MANAGEMENT

OF A

SURGICAL

PATIENT

REYNALDO O. JOSON, MD, MS Surg1998; 1999;2001

MANAGEMENT OF A SURGICAL PATIENTReynaldo O. Joson, MD, MS Surg

TABLE OF CONTENT

Preface

Introduction ..................................................................................................................... 1

Objectives ........................................................................................................................ 1

Recommended Preparations .............................................................................................. 2

Options in Learning the Program ........................................................................................ 2

Author’s Approach to the Topic ......................................................................................... 2

A Narration of a Whole Case Management including Surgical AspectHow I Usually Do ItManagement of a Patient with a Preauricular Mass ...............................................................

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Management of a Surgical Patient in an Outline Form ......................................................... 13

Steps in the Management of a Patient ................................................................................. 20

Maxims, Rules, and Guides in the Management of a Patient ................................................. 21

Advising Patients and Relatives .......................................................................................... 24

Knowing When and To Whom To Refer ............................................................................ 26

Formative and Summative Evaluation ................................................................................. 27

Answers to Formative and Summative Evaluation ............................................................... 32

Recommended Follow-up .................................................................................................. 33

References ....................................................................................................................... 33

About the Author .............................................................................................................. 33

Primary Intended Users - Students of medicine and primary health care physicians

Estimated Study Time - 2 hours

Preface

Dear Learner,

Mabuhay!

Welcome to a learning experience in becoming a health professional.

This program has been especially designed with you, the learner, and the principles of effective teaching and learning in mind.

As you go through this learning program, please bear in mind the following:

1. I am treating you as an adult learner which

1.1 Assumes you have learning aspirations and expectations andtherefore, are motivated;

1.2 Gives you the privilege to use other learning strategies in achieving the objectives in this program;

1.3 Welcomes you to go beyond the learning package as you so desire; and

1.4 Expects discipline, honesty, and maturity in fulfilling yourlearning activities.

2. We shall define learning as a positive observable change (for the better or improvement) in human behavior, disposition, attitude, performance, or capability which persists over a period of time.

3. Active learning strategies and activities will be utilized as much as possible.

4. The program will contain learning materials which I think will be relevant to your being an effective, efficient, and humane health professional.

5. The ultimate goal of the learning program is to produce health professionals who willcontribute to the health development in the Philippines.

6. When I made this program, I tried my best to facilitate your learning. Bear in mind,however, that I am not infallible. Thus, analyze carefully everything in thisprogram. Don’t hesitate to offer disagreements and constructive criticisms forown learning and for the improvement of the program.

Best wishes for a fruitful learning with the help of this program.

Reynaldo O. Joson, MD, MS Surg1998;1999;2001;2014

Management of a Surgical Patient Reynaldo O. Joson, MD, MS Surg

INTRODUCTION

The practice of medicine is essentially management of a patient, a person with a health problem.

A surgical patient is a person with a surgical disorder. A surgical disorder is a health problem or condition that is treated by surgery or an operation. A nonsurgical patient is one with a nonsurgical disorder.

Regardless of type of patient or disorder, whether surgical or nonsurgical, the basic processes in the management are essentially similar. The only difference lies in the specific treatment modality and procedure employed, whether surgical or nonsurgical means.

All primary health care physicians are expected at least to know the basic processes in the management of a surgical patient. Thus, this self-instructional program intended for primary health care physicians and which will give an overview of the processes involved in the management of a surgical patient.

OBJECTIVES

Upon completion of this program, the user is expected to be able to:

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).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.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 managementstarting from the incision to wound closure.

10. 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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RECOMMENDED PREPARATIONS

There are no specific recommended preparations needed for the user to gain benefit fromthis program. What is just required is a motivation to learn the processes involved in the management of a surgical patient.

OPTIONS IN LEARNING THE PROGRAM

You may start with the “Formative Evaluation/Summative Evaluation” at the end of this program to self-evaluate yourself prior to reading the main text or you can read the text first. The choice is yours.

AUTHOR’S APPROACH TO THE TOPIC

I have decided to approach the topic by giving you first a complete blow-by-blow account or narration of how I usually manage a patient. Although the example given is a patient with a preauricular mass, the processes illustrated here will be applicable to and are the same for any kind of patient with any kind of health problem.

When you read the narration, try to identify the processes involved. Have the learning objectives by your side to remind you on what things to look for in the narration. When you finish reading the narration, I expect you to have the appropriate answers to the first 11 learning objectives.

The next thing that you will encounter in this program after the narration is the “Management of a Surgical Patient in an Outline Form”. Reading this outline will help you further in learning the first 11 objectives.

