Surgical Referral

Structure and Terminology

Scenario 1

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A 68-year-old gentleman has been referred to you from the Emergency Department with left iliac fossa pain. He has had this pain intermittently for the past few weeks and it has become constant over the last 6 hours. He feels weak. He has a BMI of 36 and smokes 20 cigarettes a day. He has not noticed any change in his stool habit. He is slightly tachycardic and hypotensive. What are your differential diagnoses for this patient?


Answer: This scenario jumps straight to what you think is going on. Every piece of information given will help you answer this question. When approaching differentials, consider your LEFT iliac fossa differential list and state the ones that are relevant to this patient.

LEFT iliac fossa pain differentials

  • Surgical pathologies
    • Diverticulitis
    • Malignancy
    • Ischemic bowel
  • Urological pathologies
    • Ureteric calculi
  • Vascular pathologies
    • Abdominal Aortic Aneurysm
  • Gynecological pathologies – only relevant in female patients
    • Ruptures ovarian cyst




On your initial examination of this patient, you palpate a pulsatile and expansile mass. What are your next steps?


Answer: If you listed AAA in your differentials, the examiner in this scenario is leading you in this direction. Had you not stated it, the examiner may have asked is there anything else you may consider?

Your next step is to definitively rule in this diagnosis and this is done through a CT angiogram of the abdomen with contrast. You will also be aware that this is a life-threatening diagnosis and it is therefore important alert your senior at this point. You would also want to closely monitor this patient for signs and symptoms of hypovolemic shock. Please see the key points for your shock parameters.

Based on how safely and promptly you work your way through this scenario, you may be asked further questions on the pathology and the management. NICE have published clear guidelines on the management of this and these can be accessed from the below link.

https://www.nice.org.uk/guidance/ng156/documents/short-version-of-draft-guideline





 

Scenario 2

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You are the General Surgical SHO and are referred a 57-year-old patient with epigastric pain that has been worsening over the past 24 hours. They have been vomiting and appear dry on examination. Your ABCDE examination reveals tachycardia. What are your differentials for this patient?


Answer: This scenario has bypassed the ABCDE initial assessment of this patient. You should already be thinking the examiners are not keen on hearing this and this scenarios focus is different. Answer this question using your differential framework for epigastric pain.

  • Surgical pathologies
    • Perforated gastrointestinal ulcer
    • Pancreatitis
    • Cholecystitis
  • Vascular pathologies
    • Abdominal Aortic Aneurysm
    • Ischemic bowel
  • Medical pathologies
    • Myocardial infarction
    • Pneumonia




On further history taking, you establish this patient is a heavy drinker and has been drinking 20 units of alcohol a day for the past 5 years. Which differential would you lean towards and how would you assess the severity of this?


  • Answer: Pancreatitis. Be aware of the multiple scoring systems of assessing pancreatitis (Ranson, APACHE, Branson etc). In the acute setting, the GLASGOW score is most commonly used. Know it and know how your management will change based on the score.




The Glasgow score for this patient is 5, how will you manage this patient


Answer: The Glasgow score being 5 means this patient should be managed in an Intensive Care Unit. This is front loading your answer, showing your understanding of the scoring system. Your management remains as per your findings on your ABCDE assessment. Fluid resuscitation, analgesia, antiemetics and symptom-based treatment.




What are the common causes of pancreatitis?


Answer: There are some pathologies, such as pancreatitis, where a basic knowledge is required. There are no shortcuts. This is not for those interested in general surgery. This is for all of you to know.

Learning points:

https://www.nice.org.uk/guidance/ng104