Table Of ContentE
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GENERAL SURGERY Y
G
A
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OUTPATIENT DECISIONS T
, T
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N GENERAL SURGERY
second edition G
A
N
D
WA OUTPATIENT DECISIONS
L
S
H
second edition
O G
Few doctors receive formal training in how to conduct an outpatient consultation or how to compose
and dictate an outpatient letter. Trainee surgeons in each new speciality spend their first few weeks in U E
outpatient clinics learning by experience with all the pitfalls this entails. Much work involves seeing N
T
patients who have been brought back for review by their predecessors. Problems are caused by
P E
inexperience, unfamiliarity, fear of making mistakes, the pressure of patient numbers and lack of training.
A R
New doctors will find little help in the standard textbooks on how to follow-up patients. This book
provides the necessary background information to enable rational decision making in a concise and T A
economical style. It describes reasonable and safe lines of management suitable for most patients, ideal for I L
E
when discussion with a senior colleague is not possible.
N S
The information in this new edition has been revised, expanded and presented in the context of today’s
T U
specialist clinics and multidisciplinary teams. This new edition is multi-authored to take account of the
multidisciplinary approach. R
D
As well as an overall review of general outpatient issues, every major speciality is covered, with clear notes G
E
for each condition covering history, examination, investigations, results, treatment, follow-up and post- E
C
operative follow-up. The book can be read before or during clinics, and enables trainees to have an action
R
plan in mind before they walk into a consultation. I
S Y
All surgeons have to be trained to go through the process of dealing with unfamiliar clinical conditions
I
for the first time. Surgeons will use this book as a useful foundation on which to build their own personal O
knowledge.
N
other radcliffe books of related interest
S
Handbook of General Surgical Emergencies
Sam Mehta, Andrew Hindmarsh and Leila Rees
s
Safe Sedation for All Practitioners e
a practical guide c
o
James Watts n
d
Treating Common Diseases
e
Hugh McGavock and Dennis Johnston d
i
t
i
o
n EDITED BY MICHAEL GAUNT, TJUN TANG AND STEWART WALSH
www.radcliffe-oxford.com
foreword by stephen brearley
Electronic catalogue and
worldwide online ordering facility.
9781846191916_gaunt_pb.indd 1 8/9/08 10:32:04
General Surgery Outpatient Decisions
SECOND EDITION
TThhiiss ppaaggee iinntteennttiioonnaallllyy lleefftt bbllaannkk
General Surgery
Outpatient Decisions
SECOND EDITION
Edited by
MICHAEL GAUNT MD, FRCS
Consultant Vascular Surgeon, Cambridge University Hospitals NHS
Foundation Trust, Cambridge, UK
Associate Lecturer, Cambridge University, UK
TJUN TANG MRCS
Specialist Registrar in General & Vascular Surgery, Eastern Deanery, UK
Clinical Research Associate, Cambridge Vascular Unit, Cambridge University
Hospitals NHS Foundation Trust, Cambridge, UK
and
STEWART WALSH MSc, MRCS
Specialist Registrar in General & Vascular Surgery, Eastern Deanery, UK
Clinical Research Associate, Cambridge Vascular Unit, Cambridge University
Hospitals NHS Foundation Trust, Cambridge, UK
Foreword by
STEPHEN BREARLEY MChir, FRCS
Consultant Surgeon
Director, The Whipps Cross Higher Surgery Course
Radcliffe Publishing
Oxford (cid:129) New York
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2008 by Michael Gaunt, Tjun Tang and Stewart Walsh
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20160525
International Standard Book Number-13: 978-1-138-03088-6 (eBook - PDF)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts
have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any
legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that
any views or opinions expressed in this book by individual editors, authors or contributors are personal to them
and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this
book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement
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Contents
Foreword viii
Preface to second edition ix
