According to GMC Good Medical Practice, clinicians must record their work ‘clearly, accurately and legibly’. Operation notes are no exception and have several key functions. They serve reminder of procedural events, communicate information to the wider team and may be used as evidence when there are complications or complaints. The aim of this audit was to evaluate the legibility of operation notes within the Otolaryngology department at Peterborough City Hospital. Handwritten operation notes were audited from 8 dates chosen at random over a 2-month period (n = 27). Multiple surgeons and a variety of operations were included. Parameters such as legibility of the surgeon’s name, patient identification, date, name of procedure, events, findings, closure and post-op instructions were recorded. Only 11% of the operation notes were legible in all relevant parameters. The surgeon’s name was either absent or not identifiable from the handwriting in 48%. Documentation of the procedure itself and post-op instructions was illegible in 18% and 29% of notes respectively. Illegibility of operation notes is ultimately a patient safety-issue. Not only does it contribute to confusion about what happened during the surgery but also leaves room for error in terms of post-operative care and follow up. The results of the audit were discussed as part of a departmental meeting to highlight the importance of readable operation notes and help foster a culture of good record keeping. A switch to computerised operation notes could ensure legibility and thus improve standards of patient care in the hospital.
Introduction Silver nitrate is commonly used within otolaryngology to treat granulation tissue in severe otitis externa. It appears radio-opaque on CT (computed tomography) imaging and therefore can mimic bony fragments and foreign bodies. This is particularly cumbersome when the phenomena correlates to the clinical complaint. Discussion We report two cases of 73-year-old and 75-year-old males who presented with chronic otalgia and discharge. Granulation tissue in the external auditory canal was identified and chemically cauterised with silver nitrate. Subsequent CT petrous bones demonstrated an unidentified foreign body in the canal with extensive soft tissue swelling giving an impression of a wick in situ and “minor bony erosion in the left external acoustic canal” respectively. An additional CT of a 57-year-old female who had been treated with silver nitrate for granulomatous tissue reported “multiple highly radiopaque foci in the external auditory canal, suggestive of foreign body”. Though relatively unknown, this phenomenon has been reported in literature. However, there are few reports of silver nitrate artefacts in CT images of the head no cases in the context of otitis externa. Our patients avoided further imaging or surgery following clarification with the radiologists and symptomatic improvement with long-term intravenous antibiotics. Conclusion Given the prevalence of CT imaging and cauterization in otolaryngology, we recommend contemporaneously documenting the use of silver nitrate and highlighting this on request forms to avoid alarming erroneous reports, unnecessary investigation and surgical procedures. We also recommend, where clinically acceptable, to use silver nitrate prior to imaging.
We report a case of a 63-year-old man who presented with a four-day history of fever, night sweats, and left lower back pain, which radiated down to his left buttock and leg. He also had a short-lived episode of chest pain and breathlessness. He had a medical history of chronic back pain, which had been diagnosed as sciatica three years ago. Initial investigations revealed raised inflammatory markers due to a Staphylococcus aureus urinary tract infection. Despite treatment, his inflammatory markers did not improve and the left lower back pain persisted. A magnetic resonance imaging scan demonstrated features consistent with pyomyositis of the left lumbar erector spinae (paraspinal) and iliacus muscles. After prolonged antibiotic therapy, his symptoms completely resolved. Pyomyositis is a rare tropical infection of the skeletal muscles most commonly caused by Staphylococcus aureus . Risk factors include trauma and immunosuppression. This case highlights a nearly missed diagnosis of paraspinal and iliacus pyomyositis in patients with a background history of chronic lower back pain. Early diagnosis and treatment are pivotal in preventing serious complications such as septicemia and multi-organ failure.
Silver nitrate has been used in surgical practice for centuries. It was first described in 1829 by Higginbottom for the management of inflammatory wounds and ulcers. 1 Silver nitrate is an inorganic compound and when exposed to water, it ionises into free silver ions, which acts on tissues and blood vessels causing coagulation necrosis and thrombus formation. 2 Its antiseptic action is now described as being primarily related to apoptosis leading to cell death. 2 Because of these antiseptic and wound healing properties, it is commonly used as a topical agent for cauterising bleeding points; especially over mucosal surfaces, burning granulations and even cauterising the non-healing ulcers for acceleration of the healing process. 3 Granulations in necrotizing otitis externa (OE) are very common and are considered to be one of the diagnostic criteria. 4 These lesions are often managed by applying silver nitrate especially after taking biopsies due to its dual effect. 5 Silver nitrate not only provides haemostasis but further inhibits fibroblast proliferation resulting in rapid resolution of the granulation tissues. 3
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