After the outline, you will see a diagram or algorithm on “Steps in the Management of a Patient” followed by write-ups with the following titles: “Maxims, Rules, and Guides in the Management of a Patient”; “Advising Patients and Relatives”; and “Knowing When and To Whom To Refer.” Studying the diagram and the write-ups will complete your learning of all the stated objectives.

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A NARRATION WHOLE CASE MANAGEMENT INCLUDING SURGICAL ASPECT

HOW I USUALLY DO IT

Management of a Patient with a Preauricular Mass

EXPECTATIONS

Confronted with a patient with a preauricular mass, I have to be first reminded of the following:

1. I am to manage this patient’s health problem.2. Managing a patient’s health problem is essentially a problem-solving and

decision-making activity.3. My goal in the management of this patient is to resolve the patient’s health problem in

such a way that I don’t end up with a dead or disabled patient nor a dissatisfiedpatient, and God forbid, a medicolegal suit.

4. My tasks consist of the following:4.1 Establishing rapport initially and then maintaining it throughout the course of

patient management;4.2 Formulating a clinical diagnosis followed by an advice to the patient on my

findings and diagnosis;4.3 Deciding on whether I need a paraclinical diagnostic procedure and, if I need

one, selecting the most cost-effective procedure, to be followed by aninformed consent on the part of the patient; if paraclinical diagnosticprocedures are done, I need to interpret the results and correlate themwith the clinical findings to come out with a pretreatment diagnosis,again to be followed by an advice to the patient; and lastly,

4.4 I need to decide on the most cost-effective treatment procedure for the patient. 4.5 My tasks can be summarized by the following diagram:

Rapport ------------------------------------------------------------------------> Diagnosis ------------------------------------------------------------------->

Advice -----------------------------------------------------> Treatment -------------------------------------->

Advice --------------------------->

5. The outcome of my problem-solving and decision-making will be judged by thefollowing criteria:

5.1 rational5.2 effective5.3 efficient5.4 humane

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RAPPORT

Establishing rapport with the patient and his/her relatives is my best strategy for obtaining satisfaction from my patient and his/her relative. It is also my strongest strategy in the prevention of medicolegal suit in case I commit errors of commission and omission.

Here are some ways in which I try to establish rapport with my 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 treatment4. Demonstrating humaneness and compassion5. Being gentle in words and deeds (physical examination, procedure)

6. Showing the patient and relatives that I am trying my very best 7. Being helpful when it comes to medical expenses8. Making the patient and relatives feel that I am approachable and easy to talk to

CLINICAL DIAGNOSIS

In formulating the clinical diagnosis, I first verify the expressed chief complaint of the patient.

In this particular patient, the expressed chief complaint is a preauricular mass. To verify, I look at and palpate the area pointed to by the patient (let’s say, the left preauricular area). I see and feel a 5 cm mass in front of the left ear. With this, I conclude that there is really a preauricular mass on the left side of the face. Initial impression of the patient’s health problem, therefore, is a left preauricular mass. I need to be more specific than just saying there is a mass.

Thus, the next thing that I should do is determine the organ or tissue of origin of the preauricular mass.

By the location, the mass can come from any of the following organs or tissues:

1. Skin of the face2. Soft tissue3. Parotid gland4. Lymph node5. Mandible (ascending ramus)

I will say the mass is originating from the skin of the face if I see a superficial lesion on the skin surface. In this patient, there is no break or lesion on the skin. The mass is underneath the skin. I conclude, therefore, that this mass is most likely NOT a skin tumor.

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I will say the mass is originating from the mandible if I feel the mass is a bony tumor. In this patient, the mass does not feel bony. I conclude, therefore, that this mass is most likely NOT a mandibular tumor.

The left preauricular mass is beneath the skin and not a bony tumor. The considerations on the tissue or organ of origin are now trimmed down to the following:

1. Soft tissue2. Parotid 3. Lymph node

At this point, after finishing my inspection and palpation of the left preauricular mass, I have gotten the following data:

Left preauricular mass, beneath the skin, not a bony tumor, 5 cm in size,not hard, movable, nontender, border well-defined.

I know my priority at this point is still to first determine whether the mass is a soft tissue tumor, parotid tumor, or a lymph node before I decide on the kind of disease.

I feel I should investigate first the lymph node possibility because of the presence of a clinical investigative pathway for lymph node. If the mass is a lymph node, it is most likely secondary or metastatic. The primary lesion can be found in the upper part of the head (scalp and face) or in the naso-oropharnx. If there is a lesion in any of these areas, then the preauricular mass is most likely a metastatic lymph node.

I examine, therefore, the upper part of the head and the oropharynx. There is no evident lesion in these areas. I ask for any symptoms referable to the nasopharynx like nasal stuffiness and bleeding. There are none.

With these data, I place lymph node in No. 3 in the line-up of possibility of sources of tissue or organ of origin.

