Management of a Surgical Patient (Process)

Management of a Surgical Patient

[Process]

Reynaldo O. Joson, MD, MS Surg

1998; 2001; 2003; 2004

Management of a Surgical Patient [Process]

Introduction


Introduction

Practice of medicine - essentially management of a patient, a person with a health problem

Surgical patient - person with a surgical disorderSurgical disorder - health problem or condition that

is treated by surgery or an operationNonsurgical patient - one with a nonsurgical

disorder


Introduction

Regardless of type of patient or disorder, whether surgical or nonsurgical,

basic processes in the management are essentially similar

Only difference lies in the specific treatment modality and procedure employed,whether surgical or nonsurgical means


Introduction

All primary health care physicians are expected at least to know the basic processes in the management of a surgical patient.

This learning session gives an overview of the processes involved in the management of a surgical patient.


Learning Objectives


Learning Objectives1. State the overall goals in the management of a patient

(whether surgical or not).2. Enumerate the four functions of a physician in the

management of a patient (whether surgical or not).3. Describe the clinical diagnostic process.4. Describe how to determine the indication for a

paraclinical diagnostic procedure.5. Describe how a paraclinical diagnostic procedure should

be selected among several options.


Learning Objectives6. Describe how to interpret results of a paraclinical

diagnostic procedure to come out with a pretreatment diagnosis.

7. Describe how a treatment modality should be selected among several options.

8. Enumerate at least 4 essential items in the preoperative preparation of a surgical patient.

9. Enumerate in correct chronological order 7 phases in the intraoperative management starting from the incision to wound closure.


Learning Objectives10. Enumerate at least 4 items in the immediate

postoperative care of a surgical patient.11. Enumerate the two objectives of a follow-up plan after

treatment of a patient (whether surgical or not).12. Describe how to advice patients on clinical diagnosis,

paraclinical diagnostic procedures, treatment, follow-up, and health promotion and maintenance.

13. Describe when and to whom to refer.

Management of a Surgical Patient

[Process]

Reynaldo O. Joson, MD, MS Surg

2004

Self-Instructional Program

http://edhedephi.tripod.com RJoson’s Writings

http://edhedephi.tripod.com/

Facilitator’s Approach to

Learning Session



• I have decided to approach the topic by first presenting the steps in the management of a surgical patient in outline form.

Facilitator’s Approach to Learning Session

• Then, I will present some simulated patients or exercises to expound on the process.


Goals

MANAGEMENT OF A PATIENT

PROBLEM-SOLVING AND DECISION-MAKING

MANAGEMENT OF A PATIENTPROBLEM-SOLVING AND DECISION-MAKING

GOALS

RESOLUTION OF HEALTH PROBLEM

LIVE PATIENT

NO COMPLICATION

NO DISABILITY

SATISFIED PATIENT

NO MEDICOLEGAL SUIT


MD’s Tasks

MANAGEMENT OF A PATIENTPROBLEM-SOLVING AND DECISION-MAKING

TASKS

RAPPORT

DIAGNOSIS

ADVICE

TREATMENT

ADVICE

Quality Standards: Rational, effective, efficient, humane

G

O

A

L

S


Rapport


Rapport

Establishing rapport with the patient and his/her relatives

- best strategy for obtaining satisfaction from patient and his/her relative

- strongest strategy in the prevention of medicolegal suit in case of errors of commission and omission


Rapport

Some ways of establishing rapport with patient and his/her relatives:

1. Being courteous2. Showing respect to person and beliefs 3. Giving honest and clear advice on diagnosis,

paraclinical diagnostic procedures,and treatment

4. Demonstrating humaneness and compassion


Rapport

Some ways of establishing rapport with patient and his/her relatives:

