Management of a Surgical Patient (Process) - 2014
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Transcript of Management of a Surgical Patient (Process) - 2014
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Management of a Surgical Patient
[Process]
Reynaldo O. Joson, MD, MS Surg
1998; 2001; 2003; 2004;2014
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Management of a Surgical Patient [Process]
Introduction
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Management of a Surgical Patient [Process]
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
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Management of a Surgical Patient [Process]
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
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
Learning Objectives
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient
[Process]
Reynaldo O. Joson, MD, MS Surg
Self-Instructional Program
https://sites.google.com/site/patientmanagement process
http://edhedephi.tripod.com RJoson’s Writings
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Facilitator’s Approach to
Learning Session
Management of a Surgical Patient [Process]
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Management of a Surgical Patient [Process]
• 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.
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Management of a Surgical Patient [Process]
Goals
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MANAGEMENT OF A PATIENT
PROBLEM-SOLVING AND DECISION-MAKING
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MANAGEMENT OF A PATIENTPROBLEM-SOLVING AND DECISION-MAKING
GOALS
RESOLUTION OF HEALTH PROBLEM
LIVE PATIENT
NO COMPLICATION
NO DISABILITY
SATISFIED PATIENT
NO MEDICOLEGAL SUIT
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Management of a Surgical Patient [Process]
MD’s Tasks
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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
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Management of a Surgical Patient [Process]
Rapport
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Management of a Surgical Patient [Process]
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
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Management of a Surgical Patient [Process]
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
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Management of a Surgical Patient [Process]
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
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Management of a Surgical Patient [Process]
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).
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Management of a Surgical Patient [Process]
Clinical Diagnostic Process
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Management of a Surgical Patient [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
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CLINICAL DIAGNOSTIC PROCESS
DATA NEEDED
SYMPTOMS (from interview or history)SIGNS (from physical examination)PERSONAL DATA OF PATIENT
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CLINICAL DIAGNOSTIC PROCESS
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
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CLINICAL DIAGNOSTIC PROCESS
OUTPUT EXPECTED
RATIONAL
-PRIMARY CLINICAL DIAGNOSIS-SECONDARY CLINICAL DIAGNOSIS
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CLINICAL DIAGNOSTIC PROCESS
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
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CLINICAL DIAGNOSTIC PROCESS
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
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CLINICAL DIAGNOSTIC PROCESS
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
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CLINICAL DIAGNOSTIC PROCESS
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
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CLINICAL DIAGNOSTIC PROCESS
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
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic ProcessIndication - to be more definite on the clinical diagnosis
Selection
Interpretation
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
DATA NEEDED
PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
PROCESSING OF DATA
CERTAINTY OF CLINICAL Dx 1O Dx 60% 99%
needed not needed
TREATMENT PLAN FOR 1O & 2O DxDifferent Sameneeded not needed
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
OUTPUT EXPECTED
DIAGNOSTIC PROCEDURE NEEDED orNOT NEEDED
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
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)
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 60% SurgicalSecondary clinical diagnosis 40% Nonsurgical
Is a paraclinical diagnostic procedure needed?
YES
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 60% Surgical ExcisionSecondary clinical diagnosis 40% Surgical
Excision
Is a paraclinical diagnostic procedure needed?
NO unless there is a strong reason to do so (exception to the rule)
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 90% Mutilating OpSecondary clinical diagnosis 10%
Nonmutilating Op
Is a paraclinical diagnostic procedure needed?
YES unless there is a strong reason NOTto do so (exception to the rule)
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 70% ChemotherapySecondary clinical diagnosis 30%
Radiotherapy
Is a paraclinical diagnostic procedure needed?
YES unless there is a strong reason NOTto do so (exception to the rule)
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
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
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Selection
DATA NEEDED
OPTIONS OF DIAGNOSTIC PROCEDURES
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability123
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Selection
OUTPUT EXPECTED
MOST COST-EFFECTIVEDIAGNOSTIC PROCEDURE
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Selection
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
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions
1 accuracy 99% acceptable 5000 available2 accuracy 90% acceptable 3000 available3 accuracy 50% acceptable 1000 available
Which is the most cost-effective procedure?
Option 2 or Option 1?
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions
1 accuracy 95% acceptable 5000 available2 accuracy 90% acceptable 3000 available3 accuracy 50% acceptable 1000 available
Which is the most cost-effective procedure?
Option 2 or Option 1?