The consideration is now centered on soft tissue and parotid tumors. Since there are no clinical features that will differentiate the two tumors, I now have to rely on prevalence data to choose which one is more likely to be the case. I choose parotid tumor because this is very much more common than soft tissue tumor in the preauricular area.

At this point, my impression is a left preauricular mass, most likely arising from the parotid gland. I need to be more specific to include the possible disorder, whether inflammatory, malignant or nonmalignant.

Thus, the next thing I will do is look for signs for inflammation like pus, erythema, tenderness, and warmth. If there are signs of inflammation, then my diagnosis will be either parotitis or parotid abscess, depending on whether there is fluctuancy or not.

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In this patient, there are no signs of inflammation. I conclude that most likely the mass is NOT inflammatory.

The next thing I will do is look for signs of malignancy which include a hard nonosseous solid tumor, fixation, invasion of the skin, facial paresis or paralysis, ipsilateral neck nodes, and a distant mass suspicious for metastasis. If any of these signs is present, then my diagnosis will be a parotid cancer.

In this patient, there are no signs of malignancy. I conclude, therefore, that most likely the mass is NOT malignant.

With no signs of inflammation and malignancy, I am left with a non-malignant tumor consideration. Before I settle for this consideration, I will look for signs and other clues of benignity. As for signs of benignity, a reliable cue will be a cystic nature of the mass. If the mass is cystic, most likely the parotid mass is benign, a parotid cyst. As for other clues of benignity, the duration of the mass may help. If the mass has been present for a long duration of time without causing symptoms and there are no signs of malignancy, most likely the parotid mass is benign.

In this patient, the mass is not cystic and it was noted 3 years ago. These data do not support the diagnosis of benignity but they also do not negate it.

Thus, in the absence of inflammation and malignancy and considering benign parotid neoplasms are more common than malignant ones (80% vs 20%), my clinical diagnosis, therefore, is a benign parotid mass, left, most likely, pleomorphic adenoma. The basis for saying most likely pleomorphic adenoma is the prevalence of this disease. It is the most common benign parotid neoplasm.

As an added investigation to the parotid mass, beside the onset, the other pertinent questions to ask are whether there are associated symptoms and whether there is a history of previous medical consultation and treatment. To these questions, the answers are negative.

In formulating the clinical diagnosis of a preauricular mass, the signs, symptoms, and personal data of the patient are needed. In this particular patient, the age is 65 and the sex is female. These personal data as well as other personal data like civil status, occupation, and menopausal status will not make me change the diagnosis that I arrive at using pattern recognition (based on signs and symptoms) and prevalence.

The output expected in clinical diagnosis is a rational primary clinical diagnosis as well as a secondary diagnosis.

The primary clinical diagnosis is a parotid tumor, left, benign pleomorphic adenoma. I have presented the bases that makes my diagnosis rational.

As to the secondary clinical diagnosis, I will consider a malignant parotid tumor.

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I am confident of the choice of organ or tissue of origin of the preauricular mass, that is, the parotid gland. If I am not, then I have to make soft tissue tumor as my secondary diagnosis, rather than a malignant parotid tumor.

As I have said I am confident of the parotid tumor. What I am not very confident of is whether the parotid tumor is benign or malignant. The main basis for choosing benign parotid tumor over malignancy is prevalence, which is a weaker basis compared to one that is based on both pattern recognition and prevalence. PARACLINICAL DIAGNOSTIC PROCEDURE

Do I need a paraclinical diagnostic procedure?

My primary clinical diagnosis is parotid tumor, benign. My secondary clinical diagnosis is parotid tumor, malignant. My basis for choosing benign over malignant is prevalence. That makes my diagnosis not quite certain. Being uncertain, theoretically speaking, I need a paraclinical diagnostic procedure. I need to consider another factor in deciding whether I really need a diagnostic procedure.

The treatment for both primary and secondary diagnosis is operative extirpation. Whether the tumor be benign or malignant, my operative procedure will be extirpation of all gross tumors. Since my treatment plan and procedure will be the same for both my primary and secondary clinical diagnosis, then I decide that I don’t need paraclinical diagnostic procedure.

Note: Extirpation of all gross tumors may range from subtotal parotidectomy to total parotidectomy. Subtotal parotidectomy may range from partial superficial parotidectomy, total superficial parotidectomy, partial superficial and total deep parotidectomy, and partial superficial and partial deep parotidectomy.

TREATMENT

My pretreatment diagnosis is parotid tumor, left, benign.

The goal and objective of treatment will be to completely extirpate all grossly evident tumor in such a way that there will be no local recurrence and no complications, particularly, facial nerve paralysis.

The most cost-effective treatment is an operative extirpation. Drugs are ineffective.

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PREOP PREP

Preoperatively, I will

1. Secure an informed consent after I have explained the diagnosis and proposedtreatment to the patient and her relatives.