5. Being gentle in words and deeds (physical examination, procedure)

6. Showing the patient and relatives that you are trying your very best

7. Being helpful when it comes to medical expenses8. Making the patient and relatives feel that you are

approachable and easy to talk to


Learning Objectives

1. State the overall goals in the management of a patient (whether surgical or not).

2. Enumerate the four functions of a physician in the management of a patient (whether surgical or not).


Clinical Diagnostic Process


Clinical Diagnostic Process

Diagnosis - label or nature of the health problem

Clinical Diagnosis - diagnosis derived from interview (history) and physical examination

Clinical Diagnostic Process - processing of data from interview and physical examination to arrive to a diagnosis

CLINICAL DIAGNOSTIC PROCESS

DATA NEEDED

SYMPTOMS (from interview or history)SIGNS (from physical examination)PERSONAL DATA OF PATIENT


PROCESSING OF DATA

PATTERN RECOGNITION-realization that the patient’s presentationconforms to a previously learned picture or pattern of disease

PREVALENCE- choice of a diagnosis is based on the frequency of occurrence of the disease in a certain locality, in a certain age and sex group, and in the affected organ and system


OUTPUT EXPECTED

RATIONAL

-PRIMARY CLINICAL DIAGNOSIS-SECONDARY CLINICAL DIAGNOSIS


PROCESSING OF DATA




PROCESSING OF DATA

Knowing the common manifestations of 5 different diseases as follows:

Disease A - abcd (manifestations)Disease B - fghiDisease C - klmnDisease D - pqrsDisease E - uvwx

Given a patient manifesting with pqrs, your diagnosis is Disease D. What is the process used?

Pattern Recognition


PROCESSING OF DATA

Knowing the common manifestations of 3 different diseases and relative frequency of each as follows:

Disease A - abcd (manifestations) Least commonDisease B - abcd Disease C - abcd Most common

Given a patient manifesting with abcd, your diagnosis is Disease C. What is/are processes used?

Pattern Recognition but mainly Prevalence


PROCESSING OF DATA

Knowing the most common diagnosis of a thyroid nodule is a benign colloid adenomatous goiter, given a patient with a thyroid nodule, you gave the abovementioned diagnosis.

What is/are processes used?

Prevalence


PROCESSING OF DATA




Paraclinical Diagnostic Process


Paraclinical Diagnostic ProcessIndication - to be more definite on the clinical diagnosis

Selection

Interpretation


Paraclinical Diagnostic Process - Indication

DATA NEEDED

PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS



PROCESSING OF DATA

CERTAINTY OF CLINICAL Dx 1O Dx 60% 99%

needed not needed

TREATMENT PLAN FOR 1O & 2O DxDifferent Sameneeded not needed



OUTPUT EXPECTED

DIAGNOSTIC PROCEDURE NEEDED orNOT NEEDED



Certainty Plan of Treatment

Primary clinical diagnosis 98% SurgicalSecondary clinical diagnosis 1-2% Nonsurgical

Is a paraclinical diagnostic procedure needed?

NO unless there is a strong reason to do so (exception to the rule)




Primary clinical diagnosis 60% SurgicalSecondary clinical diagnosis 40% Nonsurgical


YES




Primary clinical diagnosis 60% Surgical ExcisionSecondary clinical diagnosis 40% Surgical

Excision


NO unless there is a strong reason to do so (exception to the rule)




Primary clinical diagnosis 90% Mutilating OpSecondary clinical diagnosis 10%

Nonmutilating Op


YES unless there is a strong reason NOTto do so (exception to the rule)




Primary clinical diagnosis 70% ChemotherapySecondary clinical diagnosis 30%

Radiotherapy


YES unless there is a strong reason NOTto do so (exception to the rule)



Tickler -

Which of the following statements is the strongest indication for a paraclinical diagnostic procedure?

