Where you are:
FY2 in GP surgery.Who the patient is:
Anna Parker, 26 years old, presents to the hospital with abdominal pain. Ultrasound has been done and shows dermoid Cyst in the right ovary. The consultant has decided to perform an open ovarian cystectomy via Pfannenstiel incision (8cm). The wound will be closed using absorbable sutures.
Consultant has decided to keep the patient in the hospital after the surgery for 2 days.Additional information:
noneSpecial note:
Consent has been taken from the consultant.What you must do:
Talk to the patient and address her concerns.
Please note plab2 stations have no right or wrong scheme of approach. It’s all about addressing the concerns and fulfilling the Qs task, while taking just the sufficient amount of history. So, in this particular case you can use the Surgery structure, combined with test results and counselling structure. BE FLEXIBLE.
D: Hello Miss Parker, I am one of the doctors in this surgery department. Could you please confirm for me your full name and age?
P: Anna Parker, 26 years old.
D: Nice meeting you Miss Parker. I gather from my notes that you have been scheduled for surgery. Are you aware of that?
Patient: Yes doctor and I have some concerns regarding the surgery.
D: Yes, I am here to address all your concerns. Is it okay if we have a chat about your health before that?
P: Okay doctor.
P1- Focused hx
D: Thank you. Can you tell me why you came to the surgery in the first place?
P: I came to the surgery because of pain in my tummy.
D: Can you tell me more about it?
P: I have had this pain for the last few days in the right side of my tummy.
D: Has the pain increased from before? (Changes/ Complication)
D: Do you feel dizzy? Heart racing? (Complication/ Torsion/ rupture)
P: Yes/No
D: Anything else apart from this? Vomiting? Fever? Bowel or Bladder problems?
P: Yes/No
P2- past hx
D: Has this ever happened before?
P: No.
D: Have you undergone any surgery in the past?
P: Yes/No
MAFTOSA
D: Do you have any long-term medical condition?
D: Are you taking any medication at the moment?
D: Do you have any allergies?
P: Yes/No
D: Has anyone in the family been diagnosed with any medical condition?
P: Yes/No
D: What do you do for a living?
P: I’m an accountant.
D: Who do you live with? / Is there anyone to look after you once you are discharged?
P: Yes/No
D: Do you drive?
P: Yes or no.
DESA
D: Tell me about your lifestyle, do you smoke? Alcohol?
P: Yes/No
D: Thank you for answering these questions.
Counselling:
Explain the results/ diagnosis/ procedure/ complication
D: Has anyone explained to you the results of your ultrasound scan?
P: Yes/No. She might say “I have been told I have a cyst in my ovary but I am not aware of any specifics can you please tell me more doctor?”
If no, then explain. (Always ask patient what they know and how much they
want to know)
D: As you told me, you came to the hospital with tummy pain, we did a scan and we found there was a fluid-filled sac in your right ovary which we call an Ovarian Cyst. Are you following?
P: Why do I have this?
D: Ovarian cysts often develop naturally if you have monthly periods. They can also affect people who have been through the menopause.
I am here to help as much as possible so please share with me any concerns
you have? (ALWAYS do ICE)
P: What is going to happen now?
D: We have run all the tests and as results show an ovarian cyst. Our consultants are of the opinion that performing surgery would be the best approach.
P: Why do you have to operate?
D: Even though it’s not serious at the moment, the reason we need to operate is because if it is not removed now, it can create further complications. (IF you pause while speaking, its an invitation for the patient to ask questions so be aware this a good communication tip but don’t overdo it)
P: What complications doctor?
D: It can continue to grow and has a high chance of rupture, bleeding or twisting.
P: What kind of operation will you do?
D: We will be performing an open surgery that we call an ovarian cystectomy, which is removal of the ovarian cyst. In this operation the surgeon will make a cut three to four inches in size in the lower part of your tummy just above your bikini line (Pfannenstiel incision). He will then remove the cyst and close the tummy back up again.
P: Any preparation for the surgery?
D: For this operation, you will need to be admitted the day before and you also need to fast for eight hours before the operation.
P: How big will the scars be? Will it be visible?
D: About 8 cm. The scar will be very thin and would be covered by a bikini so it wouldn’t be visible on a beach.
P: Will you be removing my ovary as well?
D: That’s a good question. So far we are only planning to remove the cyst, however if the surgeon sees that the cyst is occupying a large portion of the ovary, he may suggest removing the ovary as well.
P: Will I still be able to have children?
D: As long as the other ovary is working fine, you should be able to get pregnant and have children like everyone else.
P: How long is the operation?
D: It will take about 45 minutes to an hour.
P: How long will I stay in hospital?
D: After the operation you will be taken to the recovery room and then to the ward. You might need to stay in the hospital for 2 days, depending on how you feel after the operation.
P: Are there any complications following surgery?
D: As with all surgery there are certain complications such as bleeding, infection or damage to the surrounding structures. However, these are quite rare and we will take due care of this.
P: When can I return to work?
D: Initially it is important to rest for at least for four weeks and thereafter it all depends on how you feel. If heavy work, may need about six weeks to rest.
P: When can I have sex again?
D: Well, it is advisable to avoid intercourse for two to four weeks after surgery.
P: When can I drive after the surgery?
D: It is advisable to avoid driving until you are able to perform an emergency brake without feeling any discomfort. It will usually take 4-6 weeks.
P: What about stitches?
D: We will be using absorbable stitches, so you don’t have to worry about getting the stitches removed.
P: Is it cancerous?
D: Ovarian cysts are mostly not, however we will send the sample to the lab to be analysed to be sure.
Safety net for rupture, torsion, bleeding and any discomfort. Also you can safety net for post-operative complications
Please Note:
If the station asks about laparoscopic cystectomy, then mention
what’s below:
The operation is called a “laparoscopic cystectomy” which is keyhole surgery. The surgeon will make a small incision below your belly button and insert a small amount of harmless gas to distend your tummy and make it easier to operate inside. This gas will be removed after the operation. We will also make two small incisions on either side of your lower tummy to insert a camera and instruments.
For laparoscopic surgery:
Provided that everything goes smoothly you may be able to go back home on the same day or next day.
Work/sex/driving: Can resume after approximately two weeks depending on the patient’s recovery.