2. Provide psychosocial support to allay fear and anxiety.

3. If there is a co-existing disorder, optimize the patient’s physical health so that she can withstand the operative procedure.

4. Screen the patient for any health condition that may interfere with the outcome of thetreatment.

5. Prepare the material needs for the operation, if these are not available in the place oftreatment (hospital).

INTRAOPERATIVE MANAGEMENT

Incision:

Objectives: Long enough to facilitate accurate intraoperative evaluation and complete

extirpation of parotid tumor without complicationsPlace it at an area that will facilitate achievement of treatment goal Place it at an area that will be cosmetically acceptable to the patient

Planning and execution of incision will be based on the above objectives.

Exposure:

Objectives:To facilitate accurate intraoperative evaluationTo facilitate complete extirpation of the parotid tumor without complication

Execution:Create flaps to such an extent that will facilitate accurate intraoperative

evaluation and complete extirpation of parotid tumor withoutcomplications

Create flaps not beyond the anterior border of the parotid gland so as to avoidinjury to the branches of the facial nerve

Create viable flaps

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Intraoperative Evaluation:

Objectives:To determine the exact diagnosisTo determine the extent of the tumorTo facilitate decision on specific operative procedure and maneuvers

Execution:

Inspect and palpate to determine whether mass is really parotid in originif parotid in origin, determine whether benign or malignant,

extent of tumor, superficial or deep,inferior pole, superior pole, whole gland, etc

Decide on extent of parotidectomyTotal parotidectomySubtotal parotidectomy

Total superficial parotidectomyPartial superficial parotidectomyPartial superficial and partial deep parotidectomy

Decide on operative maneuvers

Operative Procedure Proper:

Objectives:

To completely extirpate all grossly evident tumor in such a way that there will beno local recurrence and no complications, particularly, facial nerveparalysis.

Maneuvers:

Identify facial nervemain trunk to branches (usually)branches to main trunk (if main trunk cannot be identified first)

Extirpate all gross parotid tumor with a rim of normal parotid tissue (adequately)Avoid cutting or entering into the tumor (cleanly)Avoid injury to the facial nerve while extirpating which can occur either by

cutting, burning (with cautery) or traction

Attack tumor initially through areas of lesser difficulty before entering throughdense and difficult areas

Be gentleBe meticulous and preciseEvery move must have a reason!

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Hemostasis Check:

Objectives:

To avoid bleeding and hematomaTo avoid injury to facial nerve during hemostasis check

Execution:

Choice of suture-ligature and cauterization

Avoid injury to the facial nerve during clamping, tying, and cauterization by right choice of hemostatic method and by being meticulous andprecise

Drain:

Objectives:

To prevent unwanted accumulation of fluid (serum and saliva) in the woundspace

To drain continuous salivary secretion into the wound site after a subtotalparotidectomy

Execution:

Choice of tube drain or rubber drain

Remove when drain is not needed anymore

Correct Count:

Objective:

To avoid leaving surgical instruments and sponges in the wound site

Execution:

Ensure correct instrument and gauze count before wound closure!

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Wound Closure:

Objective:

To repair the skin incision used to remove the parotid tumorTo repair the skin incision in such a way that a cosmetically acceptable scar is

effected and that will promote patient comfort (e.g. pain of skin suture removal)

Execution:

Use absorbable suture to avoid pain on suture removal (if nonabsorbable onesare used)

Appose wound edges precisely to promote a cosmetically acceptable scar POSTOP CARE

Objectives:

Supply basic needs of patientComfortAnalgesicsFluids and ElectrolytesNutrition

Wound careMonitoring for complications and treat as indicatedAdvice on home care of woundAdvice on follow-up plan

FOLLOW-UP PLAN:

Objectives:

Evaluate results of treatmentProvide psychosocial support

Monitoring guidelines:

Physical examinationSymptom-directed investigation

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Frequency of Follow-up Guidelines:

ConsiderUsual course of disease (recurrence probability and incidence)Personality of patientPatient’s convenience

OUTCOME OF MANAGEMENT

If at the end of the treatment, I have achieved all the following:

Resolution of the health problemParotid tumor extirpated with no recurrence

Live patientNo facial paralysisSatisfied patientNo medicolegal suit

Then, I can consider myself to be successful in my problem-solving and decision-makingin the management of the patient.

