at undergraduates and junior doctors, will guide and stimulate the reader to recognise, recall and apply the relevant facts to given clinical situations and also enhance success at clinical examinations. "Standard textbooks can be daunting. This book is different. I believe that students and young doctors will find this an easy read and will be able to translate the scenarios into an understanding of how clinical pathways are constructed. By asking questions through the pathways students are encouraged to develop their own ideas - a form of problem-based learning rather than learning by rote. Retention of facts is so much easier when they form part of a story." David Cade FRCS, Consultant Surgeon

Chapter 1

The art of approaching a clinical problem

Learning objectives

♦	To recollect the clinical pathway to arrive at a diagnosis of common surgical presentations.

The transfer of textbook knowledge to a specific situation is a challenging task in clinical surgery. This process requires retention of information, the organisation and recall of facts, and the precise application to a given patient. Based on this recall, the clinician arrives at a clinical judgement on which he formulates a management plan.

The first step of this process is the gathering of information. This includes taking the patient’s history, performing a physical examination, and obtaining laboratory results and results from other special examinations such as endoscopy. Of all, obtaining a good history is the most important and the most useful.

During the initial interview with the patient, it is good practice to allow and encourage the patient to explain the problem without interruptions. Some patients are excellent historians. However, some will have their own perceptions of the problem and at times this may mislead students and young doctors. Experienced clinicians use relevant or leading questions when the patient goes off at a tangent and also to fill the voids left in the patient’s description. Selecting the relevant questions for a given clinical situation may pose a challenge to students and young doctors at an early stage of their training.

Presenting complaint

Recognition of the presenting complaint is an essential prerequisite to begin the process. A time tested technique is to begin by asking the main reason for seeking medical advice.

Duration of the presenting complaint

The duration of the presenting complaint is equally important because it may have a direct impact on the diagnosis. For example, abdominal pain which lasts for a few hours may be a biliary or renal colic, whereas chronic and periodic abdominal pain may be more suggestive of peptic ulceration.

History of the presenting complaint

The history of the presenting complaint helps the clinician to understand the background of the illness and to formulate a series of leading questions which will support or will help to exclude certain diagnoses. It is again good practice to enquire as to the precise time period commencing from a day or from a month when the patient was in normal health, and then to build a detailed history of the events or symptoms which the patient could recall ‘from normal to abnormal’. Of course the case is expected to be built only upon the information obtained from the patient and the components cannot be added or ignored. The information obtained may not fit perfectly with the most likely diagnosis; this is not uncommon. The ability to recognise the most relevant information and to gather it accurately takes time and much practice.

The selection of leading questions pertinent to the case

At an early stage of training in surgery, students and young doctors are often incapable of recalling the relevant questions from their knowledge base when tested. This may be due to insufficient knowledge but, mostly, it is the inability to recognise the necessary information for a given clinical situation. Another tested technique for the early trainee in general surgery is, first to interview the patient, formulate the thought process on the evidence obtained and then to discuss the clinical scenario with one of the senior clinicians in the team managing the patient. This simple technique, if practised often, will help students and young doctors to recognise the deficient areas in their knowledge base. It will also help them to understand the reasons for not recognising the correct pathway to arrive at the most likely diagnosis and management plan. It is the technique and approach that students and young doctors must be eager to learn rather than simply attempting to memorise the factual knowledge of a clinical condition. The best way to master this art is by repeated practice and this is achieved by spending more time with patients on the surgical wards.

Organ/system diagnosis or recognition of the organ system

It is good practice to identify what is described as the organ/system diagnosis at the initial stage of history taking and then to think of a differential diagnosis. After a series of relevant or leading questions, the most likely diagnosis or the working diagnosis is reached. An experienced clinician may recognise the clinical problem with ease, which is a skill that is acquired with years of experience.

How the organ/system diagnosis, the most likely diagnosis and the working diagnosis are related in guiding clinical judgement is outlined below.

Organ diagnosis

Organ diagnosis will help to identify a series of relevant or leading questions related to the diseases or conditions which are specific to that organ system. The answers to these questions are the building blocks on which the case will be built.

A patient presenting with episodic loose stools, left-sided abdominal pain and a sense of incomplete evacuation of faeces is likely to have a disease in his colon or rectum.

Taking a patient with dysphagia as an example, the oesophagus will be the most likely organ and an obstructive lesion will be the most likely cause. But it is also possible that the stomach could be the likely organ and not the oesophagus. This is possible if the inlet of the stomach becomes obstructed due to gastric pathology.

Thinking of the possible causes of obstruction will bring further relevant questions to the mind. If the duration of dysphagia is long, for example, over 2 years, this information makes cancer less likely as the cause of the obstruction. Cancers can often progress rapidly and may not fit the overall appearance of the patient who may seem reasonably well. This will draw a list of further relevant questions for and against other benign disorders such as benign oesophageal strictures due to gastro-oesophageal reflux disease (GORD), corrosive strictures and achalasia of the cardia which can present with dysphagia. Has this patient had heartburn and acid regurgitation for a considerable length of time before the onset of dysphagia? If so, a benign oesophageal stricture due to longstanding reflux of hydrochloric acid should be considered because repeated reflux causes chronic oesophagitis which leads to fibrosis and stricture formation. Has he swallowed any corrosive substances in the past? If the answer is yes, then corrosive stricture as the cause of dysphagia is most likely, in which case the time of ingestion of the corrosive substance and the time of onset of the dysphagia become relevant to build the case further. Dysphagia for liquids and solids of longer duration will bring achalasia of the cardia into the picture. Cons...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Preface
• Foreword
• Acknowledgements
• Abbreviations
• Chapter 1: The art of approaching a clinical problem
• Chapter 2: The art of solving a clinical problem
• Chapter 3: Breast lump
• Chapter 4: Biliary colic
• Chapter 5: Obstructive jaundice
• Chapter 6: Acute pancreatitis
• Chapter 7: Dyspepsia
• Chapter 8: Acute upper gastrointestinal haemorrhage
• Chapter 9: Dysphagia
• Chapter 10: Occult gastrointestinal haemorrhage
• Chapter 11: Altered bowel habits
• Chapter 12: Anal fissures, suppuration, sinuses, fistulae and piles
• Chapter 13: Acute intestinal obstruction
• Chapter 14: Acute abdomen
• Chapter 15: Inflammatory bowel disease
• Chapter 16: The critically injured patient
• Chapter 17: Head injury
• Chapter 18: Major burns
• Chapter 19: Groin hernia
• Chapter 20: Scrotal swelling
• Chapter 21: Ureteric colic
• Chapter 22: Bladder outflow obstruction
• Chapter 23: Transient ischaemic attack
• Chapter 24: Intermittent claudication
• Chapter 25: Abdominal aortic aneurysm
• Chapter 26: Thyroid mass
• Chapter 27: Hyperthyroidism
• Chapter 28: Hyperparathyroidism
• Index
• Back Cover