Introduction x
About the editors xii
List of contributors xiii
List of abbreviations xv
1 General outpatient issues 1
Michael Gaunt, Tjun Tang and Stewart Walsh
2 Breast 10
Fiona MacNeill
Breast lump
Breast pain
Nipple discharge
Nipple retraction/inversion
Post-investigation follow-up
Male breast problems
Post-operative clinic visit
Breast cancer follow-up visit
3 Neck and endocrine 30
Bill Fleming
Thyroid lump
Thyroid lump results clinic
Post-thyroid surgery follow-up visit
Hyperparathyroidism
Cervical lymphadenopathy
Salivary gland lumps
Post-operative salivary gland lump
Thyroglossal duct cyst
MEN
Disorders of the adrenal gland
4 Oesophagus 57
Edward Cheong
Hiatus hernia
Congenital diaphragmatic hernia
Traumatic diaphragmatic hernia
Refl ux oesophagitis
Non-refl ux oesophagitis
Benign oesophageal stricture
Achalasia
Vigorous achalasia
Diffuse oesophageal spasm
Nutcracker oesophagus
Pharyngeal pouch
Motility disorders secondary to systemic disease
Oesophageal cancer
5 Stomach and duodenum 75
Richard Hardwick
Dyspepsia/epigastric pain
Dysphagia
Post-gastric surgery/potential complications
Gastric tumours
Gastric cancer
6 The small intestine and vermiform appendix 94
Alastair Windsor
Intestinal bleeding
Intestinal malabsorption
Short gut syndrome
Crohn’s disease
Carcinoid tumours
Carcinoid syndrome
AIDS enteropathy
Radiation-induced bowel disease
Post-appendicectomy follow-up
7 The spleen and lymph nodes 115
Neville Jamieson
Follow-up following splenectomy
Referral by another speciality for possible splenectomy
Assessment and management of left upper quadrant pain/mass
Conservative trauma management
Lymphadenopathy
8 Liver, biliary system and pancreas 127
Satyajit Bhattacharya and Adrian O’Sullivan
RUQ pain
Jaundice
RUQ/epigastric mass/hepatomegaly
Liver tumours/metastases
Post-cholecystectomy
Post-pancreatitis
Pancreatic Tumours
Rare HPB disorders
9 Colon, rectum and anus 190
Henry Tilney and Paris Tekkis
Rectal bleeding
Diarrhoea
Constipation
Diverticular disease
Polyps
Colorectal carcinoma
Irritable bowel syndrome
Proctitis
Radiation proctitis
Rectovaginal fi stula
Rectourinary fi stula
Rectal prolapse
Anorectal fi stulas
Pruritis ani
Incontinence
Haemorrhoids
Anal carcinoma
Pilonidal sinus disease
Stomas
10 Vascular 239
Umar Sadat and David Cooper
Assessment of painful legs
Carotid artery disease
Buerger’s disease
Aortic and iliac aneurysms
Peripheral artery aneurysms
Vasospastic disorders of the arteries
Primary varicose veins
Superfi cial thrombophlebitis
Recurrent varicose veins
Chronic venous insuffi ciency
Leg ulceration
The swollen limb
Lymphoedema
The diabetic foot
Arterial disease of the upper limb
Thoracic outlet compression syndrome
Amputation
11 Lumps and bumps 294
Miles Banwell and Michael Irwin
Skin lumps
Groin lumps
Lymph nodes
Ingrowing toenails
Scrotal lumps/testicular swellings
Index 321
Foreword
Doctors in clinical practice spend most of their time making decisions, often without
realising it. The decisions most often recognised as such are those concerning treatment
– not simply what treatment to recommend but whether to recommend any treatment
at all – but decision making starts whenever a doctor fi rst meets a patient, not when the
patient’s work up has been completed. Doctors are constantly having to decide what ques-
tions to ask in the light of the patient’s presenting complaint, what physical examination
to undertake, whether to investigate further, what investigations to do, what explanation
to give to the patient at each stage, whether the information gleaned is suffi cient to make
a sound diagnosis and develop a treatment plan, and so on.
In order to be soundly based, all these decisions need to be founded on an understand-
ing of the pathology of surgical and other diseases, the symptoms to which they may give
rise, the physical signs which they may produce and the investigations which may be used
to detect them, including the reliability of those investigations. Much of this informa-
tion is conveniently brought together in this book, which aims to lead the inexperienced
surgical trainee systematically through the assessment and management of a wide range
of conditions frequently seen in surgical outpatient clinics, pointing out some common
pitfalls along the way.