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MANAGEMENT OF A SURGICAL PATIENT IN AN OUTLINE FORM

MANAGEMENT OF A PATIENT

PROBLEM-SOLVING AND DECISION-MAKING

GOALS

RESOLUTION OF HEALTH PROBLEM

LIVE PATIENT

NO COMPLICATION

NO DISABILITY

SATISFIED PATIENT

NO MEDICOLEGAL SUIT

TASKS

RAPPORT ------------------------------------------------------------------------->

DIAGNOSIS ---------------------------------------------------------------------->

ADVICE ---------------------------------------------------->

TREATMENT ---------------------------->

ADVICE ---------------->

Quality Standards:

Rational, effective, efficient, humane

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CLINICAL DIAGNOSIS

DATA NEEDED

SIGNSSYMPTOMSPERSONAL DATA OF PATIENT

PROCESSING OF DATA

PATTERN RECOGNITION-realization that the patient’s presentation conforms to apreviously 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

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PARACLINICALDIAGNOSTIC PROCEDURE

INDICATION

DATA NEEDED

PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS

PROCESSING OF DATA

CERTAINTY OF CLINICAL Dx 1O Dx 1% ------------------------------------------- 99%

needed------------------------------------not needed

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

OUTPUT EXPECTED

DIAGNOSTIC PROCEDURE NEEDED orNOT NEEDED

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PARACLINICAL

DIAGNOSTIC PROCEDURESELECTION

DATA NEEDED

OPTIONS OF DIAGNOSTIC PROCEDURES

SELECTION PROCESS

Options Benefit Risk Cost Availability123

OUTPUT EXPECTED

MOST COST-EFFECTIVEDIAGNOSTIC PROCEDURE

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TREATMENTSELECTION

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!

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SURGICAL TREATMENTPREOP PREPARATION

INFORMED CONSENT PSYCHOSOCIAL SUPPORT OPTIMIZATION SCREENING OPERATIVE MATERIALS

SURGICAL TREATMENT INTRAOP MANAGEMENT

PHASES

INCISION EXPOSURE INTRAOP EVALUATION OPERATIVE PROCEDURE PROPER HEMOSTASIS CHECK CORRECT COUNT WOUND CLOSURE

Quality Standards:

GENTLE

METICULOUS and PRECISE

NO IATROGENIC INJURIES

NO UNNECESSARY MOVESEVERY MOVE HAS A REASON!

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SURGICAL TREATMENT POSTOP CARE

SUPPLY BASIC NEEDS OF PATIENT COMFORT

ANALGESICS FLUID AND ELECTROLYTES NUTRITION

SUPPORT ORGAN FUNCTION WOUND CARE MONITORING FOR COMPLICATIONS ADVICE ON

HOME CARE FOLLOW-UP PLAN

SURGICAL TREATMENT FOLLOW-UP PLAN

OBJECTIVES:

EVALUATE TREATMENT OUTCOME PROVIDE PSYCHOSOCIAL SUPPORT

MONITORING GUIDELINE:

PHYSICAL EXAMINATIONSYMPTOM-DIRECTED

INVESTIGATION

FF-UP FREQUENCY GUIDELINES: CONSIDER USUAL COURSE OF DISEASE PERSONALITY OF PATIENT PATIENT’S CONVENIENCE

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STEPS IN THE MANAGEMENT OF A PATIENT

M.D.||v

PATIENT----------------------------------------------------------------------------------------------GOALS

||

|

Interview --------------------------------------|--------------------------------Physical exam (symptoms) | (signs)

|Clinical Diagnostic Process

| Pattern recognition| Prevalence|

Clinical Diagnosis ------------------------------------Advice| || Paraclinical Diagnostic | Procedure -------------------------Advice| || | - Indication| | - Selection (benefit/risk/cost/avail)| | - Interpretation| |

Pretreatment Diagnosis ----------------------------Advice|||

Selection of Treatment -----------------------------Advice (Benefit/risk/cost)

|||

Treatment ---------------------------------------------Advice|||

Health Promotion and Maintenance ----------------------Advice

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MAXIMS, RULES, AND GUIDES IN THE MANAGEMENT OF A PATIENT

BASIC MAXIMS

1. Nothing is absolute in medicine.1.1 There are exceptions to the rules.1.2 Anything is possible.

1.3 There are more than one way of doing things in medicine.1.4 There is no such thing as absolutely certain diagnosis, whether it be clinical,

paraclinical, histopathologic, or postmortem diagnosis.

2. The only routine in medicine is a rational decision-making in the management of a patient with

a health problem.2.1 Rational decision-making weighs the probability of being successful in the

achievement of the goals in the management of a patient.2.2 Rational decision-making relies more on general rules than on the exceptions.2.3 Rational decision-making banks on the more common rather than on the least

common or rare events.2.4 Rational decision-making uses processes rather than gut-feel.2.5 A rational decision-making may not always be correct. As long as the decision-

making is rational, it is acceptable. A rational decision-making is more oftencorrect than wrong compared to an irrational decision-making.

2.6 A decision-making is deemed correct only after its implementation has resulted in theachievement of the goals in the management of a patient.

