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1. What are the six steps in the management of a patient on a surgical ward?
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Correct answer:
- History-taking; this means carefully listening to the patient's story.
- Examination of the patient.
- Writing your notes.
- Constructing a differential diagnosis; ask the question: what diagnosis would best explain this clinical picture?
- Special investigations; which laboratory and imaging tests are required to confirm or refute the clinical diagnosis?
- Management; decide on the management of the patient, remember that this will include reassurance, relief of pain and, as far as possible, allaying the patient’s anxiety.
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To elicit a good history, what questions do you always need to ask?
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Correct answer:
(Open questions) When were you last well? What happened next? If you have a positive finding do not leave the subject until you know everything about it, e.g. site, onset, character, radiation, associated features, timing, exacerbating or relieving features, severity.
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3. Why do most patients come to see a doctor?
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Correct answer:
Pain or bleeding.
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4. If a patient presents with bleeding, what questions do you need to ask?
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Correct answer:
Ask about the sort of blood, when, how much, were there clots, was it mixed with food/faeces, was it associated with pain?
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5. How can you ask a patient where their pain is precisely?
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Correct answer:
Ask them to point to their pain.
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6. If a patient tells you they have back pain, what do you want to know?
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Correct answer:
Where is the pain in their back? Lumbar? Neck? Etc.
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7. Why is testicular pain often felt in the periumbilical region?
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Correct answer:
This reflects the intra-abdominal origin of this organ before its descent into the scrotum - never be fooled by the child with testicular torsion who points to the central abdomen.
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8. What is the classical quartet of examination?
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Correct answer:
Inspection; palpation; percussion; auscultation.
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9. How should you inspect the patient?
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Correct answer:
Learn the art of careful inspection, and keep your hands off the patient until you have done so. Inspect the patient generally, how he lies, how he breathes, and so on. Look at the hands and feel the pulse.
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10. What should you do once you have generally inspected the patient, looked at their hands and felt their pulse?
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Correct answer:
- Only after careful inspection proceed to palpation.
- If you are examining the abdomen, ask the patient to cough. This is a surrogate test of rebound tenderness and indicates where the site of inflammation is within the peritoneal cavity.
- Remember to examine the ‘normal’ side first, the side that is not symptomatic, be it abdomen, hand, leg or breast.
- Look at the patient while you palpate.
- If there is a lump, decide which anatomical plane it lies in. Is it in the skin, in the subcutaneous tissue, in the muscle layer or, in the case of the abdomen, in the underlying cavity? Is the lump pulsatile, expansile, mobile in all directions, etc.?
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11. How should you write your medical notes?
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Correct answer:
- Always write up your findings completely and accurately.
- Start by recording the date and the time of the interview.
- Write all the negative as well as positive findings.
- Avoid abbreviations like PID - you may mean pelvic inflammatory disease but the next person might interpret it as a prolapsed intervertebral disc.
- Illustrate your examination unambiguously - use anatomical reference points and measure the diameter of lumps accurately.
- When drawing abdominal findings use a hexagonal representation. A continuous line implies an edge; shading can represent an area of tenderness or the site where pain is experienced. If you can feel all around a lump, draw a line to indicate this; if you can only feel the upper margin, show only this. Annotate the diagrams with your findings.
- At the end of your notes write a single paragraph summary, and make a diagnosis, or write down a differential diagnosis.
- Outline a management plan and state what investigations should be done, indicating which you have already arranged.
- Sign your notes and print your name, the date and time and position legibly underneath.
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12. What is the purpose of presenting a case to your colleagues?
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Correct answer:
To convey to your colleagues the salient clinical features, diagnosis or differential diagnosis, management and investigations of your patient.
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13. How should you present a case?
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Correct answer:
- The presentation should not be merely a reading of the case notes, but should be succinct and to the point, containing important positive and negative findings.
- Do not use words such as ‘basically’, ‘essentially’ or ‘unremarkable’, which are padding and meaningless.
- Avoid saying that things are ‘just’ palpable - either you can feel it or you cannot. Make up your mind.
- At the end of a good presentation the listener should have an excellent word picture of the patient and his or her problems, what needs to be watched and what plans you have for management.