Everything in medicine or surgery is not clear. Actually it is not possible to explain every patient problem on a scientific basis. Now this is going to make the life of surgeon more difficult because the first requisite for surgeon's treatment criteria is a logical connection of the pathology and patient symptom. A surgeon with clear mind cannot put his scalpel on his patient without assuring himself first that his intervention is going to give some benefit. 'First no harm' and no surgery is without risk.
Here come our patient, who presented to nephrology for abdominal pain and dysphagia. He was worked up for dysphagia and found to have Gastroesophageal reflux disease and hiatal hernia. He underwent Nissen Fundoplication and was relieved of symptoms for one year. Unfortunately a year later he presented with severe abdominal pain and on investigation it was found that he had migration of wrap. He had a revision surgery (which included unwrapping of the migrated wrap, collis gastroplasty, mesh hiatoplasty and a new fundoplication). Following surgery he was relieved of symptoms.
About one and half year passed and then he started complaining of abdominal pain, mainly around umbilicus. Given the history of the patient, the surgeon was naturally worried whether there was a recurrence of disease. Many investigations were done including an Endoscopy, Barium swallow, Ultrasonography, CT scan of abdomen and blood tests. All the imaging and lab tests were within perfect normal range. Now as a resident I was in charge of this patient and he used to call me whenever he had pain. I prescribed him PPIs, antispasmodics, analgesics. But according to the patient none seemed to give an effective pain relief. Later I was getting restless seeing his messages, because it was like treating blindly. On requesting multiple times , the patient came to emergency room. He was kept in observation for 24 hours. Inspite of complaining pain, he did not have any tachycardia, seemed to be comfortable and his abdomen was soft. His imagings were rediscussed with the most senior faculty and nothing wrong could be found.
I don't know what exactly worked, but after some counselling by senior surgeon, that we cannot find any serous problem with him after all the elaborate tests, he said there is some decrease in the pain. He was discharged.
Now what i want to share is that moment in each surgeons' clinic life, when they find nothing can logically explain the patient problem and no medication relieve patient problem. Attributing the problem to the patient psychology is a diagnosis of exclusion. Once a surgeon operates on a person they develop an unwritten responsibility for any complaint related to that body part. And this often puts them in difficult situation. Solving a patient problem is not easy as answering an MCQ. Checking 'none of the above' is not going to solve a real life situation.
This is another reason, why our senior professors always advice. Take a good history and confirm that the patient has significant symptoms and those symptoms are related to the pathology which you are going to operate for.
Here come our patient, who presented to nephrology for abdominal pain and dysphagia. He was worked up for dysphagia and found to have Gastroesophageal reflux disease and hiatal hernia. He underwent Nissen Fundoplication and was relieved of symptoms for one year. Unfortunately a year later he presented with severe abdominal pain and on investigation it was found that he had migration of wrap. He had a revision surgery (which included unwrapping of the migrated wrap, collis gastroplasty, mesh hiatoplasty and a new fundoplication). Following surgery he was relieved of symptoms.
About one and half year passed and then he started complaining of abdominal pain, mainly around umbilicus. Given the history of the patient, the surgeon was naturally worried whether there was a recurrence of disease. Many investigations were done including an Endoscopy, Barium swallow, Ultrasonography, CT scan of abdomen and blood tests. All the imaging and lab tests were within perfect normal range. Now as a resident I was in charge of this patient and he used to call me whenever he had pain. I prescribed him PPIs, antispasmodics, analgesics. But according to the patient none seemed to give an effective pain relief. Later I was getting restless seeing his messages, because it was like treating blindly. On requesting multiple times , the patient came to emergency room. He was kept in observation for 24 hours. Inspite of complaining pain, he did not have any tachycardia, seemed to be comfortable and his abdomen was soft. His imagings were rediscussed with the most senior faculty and nothing wrong could be found.
I don't know what exactly worked, but after some counselling by senior surgeon, that we cannot find any serous problem with him after all the elaborate tests, he said there is some decrease in the pain. He was discharged.
Now what i want to share is that moment in each surgeons' clinic life, when they find nothing can logically explain the patient problem and no medication relieve patient problem. Attributing the problem to the patient psychology is a diagnosis of exclusion. Once a surgeon operates on a person they develop an unwritten responsibility for any complaint related to that body part. And this often puts them in difficult situation. Solving a patient problem is not easy as answering an MCQ. Checking 'none of the above' is not going to solve a real life situation.
This is another reason, why our senior professors always advice. Take a good history and confirm that the patient has significant symptoms and those symptoms are related to the pathology which you are going to operate for.
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