THE DIAGNOSTIC PROCESS AND THE DIAGNOSIS

1. The diagnostic process starts from the time a physician sees the patient up to after treatment.2. A diagnosis is an identification label of the patient’s health problem.3. The diagnostic process must be rational for it to be acceptable.4. A diagnosis that is based on a rational process is not always correct. However, a diagnosis is

more often correct than wrong if it is rationally arrived at.5. A diagnosis is almost always an educated guess.

INTERVIEW AS A DIAGNOSTIC TOOL

1. Identify the chief complaint or main problem of the patient. Once identified, use it as thesteering wheel in the diagnostic investigation of the patient.1.1 Inquire on the circumstances associated with the chief complaint.1.2 Inquire on symptoms. Symptoms are those manifestations perceived by the patient.1.3 Get clues from the “circumstances and symptoms” to be used in the diagnosis of the

patient.2. Be effective. Be complete. Be efficient. Be relevant.3. Know how to get cues from data.

to interpret data.

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4. Know which data to pursue.to put in the background.to use in the diagnosis.not to use in the diagnosis.

PHYSICAL EXAMINATION AS A DIAGNOSTIC TOOL

1. Use the identified chief complaint or main problem of the patient as a guide on what to examine.

1.1 Look for signs. Signs are those manifestations perceived by the physicians.1.2 Get clues from the signs to be used in the diagnosis of the patient.

2. Be effective. Be accurate. Be complete. Be efficient. Be relevant.3. Know how to get cues from data.

to interpret data.4. Know which data to pursue.

to put in the background.to use in the diagnosis.not to use in the diagnosis.

INTERVIEW AND PHYSICAL EXAMINATION

1. Interview and physical examination can be done in any order as dictated by the circumstances.2. Interview and physical examination can be done simultaneously.3. The goal of interview and physical examination is diagnosis.4. Correlate data from interview and physical examination to come out with a rational clinical

diagnosis.5. If there is a question on which data to put more reliance on, choose the “sign” data over

“symptom” data. Remember, however, that for the “sign” data to be reliable, they mustbe accurate.

CLINICAL DIAGNOSTIC PROCESS

1. A clinical diagnosis is one that is derived from the interview and physical examination, or put in another way, it is one that is derived from the symptoms and signs.2. After the interview and physical examination, the symptoms and signs are analyzed to come out with a clinical diagnosis. Essentially, two processes are used in coming out with a clinicaldiagnosis. These two processes are pattern recognition and prevalence.3. Pattern recognition means the realization that the patient’s presentation conforms to a

previously learned picture or pattern of disease.4. Prevalence means the 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 andsystem.

5. Elemental steps in making a diagnosis:5.1 Identify which organ or tissue or system is involved.5.2 Then, identify the disease in general terms, such as inflammation, infection, tumor,

trauma, endocrine, etc.

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5.3 Then, try to be more specific in identifying the disease, if possible, such as malignantneoplasm, abscess, etc.

6. Knowing the nomenclature of diseases facilitates diagnostic labeling.

PARACLINICAL DIAGNOSTIC PROCESS

1. After the clinical diagnosis, the next step to do is to determine whether a paraclinical diagnostic

procedure is needed or not. A paraclinical diagnostic procedure is a diagnostic procedure that is done after the clinical diagnosis is arrived at and its objective is to make the diagnosis more definite.

2. To decide whether a paraclinical diagnostic procedure is needed or not, a physician shouldconsider the following factors:2.1 How certain he is with the clinical diagnosis.

If he is quite certain or very certain, in general, a paraclinical diagnostic procedure is not needed. The quite certain clinical diagnosis becomes automatically the pretreatment diagnosis.If he is not quite certain or uncertain, in general, a paraclinical diagnosticprocedure is needed.In general, a clinical diagnosis is said to be quite certain if it is based primarily on signs that are reinforced by the symptoms and prevalence data.A clinical diagnosis is said to be uncertain if it is based primarily on symptomsor on prevalence data.

2.2 Whether a more definite diagnosis is needed or not for some reasons or another.If the contemplated treatment procedure is mutilating, risky, etc., then a more

definite diagnosis is needed. If the treatment for the differential diagnosis is the same as that for the primary

clinical diagnosis, then a paraclinical diagnostic procedure may not beneeded. If it is different, then a more definite diagnosis is indicated.

3. Once a decision is made that a paraclinical diagnostic procedure is needed, the next step is to choose the most cost-effective procedure for the patient by considering the various factors (tabulate, compare, and analyze):

Procedures Benefit (goal) Risk Cost AvailabilityOption1Option2Option3

4. After the paraclinical diagnostic procedure has been done, the next step is to interpret the result.

The result of the paraclinical diagnostic procedure must be correlated with the signs andsymptoms of the patient to come out with a pretreatment diagnosis.

