what investigation would you do next?
Clinical knowledge exams, at my medical school at least, tends to be not so clinical. For example:
Choose the most appropriate investigation to be performed next.
- A 59 year old male present with severe central abdominal pain radiating through to the back. His bp is 90/70 and a tender pulsatile central abdominal mass is palpable.
- A 29 year old male presents with 1 day history of periumbilical pain that has migrated to the right iliac fossa. Examination reveals local tenderness in the RIF and raised WCC.
In question 1, the diagnosis is no doubt a ruptured AAA given the hypotension and central abdo pain radiating to the back. What i understand is that you do not waste time with imaging (which under exam situations, i would clearly put CT abdomen) and you take the patient to the theatre for a laparotomy. This is supported by Case Files : Surgery, and the relevant case was written by Henry Veldenz, Chief of Surgery at Hardin Memorial Hospital, Kentucky. I quote:
“For a patient presenting with AAA rupture (back pain, hypotension, and a pulsatile epigastric mass), operative open repair is the most available and most potentially life-saving therapy. If AAA rupture is clinically suspected, the patient should undergo emergent operative repair. There is no role for radiologic imaging if clinical impression is a rAAA – the delay involved in obtaining imaging is too risky for the patient compared to a potentially negative exploration”
Going off on a tangent, for rAAA, if this patient presents to a hospital which has no vascular surgical cover, you would no doubt if a transfer to a nearby hospital which has a vascular surgeon on cover is better for the patient’s outcome. Would this delay in transportation make a difference? This is a question we tried to answer with this paper.
68 patients presented to the hospital with an onsite vascular service (group A) and 33 presented at sites without a vascular service (Group B)… the significant difference in time to operation between the two groups did not influence patient outcome, nor did the lack of an “on-site” vascular service lead to selective intervention….
The conclusion we drew has workforce planning implications, e.g. if the administration wishes to extend vascular surgeon service to a peripheral hospital in a particular health network.
An image you wish you wouldn’t have to see on a computer monitor. (image credit: learning radiology)
In question 2, classic appendicitis. We recently had such a question in our GP written exam, and one of the options was “no further investigation required”. Other options relevant include abdo U/S and abdo CT. I chose the first one. When the diagnosis is clear, there is no need to waste unnecessary resources. I raised this point with Dr Alice, a surgical resident in USA, who blogs at “Cut on the dotted line”. I did learn something from her comment. I love how she described it as “fun” to convince her attending to operate without a CT in a ?appendicitis.
Alright, rant over. Cheers
One thing you will learn, Jeffrey, is that the key to exams is understanding what they are for before you start answering them. There are exams to see how smart you are, or how much factual information you can accumulate (e.g. anatomy, physiology, etc) and there are exams to test your skill and judgement (complex clinical decision making, etc.).
Most of these skill and judgement exams exist for the purpose of mandating minimum standards, not maximising factual knowledge or performance. The goal of your clinical exams is to minimise the chance that you will choose an option that leads to the patient being dead or permanently disabled.
Therefore the answer to your exam questions depends on whether you are trying to give a “safe” answer – one that solves the patient’s problem with minimum risk given that you are not aware of all the possible variables, or whether you are trying to give the “best” real-life answer – one which is most likely to give the patient the best possible outcome on the assumption of certain variables (ie you are in a tertiary hospital with excellent laparoscopic facilities, quick-turnaround CT, an endovascular lab etc).
The “safe” answer is that your first patient goes to laparotomy and probable open AAA repair, and your second patient goes to open surgery and probable appendicectomy. Advanced registrars will be expected to outline what happens if they find something unexpected (eg a perforated DU and an unruptured AAA, or a lily-white appendix). In real life an alternative answer may be appropriate for that specific surgeon, at that specific institution, with that specific patient.
Just keep in mind that at the end of your medical degree the expectation is that you will be a safe doctor, not a super doctor. If you act like you are a super doctor, then you are probably not all that safe.
In real life, the ruptured AAA is no longer that simple, either. If the patient is unstable, yes, OR immediately (although, in my experience, the patient will not make it past the ER docs without a CT). If the BP seems moderately stable, at least at my institution, it’s now desirable to get a CT angio in order to determine if the patient would be a candidate for an endovascular repair. If so, we would take them to the main OR, and have the open instruments standing by, but start out endovascularly.
Often by the time a AAA ruptures, it’s so big that the neck isn’t feasible to seat a graft in; but if it works, it saves the patient a lot of morbidity.
Also, if the patient is having upper/mid-back pain, a CT angio can help distinguish between a dissection and rAAA. I’ve seen those confused several times, especially by outlying hospitals’ ERs.
is appendicectomy — especially open — really the “safe” answer for scenario B? There’s no real rush to theatre if the patient has an unperfed appendix, and so the downside of doing the CT is more subtle, as is the upside.
Downside: cost, radiation dosage, annoying radiology registrars.
Upside: identify non-appendiceal pathology, especially in the multiply-entered-belly case where an open appendix may be more appropriate.
as for investigations: I’d still CXR/ECG/ABG pt 1. quick, cheap, and gives you useful information (not that it’d necessarily change your management).
(congrats on the publication, btw. being last author is an unusual place.)