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions
1 yield greatest acceptable 4000 available2 yield 90% acceptable 4000 available3 yield 80% acceptable 3000 available
Which is the most cost-effective procedure?
Option 1
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Interpretation
DATA NEEDED
PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS
RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Interpretation
INTERPRETATION PROCESS
CORRELATE RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE
WITH PRIMARY AND SECONDARY CLINICAL DIAGNOSIS
CONGRUENT - ACCEPTINCONGRUENT - MAKE A DECISION!
(Accept or Hold!)
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Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Interpretation
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
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Management of a Surgical Patient [Process]
Learning Objectives
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.6. Describe how to interpret results of a paraclinical
diagnostic procedure to come out with a pretreatment diagnosis.
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
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).
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Management of a Surgical Patient [Process]
Treatment Process
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Management of a Surgical Patient [Process]
Treatment Process - Selection
DATA NEEDED
PRETREATMENT DIAGNOSISSEVERITY OR STAGE
GOALS AND OBJECTIVESTREATMENT OPTIONS
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Management of a Surgical Patient [Process]
Treatment Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability123
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Management of a Surgical Patient [Process]
Treatment Process - Selection
OUTPUT EXPECTED
MOST COST-EFFECTIVETREATMENT PROCEDURE
ACHIEVEMENT OF GOALS OF PATIENT MANAGEMENT!
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Management of a Surgical Patient [Process]
Treatment Process - Selection
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
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Management of a Surgical Patient [Process]
Treatment Process - Selection
SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions
1 SR1 = SR2 lesser 5000 available 2 SR2= SR1 more 5000 available
Which is the more cost-effective treatment option?
Option 1
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Management of a Surgical Patient [Process]
Treatment Process - Selection
SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions
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
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Management of a Surgical Patient [Process]
Treatment Process - Selection
SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions
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
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Management of a Surgical Patient [Process]
Surgical Treatment Process
PREOP PREPARATION
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Management of a Surgical Patient [Process]
Surgical Treatment Process - Preop Preparation
INFORMED CONSENTPSYCHOSOCIAL SUPPORTOPTIMIZATIONSCREENINGOPERATIVE MATERIALS
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Management of a Surgical Patient [Process]
Surgical Treatment Process
INTRAOP MANAGEMENT
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Management of a Surgical Patient [Process]
Surgical Treatment Process - Intraop Mgt
PHASES
INCISIONEXPOSUREINTRAOP EVALUATIONOPERATIVE PROCEDURE PROPERHEMOSTASIS CHECKCORRECT COUNTWOUND CLOSURE
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Management of a Surgical Patient [Process]
Surgical Treatment Process - Intraop Mgt
Quality Standards:
GENTLE
METICULOUS and PRECISE
NO IATROGENIC INJURIES
NO UNNECESSARY MOVESEVERY MOVE HAS A REASON!
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Management of a Surgical Patient [Process]
Surgical Treatment Process
POSTOP CARE
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Management of a Surgical Patient [Process]
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
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Management of a Surgical Patient [Process]
Surgical Treatment Process
POSTOP FOLLOW-UP PLAN
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Management of a Surgical Patient [Process]
Surgical Treatment Process - Postop Follow-up Plan
OBJECTIVES:
EVALUATE TREATMENT OUTCOME PROVIDE PSYCHOSOCIAL SUPPORT
MONITORING GUIDELINE:
PHYSICAL EXAMINATIONSYMPTOM-DIRECTED
INVESTIGATION
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Management of a Surgical Patient [Process]
Surgical Treatment Process - Postop Follow-up Plan
FF-UP FREQUENCY GUIDELINES: CONSIDERUSUAL COURSE OF DISEASEPERSONALITY OF PATIENTPATIENT’S CONVENIENCE
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
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).
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Management of a Surgical Patient [Process]
Learning Objectives
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.
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Management of a Surgical Patient [Process]
HOW TO GIVE
ADVICES
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
REFERRAL
WHEN
TO WHOM
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
Learning Objectives
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
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.
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Management of a Surgical Patient [Process]
HOPE
u have enjoyed this learning session!
Text or email me for any feedback and questions:
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Management of a Surgical Patient [Process]
Recommended Additional Readings:
Basic Introduction to the Operation
Maxims, Rules, and Guides in the Management of a Patient
Preoperative Evaluation (Risk Assessment and Management)
Text or email me for any feedback and questions: