Scalpel's Edge

A surgeon's notes

Friday’s List – General Surgical Outpatients (monsoon edition)

2015 06 09 16 46 05

Usually on a Friday I am in theatre, but yesterday I was in outpatients.  Outpatients at Tansen Hospital works differently to what I am used to.  On each working day (every day except Saturday and Wednesday), patients can buy a ticket to be seen by a doctor.  The number of tickets depends on the service (male medical, female medical or paediatric).  When the tickets have all been sold, any remaining patients can return the next day, or buy a more expensive emergency department ticket.  There are no appointments.

Once patients have their ticket, they wait, sometimes for hours, to be seen by a doctor.  They may have investigations arranged, which they pay for and do on the same day (also no appointments usually) and then return with their results, waiting again to be seen.  The medical clinics are run by family doctors, or general practitioners, and paediatricians.

Patients who need to be seen by the surgeons get seen by the medics first who refer them to general surgery or orthopaedics. They have to wait again for their turn in that clinic.

In general clinic on Friday, we were relatively busy, but not ridiculously so.  We started at 1030am and finished at 5:30pm, with a one hour lunch break.  The cases we saw were relatively spread across specialities.

Paediatric surgery

  • 7F Chronic wound sinus two months after incision of submandibular abscess (booked for excision)
  • 3M Abdominal pain and two weeks of fever.  Not consistent with appendicitis or surgical abdomen.  Admitted under paediatrics.
  • 35day old infant with hydrocoele, not communicating, no hernia.  He will return for repair when older.
  • 3M with rectal prolapse seen by the emergency department.  Improving with medical treatment.

General surgery

  • 70M Skin lesion on face and buttock (sent to minor OR for excision under local)
  • 34M with motorbike muffler burn.  Looking good.  For grafting next week if needed.
  • 40F For review of skin graft for 1% flame burn.  Skin graft well taken (Discharged)
  • 25F Review of abdominal pain post caesar.  No wound infection. (Patient reassured).
  • 17M with inguinal hernia (Booked for hernioplasty next week).
  • 34M follow up after fistulotomy.  Healed.
  • 36F follow up after self inflected chest burn. (Booked for neck contracture release and further skin grafting).
  • 20M with Inguinal hernia (booked for surgery next week)
  • 67F with symptomatic cystocoele.  Ultrasound is normal and she will return for a surgery date after rice harvest.
Urology
  • 65M Post urinary retention after insertion of foley catheter in emergency, with benign prostatic hypertrophy (commenced on medication and referred to another centre for TURP, trial of void arranged)
  • 45M with bilateral hydronephosis and renal stones, with flank pain.  About a month ago, he was admitted at another hospital for work up and had a lot of investigations, but no treatment.  I decide to repeat his ultrasound, to try to identify the point of obstruction in poorer kidney.  Our ultrasonographers are very good, and sometimes better than outside providers.
  • 30F with left flank pain and hydronephosis. No stone seen.  She’ll come back after an IVP.
  • 24M Left flank pain with PUJ stone.  (Medical therapy as initial treatment)
  • 59M Cholelithiasis after ERCP for choledocholithiasis. (Advised to have lap chole, but wants to defer until after rice harvest.  He will come back for a date then).
Other stuff that I have no idea about
  • 60M with a rhinophyma.  Referred to ENT services at another hospital.
  • 34F with trismus post tooth extraction 3 weeks earlier. 

Admissions

  • 70M with right iliac fossa mass and tenderness, 10 days history.  Admitted for ultrasound and investigations. He went on to have a laparotomy last night which showed perforated appendicitis.  (They seem to all be appendicitis here.  Colon cancer is pretty uncommon, in elective or emergency presentation)
  • 24F with antenatal mastitis.  She had aspiration of an abscess a week earlier, and was non-compliant with antibiotics.  Ultrasound confirmed no abscess, but diffuse mastitis, so I admitted for a short course of IV flucloxacillin to ensure compliance.
  • 55M with partially treated appendicitis.  Improving after two days of oral antibiotics, so I admitted for some IV antibiotics and review.  It’s possible he will avoid surgery this episode.  (This presentation is much more common than at home, where people get treated at health posts and pharmacists with easy access to broad spectrum antibiotics).
  • 55M with infected hydrocele wound.  Admitted for debridement and dressings.
  • 33M with laceration/degloving injury of right ear where he was hit by a rock falling off the side of a cliff.  Admitted for repair in main theatre.

Note:  I know the photo does not at all relate to outpatients, but you don’t really want to see the photos…..

One response to “Friday’s List – General Surgical Outpatients (monsoon edition)”

  1. Russ says:

    Hey Cris and Luke. Haven’t been replying to your blog posts but have read them all. Your Dad sends them out to lots of people, which is great! I’ve really appreciated your reflections on life in Nepal and in the operating theatre. Love all the pics too. I especially liked your reflections about the meaning of mission. I’m glad you are staying another six months….i think that’s a good decision. Karen and I are off to Europe for a month this coming Sunday. Blessings to you all. Russ.

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