Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, February 02, 2009

Clear That Patient!

Hello Bloggers, and welcome to that fabulous new medical game show, Clear That Patient!


As you know, Clear That Patient! is all about balancing risks. Technically, of course, it is understood that the concept of "Medical Clearance" is flawed. It is sad but true that, taken literally, the statement, "Medically cleared" over your signature could be construed by an unscrupulous attorney as an assurance that all will go well, potentially leaving your hiney on the chopping block in the event of any misadventure. ("But doctor, you said the patient was cleared. Shouldn't you have known he was going to have an MI in the middle of the procedure?")

Your job, contestants, is to examine each of the following scenarios and decide whether or not, in your expert judgment, the benefits of the proposed surgical procedure outweigh the medical, surgical and anesthesia risks given the medical facts presented. Your final answer needs to reflect your opinion as to whether you can, in good conscience, allow the patient -- as presented -- to undergo the proposed operation RIGHT NOW. Possible answers include:
  1. Yes, go ahead.
  2. Needs further workup first, but okay if everything checks out.
  3. No way; not until the patient is better controlled.
It is also understood that the anesthesia, surgical and postoperative care will be the absolute best possible in all cases.

Ready? Okay then; here we go:

38-year-old male with a BP of 240/140 and a creatinine of 4 (refusing ER and hospital evaluation of headaches, melena and hematuria AND has blown off multiple nephrology appointments) presents requesting surgical clearance to fix his umbilical hernia.

65-year-old male requesting repair of a volleyball-sized scrotal hernia presenting at the hospital's surgical clinic, found to be in atrial fibrillation.

35-year-old female, three pack-a-day smoker, diabetic with an A1c of 14, who needs a vaginal hysterectomy after multiple LEEP procedures who now has severe cervical dysplasia.


And now, contestants, for extra credit:

Guess which of these patients have I actually seen, either in training or in my practice.


At Mon Feb 02, 06:53:00 AM, Anonymous Anonymous said...

VOLLEYBALL-SIZED scrotal hernia?

How did that dude wear pants?

At Mon Feb 02, 08:34:00 AM, Anonymous Anonymous said...

All of them?

At Mon Feb 02, 08:38:00 AM, Anonymous Anonymous said...

My guess is that you've see all of the patients at one time or another.

Patient 1: The only surgery that's going to help that dude is dialysis catheter insertion.

Patient 2: Probably the healthiest of the bunch. Needs a bit of evaluation for his a-fib, but once everything checks out and is stable, he's good to go.

Patient 3: This lady is Fournier's gangrene waiting to happen. No way I'd clear her.

At Mon Feb 02, 08:50:00 AM, Blogger OHN said...

No doubt all three...and probably an additional 10 with other various maladies.

At Mon Feb 02, 01:28:00 PM, Blogger knitalot3 said...

All of them.

I pity the surgeon.

At Mon Feb 02, 07:55:00 PM, Blogger The Happy Hospitalist said...

Anesthesiologists clear patients. They are the ones holding the key to life on the OR table.

Internists and family medicine docs decide if further evaluation is necessary or not.

I'm sure you've seen all three, in the same day. I know I do.

At Mon Feb 02, 10:12:00 PM, Blogger Nurse K said...

Nurse guesses

A: Hernia is least of dood's worries. Needs multiple problems evaled and treated first, esp. that bleeding from every orifice and intracerebral hemorrhage htn problem. Should be admitted to the hospital!!!

B. Standard pre-op labs for an old guy w/EKG and surgery soon!

C. Cervical dysplasia can wait a bit for her to reduce her smoking and her blood sugars. No special reason to risk infection by clearing her this second.

At Tue Feb 03, 01:42:00 AM, Anonymous Anonymous said...

Patient A: No way.

Patient B: Go Ahead. (rate control, heparin when appropriate p surgery etc)

Patient C: Admit for tight glucose control and proceed. Will be high risk after DC but needs surgery.

I think you've seen all three.

At Thu Feb 05, 12:17:00 PM, Blogger GuitarGirlRN said...

Yeah, I agree with Nurse K. 1) no way, 2) check him out a bit and then go ahead, and 3) She definitely needs more control over her sugars. I see a bad infection in her future!

At Tue Feb 10, 05:00:00 PM, Blogger Midwife with a Knife said...

A: No Way (treat the ttp first..)

B: No way (take care of it after the a-fib is controlled)

c: Sure, go ahead.. She does need better diabetic control, but bringing down her HbA1c will take a long time. This hyst shouldn't wait for several years. Besides, if it takes her longer, are we going to let her have cervical cancer because she's a bad diabetic.

At Thu Feb 12, 08:03:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

Patient A - Forget it.

Patient B - Tune up and go.

Patient C - She needs another leep anyway to rule out invasion anyway. Then take a couple of months to get her sugars down and cut back on the cigs. It's a shame, really. The cigs are probably the reason she's not clearing the dysplasia.

I think you saw all 3 - what did you do?


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