A. You can never be absolutely certain of your clinical diagnosisB. You want to confirm a clinical diagnosis which are certain ofC. You want to document a clinical diagnosis which you are certain

ofD. When you are not certain of your clinical diagnosis

Best Answer is D


Paraclinical Diagnostic Process - Selection

DATA NEEDED

OPTIONS OF DIAGNOSTIC PROCEDURES



SELECTION PROCESS

Options Benefit Risk Cost Availability123



OUTPUT EXPECTED

MOST COST-EFFECTIVEDIAGNOSTIC PROCEDURE



SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions1 most direct acceptable 1000 available2 indirect acceptable 1500 available3 indirect acceptable 1000 available

Which is the most cost-effective procedure?

Option 1



SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions

1 accuracy 99% acceptable 5000 available2 accuracy 90% acceptable 3000 available3 accuracy 50% acceptable 1000 available


Option 2 or Option 1?




1 accuracy 95% acceptable 5000 available2 accuracy 90% acceptable 3000 available3 accuracy 50% acceptable 1000 available


Option 2 or Option 1?




1 yield greatest acceptable 4000 available2 yield 90% acceptable 4000 available3 yield 80% acceptable 3000 available


Option 1


Paraclinical Diagnostic Process - Interpretation

DATA NEEDED

PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS

RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE



INTERPRETATION PROCESS

CORRELATE RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE

WITH PRIMARY AND SECONDARY CLINICAL DIAGNOSIS

CONGRUENT - ACCEPTINCONGRUENT - MAKE A DECISION!

(Accept or Hold!)



Tickler -Determine which paraclinical diagnosis should be accepted as the pretreatment diagnosis and which one should be put on hold for further decision-making. Write (A) for accept and (H) for hold.7.1 Paraclinical diagnosis is the same as the primary clinical

diagnosis.7.2 Paraclinical diagnosis is the same as the secondary clinical

diagnosis7.3 Paraclinical diagnosis is a clinical diagnosis least considered.7.4 Paraclinical diagnosis does not jibe with the clinical picture or

diagnosis.

7.1 A 7.2 A 7.3 H 7.4 H


Learning Objectives

3. Describe the clinical diagnostic process.4. Describe how to determine the indication for a


be selected among several options.6. Describe how to interpret results of a paraclinical



Learning Objectives7. Describe how a treatment modality should be selected

among several options.8. Enumerate at least 4 essential items in the preoperative

preparation of a surgical patient.9. Enumerate in correct chronological order 7 phases in

the intraoperative management starting from the incision to wound closure.




treatment of a patient (whether surgical or not).


Treatment Process


Treatment Process - Selection

DATA NEEDED

PRETREATMENT DIAGNOSISSEVERITY OR STAGE

GOALS AND OBJECTIVESTREATMENT OPTIONS



SELECTION PROCESS

Options Benefit Risk Cost Availability123



OUTPUT EXPECTED

MOST COST-EFFECTIVETREATMENT PROCEDURE

ACHIEVEMENT OF GOALS OF PATIENT MANAGEMENT!



SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions

1 greatest surv rate acceptable 5000 available2 rate < 1 > 3 acceptable 4000 available3 least surv rate acceptable 3000 available

Which is the most cost-effective treatment option?

Option 1




1 SR1 = SR2 lesser 5000 available 2 SR2= SR1 more 5000 available

Which is the more cost-effective treatment option?

Option 1




1 as effective as 2 acceptable 8000 available2 as effective as 1 acceptable 4000 available

Which is the more cost-effective treatment option?

Option 2




1 most effective acceptable 2000 available2 effectivity <1 >3 acceptable 3000 available3 least effective acceptable 4000 available

Which is the most cost-effective treatment option?

Option 1


Surgical Treatment Process

PREOP PREPARATION


Surgical Treatment Process - Preop Preparation

INFORMED CONSENTPSYCHOSOCIAL SUPPORTOPTIMIZATIONSCREENINGOPERATIVE MATERIALS



INTRAOP MANAGEMENT


Surgical Treatment Process - Intraop Mgt

PHASES

INCISIONEXPOSUREINTRAOP EVALUATIONOPERATIVE PROCEDURE PROPERHEMOSTASIS CHECKCORRECT COUNTWOUND CLOSURE


Surgical Treatment Process - Intraop Mgt

Quality Standards:

GENTLE

METICULOUS and PRECISE

NO IATROGENIC INJURIES

NO UNNECESSARY MOVESEVERY MOVE HAS A REASON!



