approach to the surgical patient

8/14/2019 Approach to the Surgical Patient

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Approach to the Surgical Patient

Department of Gastrointestinal Surgery

Dr. Wang Ailiang


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Management of surgical disorders

Application of technical skills

Training in basic sciences to

diagnosis and treatment

A genuine sympathy and deep

love for the patient


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surgeon

Doctor in the

oldfashioned sense

Applied scientist

Engineer

Artist

A minister to his or her

fellow human beings


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Eduardo Bassini (1844-1924)Eduardo Bassini (1844-1924)


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The history

Gain the patients

confidence

Convey the

assurance of

available help

Patient is a person

who need help

not only a case

Gentle

considerate

Formally

structured

Avoid

overstructuring

and leading

questions

novice


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Building the history (special emphasis)

Pain

Vomiting

Change in bowel habits

Hematemesis or hematochezia

Trauma

Family history

Patients emotionalbackground


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Pain (careful analysis of nature)

How the pain began?

Was it explosive in onset, rapid, or

gradual? What is the precise character of it?

Cannot be relieved by medication?

Constant or intermittent? Classic association? (rhythmic

pattern of small bowel obstruction)


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Pain (attention)

Patients reaction :overreacting

Very severe pain: infection,

inflammation, vascular disease Moderate pain: with fear, anxiety

Calculated reassurance being given

in the care is more effective than aninjection of morphine


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vomiting

What?

How much?

How often?

What did the vomitus look

like?

Projectile?

See the vomitus


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Change in Bowel Habits

Regular evacuation distinct

change

Intermittent alterations of

constipation and diarrhea

colon cancer?

Size and shape of stool


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Hematemesis or Hematochezia

Does it clot?

Bright or dark red?

Is it changed?

In coffee-ground vomitus of

slow gastric bleeding?

In the dark, tarry stool of upper

gastrointestinal bleeding?


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Hematemesis or Hematochezia

The most common error:

bleeding from rectum

hemorrhoids


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Trauma

The patients position when

the accident occurred?

Consciousness lost?

Retrograde amnesia? (inability

to remember events just

preceding the accident cerebral damage


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Trauma

Brain

damage

can be

excluded

Remember

every detail

Of an

accident

Has not

lost

consciousness

No evidence

of external

Injury

to head


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Trauma

Gunshot

and

stab

wound

Natureof

weapon

Sizeand

shape

Probable

trajectory

Theposition

of patient

when hit


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Past History

May illuminate obscure areas

of the present illness

In order to make certain that

important details of the past

history of will not be

overlooked, the system reviewmust be formalized and

thorough.


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Past History

Important to consider the nutritional

background of the patient

Malnourished patient responds poorlyto disease, injury, and operation

Carcinoma can be more fulminating in

malnourished patient

Malnourishment can be elicited by

questioning


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Past History

Acute nutritional deficiencies,

particularly fluid and

electrolyte losses, can beunderstood only in the light of

the total history.

Diuretics or sodium-restricteddiet low serum sodium


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Past History

Detailed history: helpful in estimating the

probable trends in serum electrolyts.

Vomiting without bile maybe acutepyloric stenosis with benign ulcer

hypochloremic alkalosis

Chronic vomiting without bile, withpreviously digested food chronic

obstruction, carcinoma should be considered


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Past History

Possible: to begin therapy before the

results of laboratory test .

Why???

Specific nature and probable extent

of fluid and electrolyte losses can

often be estimated on the basis ofthe history and the physicians

clinical experience


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Past History

Laboratory data should be

obtained as soon as possible

The possible course may be:

detailed history analysis,

estimate therapy

(experience) laboratorydata adjust therapy

(scientific)


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Patients Emotional Background

Psychiatric consultation

seldom required in surgery, but

great helpful Before or after

operationpsychotic

disturbancepsychiatrist Most of time :surgeon can deal

with


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Patients Emotional Background

Importance of psychosocial

factors in surgical

convalescence The patient: emotional, social,

economic, family..problems

have nothing to do with theillness itself


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Physical Examination

Physical examination

Certain special procedures:

gastroscopy, esophagoscopy,laborotory tests, X-ray

examination etc.

Follow-up examination


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Physical Examination

Prevent unecessary

thoroughness

Painful, inconvenient, andcostly procedures should not

be ordered unless its

necessary in making clinicaldecisions.


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Elective Physical Examination

Good habit in orderly and

detailed fashionno step

omitted Modify the routine in

emergency

Complete examination help thebeginner to know the nomal

and the abnormal


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All patients examined:

sensitive, somewhat

embarrassed How to let patients relax:

examining room, comfortable

table, drapes, talk a bit (takinghistory)


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Timehonored essential steps:

inspection, palpation,

auscultation, percussion Successful palpation requires

skill and gentleness

Palpation: the laying on ofhands that has been called part

of the ministry of medicine


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One finger of patient to

precisely localize the extent of

the tenderness. Auscultation (exclusive

province of physician before),

is now more important insurgery.


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Examination of the Body Orifices

Ears

Mouth

Rectum

Pelvis


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Emergency Physical Examination

Primary considerations:

Breathing?

Airway open?

Pulse?

Heart beating?

Massive bleeding?


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Alter the routine P.E. to to fit

the circumstances

History: left for laterconsideration, limited to a

single sentence or no history

(unconscious patient)


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No breathing, airway obstruction: thrust

the fingers into mouth and pull tongue

forward Unconscious: intubate and start mouth-to-

mouth respiration

No pulse or heartbeat: cardiac

resuscitation

Massive bleeding from extremity:

elevation and pressure


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After emergency treatment, a

rapid survey examination must

be done. Failure to do serious

mistakes


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Emergency treatment before any further

examination (life-threatening injuries):

Penetrating wounds of heart Large open sucking wounds of chest

Massive crush injuries with flail chest

Massive external bleeding


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Laboratory And Other Examinations

Laboratory examinations

Imaging studies

Special examinations


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Laboratory examinations Objectives :

Screening for asymptomatic disease thatmay affect surgical result (unsuspectedanemia or diabetes)

Appraisal of diseases that maycontraindicate elective surgery or requiretreatment before surgery (diabetes, heartfailure)

Diagnosis of disorders that requiresurgery ( hyperparathyroidism,

pheochromocytoma)

Evaluation of the nature and extent of

metabolic or septic complications


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A complete blood and urine

examination is necessary.

A history of renal, hepatic, orheart disease requires detailed

studies.


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Medical consultation required

in total appraisal

The total management must be

surgeons responsibility and is

not to be delegated.


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Imaging studies

To avoid serious mistakes

closest cooperationbetween

the radiologist and the surgeon Surgeon should provide an

adequate account of the history

and physical findings,especially in emergency


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Imaging studies

Radiologic diagnosis (not definitive)

repeated examination in history and

P.E. Negative X-ray, doesnt exclude ulcer or

neoplasm.

Such as small lesion in right colon

Clear diagnosis with history and P.E.,

operation despite negative imaging

studies


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Cystoscopy

Gastroscopy

Esophagoscopy

Colonoscopy

Angiography

bronchoscopy


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Be familiar with indications

and limitations

Make good use for diagnosticappraisal of surgical disorders


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approach to the surgical patient

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