That such a book is needed is beyond doubt. Just as well-informed and thoughtful
decision making leads to optimal patient care, poor decision making, even over apparently
trivial matters, may lead to patients being harmed and to litigation. Many more actions
in medical negligence result from poor decisions than from poor surgical technique. Yet
it is still not rare for young surgeons to be asked to see patients in clinics without direct
supervision and without their having been given any specifi c training in how to meet
the particular demands of outpatient work. The decisions these doctors make, whether
to investigate, to treat, to follow-up or to discharge, may not be systematically checked.
Surgical trainees who may be about to face the challenge of outpatient work for the fi rst
time, or in an unfamiliar speciality, are likely to fi nd that the advice and wisdom con-
tained in this volume gives them the framework they need to perform effectively from
the outset.
The book may also be useful to those approaching surgical exams. Nowadays, surgical
viva voce examinations tend to focus not on surgical topics but on clinical scenarios. The
examiners want to fi nd out whether candidates can analyse clinical information logically,
draw appropriate conclusions and propose rational management strategies. These are
precisely the intellectual processes which this book seeks to inculcate and to foster.
Sadly, there are still a few surgeons who see outpatient clinics as a regrettable necessity
in order to recruit patients on whom they can operate. Often this point of view seems to
go hand in hand with an unsophisticated and unthinking approach to decision making.
The refl ex response which equates one hernia with one operation or bleeding at stool with
a fl exible sigmoidoscopy is neither stimulating for the doctor nor good for the patient.
Sophistication in diagnosis and decision making not only leads to optimal patient care
but enormously increases the job satisfaction of the doctor. I hope that readers of this
book will fi nd that it increases their enjoyment of outpatient work, as well as helping
them to perform to a high standard in the clinic.
Stephen Brearley MChir, FRCS
Consultant Surgeon
Director, The Whipps Cross Higher Surgery Course
August 2008
viii
Preface to second edition
Welcome to the second edition of General Surgery Outpatient Decisions. I found
publication of the fi rst edition a very rewarding experience, especially when people
who had read the book took time to contact me and tell me how much they enjoyed it.
Occasions that stick in the memory include when a professor of surgery from Turkey who
was visiting Cambridge tracked me down in Addenbrooke’s Hospital to tell me that he
had found my book in the library and had spent three hours sitting on the fl oor reading
it. More recently a delegate approached me after a teaching session at another hospital to
tell me how he used the book every day and recommended it to all his junior colleagues.
The book was now dog-eared and full of his notes, written in the margin, which was
exactly how I envisaged the book would be used.
Since the fi rst edition was published, surgical outpatient services have undergone
tremendous change. The traditional general surgical clinic has largely been replaced by
specialist clinics where decisions on patient management are taken by multidisciplinary
teams (MDTs). Breast clinics are the most striking example of this approach and there
is no doubting the improvement in care and outcomes that has resulted. Therefore, this
new edition is a multi-author edition to take account of the multidisciplinary approach.
However, working in MDTs brings its own challenges, not least because surgeons are still
expected to take overall responsibility for the patient, especially when things go wrong.
Increasing sub-specialisation also brings challenges to the trainee surgeon experiencing
that speciality for the fi rst time. MDTs develop their own way of working and decision
making, which can be diffi cult to understand for the newcomer. In order to refl ect
this new way of working, I have recruited two surgical registrars of the highest calibre:
Tjun Tang and Stewart Walsh, whose experience of working in this environment is still
current.
Once again, this book attempts to provide the necessary background information
to enable rational decision making in a concise and economical style. I hope you fi nd
this book useful in your everyday practice and in preparation for your professional
examinations, where the question, ‘Yes the theory is all very well but what would you
actually do?’ can be the most diffi cult to answer; and may make the difference between
success and failure.
When I wrote the fi rst edition I had no idea how far across the world it would spread.
A medical secretary from our hospital, on holiday in Vietnam, wandered into a bookshop,
found my book for sale there and took a photograph to prove it! Although this book is
written by surgeons working in the British National Health Service, I believe the medical
problems described in this book are common to all healthcare systems. All surgeons have
to be trained and go through the process of dealing with unfamiliar clinical conditions
for the fi rst time. Therefore, I hope surgeons from all countries will use this book as a
useful foundation on which to build their own personal knowledge.
Finally, I would like to thank my fellow editors and the expert contributors to this book
for their hard work and dedication to the cause.
Michael Gaunt
Cambridge, UK
August 2008
ix