SELECTION OF TREATMENT

1. Selection of treatment procedure is based primarily on the pretreatment diagnosis.

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2. Select the most cost-effective treatment for the patient after considering the various factors(tabulate compare, and analyze):

Treatment Benefit (goal) Risk Cost AvailabilityOption1Option2Option3

3. The final decision on the type of treatment to institute will rest on the patient.4. Know when and to whom to refer.

ADVICE AND INFORMED CONSENT

1. After the interview and physical examination and after the physician has arrived to a clinicaldiagnosis, the next step is to advise the patient on the nature of his health problem.

2. After the clinical diagnosis has been explained to the patient and/or his relatives, the next stepis to advise whether a paraclinical diagnostic procedure is needed or not. If a paraclinical diagnostic procedure is needed, the patient is informed of the various options. He is advised on the most cost-effective option. Performing the paraclinical diagnosticprocedure can only be carried out after the physician has secured an informed consent from the patient.

3. After the paraclinical diagnostic procedure has been performed, the next step is to advise thepatient on the results.

4. After a pretreatment diagnosis has been gotten, the next step is to inform the patient on thevarious options of treatment. He is advised on the most cost-effective treatment option.Carrying out the treatment procedure can be done only after the physician has secured aninformed consent from the patient.

5. After treatment, the patient should be advised on the results and subsequent management, specifically follow-up. The patient should also be given advice on health maintenance.

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ADVISING PATIENTS AND RELATIVES

A physician deals with both patients and their relatives or guardians.

A successful physician-patient-relative relationship is based on the establishment and maintenance of good rapport initiated and accomplished by the physician. A good rapport basically emanates from the trust and confidence given by the patient-relative to the physician. This trust and confidence can be gained by the physician through many ways. The following are some qualities of the physician that will promote trust and confidence of the patient-relative:

Competent physicianHonestGentleCompassion and shows concernCourteousPatient, persevering, and understanding

Advising a patient and his relatives is a major pathway through which a rapport can be established and maintained by the physician.

In managing a patient, advising is usually needed on:

1. clinical diagnosis2. need for a paraclinical diagnostic procedure3. nature of a paraclinical diagnostic procedure4. results of a paraclinical diagnostic procedure5. plan of treatment6. outcome of treatment7. prognosis of the disease8. maintenance of health after treatment

Advising a patient and his relatives on any matter can make or break the physician-patient-relative relationship. Thus, it is important that the physician knows how to advise.

The following are tips in advising: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.For example, slowly divulge the diagnosis of an incurable disease or a frightening disease.

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

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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KNOWING WHEN AND TO WHOM TO REFER

There will always be patients whose health problems will be beyond a physician’s existing competencies.

Such patients may have a very unusual health problem whose diagnosis is extremely difficult.

Such patients may have usual health problems but whose treatment is beyond a physician’s existing competencies (example - a primary health care physician who has not been trained to do a surgical operation).

Whether a person is still in medical school or has graduated, there will always be patients whose health problems are beyond his present existing competencies.

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.

Refer means asking for help from and conferring with colleagues. Referring a patient to a colleague may mean totally transferring the care of a patient to him or continuing to manage the patient with his help. A proper communication either oral or written is in order.

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

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Management of a Surgical PatientReynaldo O. Joson, MD, MS Surg

Formative Evaluation/Summative Evaluation

(Based on Learning Objectives)

I. Answer as concisely as you can.

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).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.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 managementstarting from the incision to wound closure.

10. 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. *The answers can easily be found in the text of this self-instructional program.

II. Choose the best answer/Analyze and decide as instructed:

1. The most cost-effective way of managing the problem of a legal suit (potential and actual) in a medical practice is:

A. Ordering all possible screening laboratory examinationsB. Establishing good rapport with the patient and his relativesC. Asking all patients to sign a waiver of physician’s liabilitiesD. Securing a malpractice insurance

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2. A patient walks into your health clinic to consult you. You should initially establish which of the functions of a physician?

A. DiagnosisB. Treatment

C. AdviceD. Rapport

3. Determine the clinical diagnostic process used in the various scenarios.

A. Pattern recognitionB. PrevalenceC. Pattern recognition and prevalence

3.1 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.

3.2 Knowing the common manifestations with its usual temporal sequence of 3 differentdiseases as follows:

Disease A - a-b-c-d (manifestations)Disease B - b-c-d-a Disease C - a-b-d-c

Given a patient manifesting with a-b-c-d, your diagnosis is Disease A.

3.3 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.

3.4 Knowing the common manifestations of 3 different diseases and relative frequency of each as follows:Disease A - abcd (manifestations) Least commonDisease B - abde Disease C - abdf Most common

Given a patient manifesting with abcd, your diagnosis is Disease A.

