Download - 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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Elective Physical Examination
All patients examined:
sensitive, somewhat
embarrassed How to let patients relax:
examining room, comfortable
table, drapes, talk a bit (takinghistory)
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Elective Physical Examination
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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Elective Physical Examination
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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Emergency Physical Examination
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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Emergency Physical Examination
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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Emergency Physical Examination
After emergency treatment, a
rapid survey examination must
be done. Failure to do serious
mistakes
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Emergency Physical Examination
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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Laboratory examinations
A complete blood and urine
examination is necessary.
A history of renal, hepatic, orheart disease requires detailed
studies.
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Laboratory examinations
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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Special examinations
Cystoscopy
Gastroscopy
Esophagoscopy
Colonoscopy
Angiography
bronchoscopy
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Special examinations
Be familiar with indications
and limitations
Make good use for diagnosticappraisal of surgical disorders
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