POSTOP CARE


Surgical Treatment Process - Postop Care

•SUPPLY BASIC NEEDS OF PATIENTCOMFORTANALGESICSFLUID AND ELECTROLYTESNUTRITION

SUPPORT ORGAN FUNCTION WOUND CAREMONITORING FOR COMPLICATIONSADVICE ON

HOME CARE FOLLOW-UP PLAN



POSTOP FOLLOW-UP PLAN


Surgical Treatment Process - Postop Follow-up Plan

OBJECTIVES:

EVALUATE TREATMENT OUTCOME PROVIDE PSYCHOSOCIAL SUPPORT

MONITORING GUIDELINE:

PHYSICAL EXAMINATIONSYMPTOM-DIRECTED

INVESTIGATION


Surgical Treatment Process - Postop Follow-up Plan

FF-UP FREQUENCY GUIDELINES: CONSIDERUSUAL COURSE OF DISEASEPERSONALITY OF PATIENTPATIENT’S CONVENIENCE


Learning Objectives7. Describe how a treatment modality should be selected

among several options.8. Enumerate at least 4 essential items in the preoperative

preparation of a surgical patient.9. Enumerate in correct chronological order 7 phases in

the intraoperative management starting from the incision to wound closure.




treatment of a patient (whether surgical or not).


Learning Objectives

12. Describe how to advice patients on clinical diagnosis, paraclinical diagnostic procedures, treatment, follow-up, and health promotion and maintenance.



HOW TO GIVE

ADVICES


HOW TO GIVE ADVICES

1. Always include the relatives of the patient in the advising, if they are available.

2. Assess the psychological make-up, the health beliefs, and the level of competency of the patient and the relatives before making any advice. Make strategies that will promote rapport.2.1 Be honest but not brutally frank.

Example, slowly divulge the diagnosis of an incurable disease or a frightening disease.

2.2 Use terminologies or explanations that can be easily understood by the patient and his relatives.


HOW TO GIVE ADVICES

3. Use all kinds of strategies that will make the patient and his relatives like you.

4. Explain to the patient and relatives the processes you use in arriving to a diagnosis, recommendation for a paraclinical diagnostic procedures and treatment.


REFERRAL

WHEN

TO WHOM


Referral - When to Refer?

All physicians, both certified and not yet certified, must know their limitations.

Only they themselves can determine their own limitations.

They must realize their limitations so that they do not cause undue harm to their patients and so that they know when to refer to colleagues.


Referral - To Whom to Refer?

Referral must be made to somebody who may or can solve the patient’s health problem

rationally, effectively, efficiently, and humanely, and

who has a good track record of handling the kind of problem on hand.


Learning Objectives


Learning Objectives1. State the overall goals in the management of a patient

(whether surgical or not).2. Enumerate the four functions of a physician in the

management of a patient (whether surgical or not).3. Describe the clinical diagnostic process.4. Describe how to determine the indication for a


be selected among several options.


Learning Objectives6. Describe how to interpret results of a paraclinical


7. Describe how a treatment modality should be selected among several options.

8. Enumerate at least 4 essential items in the preoperative preparation of a surgical patient.

9. Enumerate in correct chronological order 7 phases in the intraoperative management starting from the incision to wound closure.




treatment of a patient (whether surgical or not).12. Describe how to advice patients on clinical diagnosis,

paraclinical diagnostic procedures, treatment, follow-up, and health promotion and maintenance.



HOPE

u have enjoyed this learning session!

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Health & Medicine

Management of a Surgical Patient (Process)