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

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4. Determine whether a paraclinical diagnostic procedure is indicated or not in the various scenarios. Write (I) if indicated and (NI) if not indicated.

Certainty Plan of Treatment4.1

Primary clinical diagnosis 98% Surgical

Secondary clinical diagnosis 1-2% Nonsurgical

4.2 Primary clinical diagnosis 60% SurgicalSecondary clinical diagnosis 40% Nonsurgical

4.3 Primary clinical diagnosis 60% Surgical excisionSecondary clinical diagnosis 40% Surgical excision

4.4Primary clinical diagnosis 90% Mutilating operationSecondary clinical diagnosis 10% Nonmutilating operation

4.5 Primary clinical diagnosis 70% ChemotherapySecondary clinical diagnosis 40% Radiotherapy

5. 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 are certain ofD. When you are not certain of your clinical diagnosis

6. Determine what paraclinical diagnostic procedure should be selected in the various scenarios.Write your choice in term of the option number enclosed in parenthesis, like so (#).

Procedure Benefit Risk Cost (PhP) AvailabilityOptions

6.11 most direct acceptable 1000 available2 indirect acceptable 1500 available3 indirect acceptable 1000 available

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

296. Determine what paraclinical diagnostic procedure should be selected in the various scenarios.Write your choice in term of the option number enclosed in parenthesis, like so (#).

Procedure Benefit Risk Cost (PhP) AvailabilityOptions

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

6.41 yield 90% acceptable 2000 available2 yield 90% acceptable 2500 available3 yield 95% acceptable 4000 available

7. 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.

8. Determine what treatment modality should be selected in the various scenarios.Write your choice in term of the option number enclosed in parenthesis, like so (#).

Procedure Benefit Risk Cost (PhP) Availability

8.11 greatest survival rate acceptable 5000 available2 rate < 1 > 3 acceptable 4000 available3 least survival rate(SR) acceptable 3000 available

8.2 1 SR1 = SR2 lesser 5000 available

2 SR2= SR1 more 5000available

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

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

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9. To whom will you refer your patient for further management? Somebody who is

A. well-known because of his frequent exposure in the media.B. well-known because of his extensive research.C. a certified specialist by both American and Philippine medical societies.D. known for his good outcome in management.E. a well-known academician in the premier medical school in the Philippines

See answers on the next page.

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Management of a Surgical PatientReynaldo O. Joson, MD, MS Surg

AnswersFormative Evaluation/Summative Evaluation

(Based on Learning Objectives)

I. See answers in the text.

II. Choose the best answer/Analyze and decide as instructed:

1. B2. D3. 3.1 A 3.2 A3.3 C3.4 A3.5 B4. 4.1 (NI)4.2 (I)4.3 (NI) 4.4 (I)4.5 (I) 5. D6. 6.1 (1) 6.2 (2)6.3 (1)6.4 (1)7.7.1 (A)7.2 (A)7.3 (H)7.4 (H)88.1 (1)8.2 (1)8.3 (2)8.4 (1)9. D

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RECOMMENDED FOLLOW-UP

Learning should not stop after reading this self-instructional program.

I strongly advise you to apply what you learned in this program to actual patients.

Remember there are so many ways of doing things and there is the option to refer. Remember what counts in the end is a resolution of the health problem in such a way

that the patient does not end up dead or disabled and in such a manner thatthe patient and his relatives are satisfied and you don’t have a medicolegal suitin your hand.

Lastly, remember also that your problem-solving and decision-making will be judged bythe following criteria:

Rational - with basisEffective - achievement of goalsEfficient - achievement of goals in least time, cost, and effortHumane or with compassion - you are guided by the golden rule

The maxims, rules, and guides in this self-instructional program can be applied to any kind of patient and I think they will withstand the test of time. So, master it.

REFERENCES

There are no specific references that I used for this program. I did not refer to any books, manuals, or journals when I wrote this program. With the intended readers and objectives in mind, I made a topic outline and then developed each topics. I incorporated my past writings. I relied heavily on myself, especially, on my 19 years of experience in medical education and 25 years of experience as a surgeon.

ABOUT THE AUTHOR

Dr. Reynaldo O. Joson is presently an associate professor at the Department of Surgery of the University of the Philippines, College of Medicine. He was previously the Chief of the Division of the Head and Neck, Breast, Esophagus, and Soft Tissue Surgery of the Department of Surgery at the Philippine General Hospital (1994-2000).

He is currently the chair of the Department of Surgery of Ospital ng Maynila Medical Center (2001-).

He finished his residency in general surgery at the Philippine General Hospital in 1981. He is a diplomate of the Philippine Board of Surgery.

He obtained his Master of Science in General Surgery from the University of the Philippines College of Medicine in 1998. He is also a holder of Master in Hospital Administration and Master in Health Profession Education.

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