Approach To The Surgical Patient

Approach to the Surgical Patient Department of Gastrointestinal Surgery Dr. Wang Ailiang

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

surgeon • Doctor in the oldfashioned sense • Applied scientist • Engineer • Artist • A minister to his or her fellow human beings

Eduardo Bassini (1844-1924)

The history • Gain the patient’s 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

Building the history • • • • •

Detective work Inductive reasoning → diagnosis Determine the facts Search for essential clues Patient may conceal the most important symptom

Building the history (special emphasis) • • • • • • •

Pain Vomiting Change in bowel habits Hematemesis or hematochezia Trauma Family history Patient’s emotional background

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)

Pain (attention) • Patient’s 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 an injection of morphine

vomiting • • • •

What? How much? How often? What did the vomitus look like? • Projectile? • See the vomitus

Change in Bowel Habits • Regular evacuation → distinct change • Intermittent alterations of constipation and diarrhea → colon cancer? • Size and shape of stool

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?

Hematemesis or Hematochezia • The most common error: bleeding from rectum →→hemorrhoids

Trauma • The patient’s position when the accident occurred? • Consciousness lost? • Retrograde amnesia? (inability to remember events just preceding the accident → cerebral damage

Trauma Brain damage can be excluded

Remember every detail Of an accident

Has not lost consciousness

No evidence of external Injury to head

Trauma Gunshot and stab wound

Nature of weapon

Size and shape

Probable trajectory

The position of patient when hit

Family History polyposis Other Endocrine abnormalities

cancer

diabetes Family history related

Multiglandular syndromes

PeutzJeghers syndromes

Chronic pancreatitis

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 review must be formalized and thorough.

Past History • Important to consider the nutritional background of the patient • Malnourished patient responds poorly to disease, injury, and operation • Carcinoma can be more fulminating in malnourished patient • Malnourishment can be elicited by questioning

Past History • Acute nutritional deficiencies, particularly fluid and electrolyte losses, can be understood only in the light of the total history. • Diuretics or sodium-restricted diet→ low serum sodium

Past History • Detailed history: helpful in estimating the probable trends in serum electrolyts. • Vomiting without bile→ maybe → acute pyloric stenosis with benign ulcer → hypochloremic alkalosis • Chronic vomiting without bile, with previously digested food → chronic obstruction, carcinoma should be considered

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 of the history and the physician’s clinical experience

Past History • Laboratory data should be obtained as soon as possible • The possible course may be: detailed history→ analysis, estimate→ therapy (experience)→ laboratory data→ adjust therapy (scientific)

Patient’s Emotional Background • Psychiatric consultation seldom required in surgery, but great helpful • Before or after operation→psychotic disturbance→psychiatrist • Most of time :surgeon can deal with

Patient’s Emotional Background • Importance of psychosocial factors in surgical convalescence • The patient: emotional, social, economic, family…..problems have nothing to do with the illness itself

Physical Examination • Physical examination • Certain special procedures: gastroscopy, esophagoscopy, laborotory tests, X-ray examination etc. • Follow-up examination

Physical Examination • Prevent unecessary thoroughness • Painful, inconvenient, and costly procedures should not be ordered unless it’s necessary in making clinical decisions.

Elective Physical Examination • Good habit in orderly and detailed fashion→→no step omitted • Modify the routine in emergency • Complete examination help the beginner to know the nomal and the abnormal

Elective Physical Examination • All patients examined: sensitive, somewhat embarrassed • How to let patients relax: examining room, comfortable table, drapes, talk a bit (taking history)

Elective Physical Examination • Timehonored essential steps: inspection, palpation, auscultation, percussion • Successful palpation requires skill and gentleness • Palpation: the laying on of hands that has been called part of the ministry of medicine

Elective Physical Examination • A disappointed and critical patient often will say of a doctor: “He hardly touched me.” • Careful, precise, and gentle palpation not only gives the physician the information being sought but also inspires confidence and trust.

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 in surgery.

Examination of the Body Orifices • • • •

Ears Mouth Rectum Pelvis

Emergency Physical Examination • • • • •

Primary considerations: Breathing? Airway open? Pulse? Heart beating? Massive bleeding?

Emergency Physical Examination • Alter the routine P.E. to to fit the circumstances • History: left for later consideration, limited to a single sentence or no history (unconscious patient)

Emergency Physical Examination • No breathing, airway obstruction: thrust the fingers into mouth and pull tongue forward • Unconscious: intubate and start mouth-tomouth respiration • No pulse or heartbeat: cardiac resuscitation • Massive bleeding from extremity: elevation and pressure

Emergency Physical Examination • After emergency treatment, a rapid survey examination must be done. • Failure to do → serious mistakes

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

Laboratory And Other Examinations • Laboratory examinations • Imaging studies • Special examinations

Laboratory examinations Objectives : • ⑴Screening for asymptomatic disease that may affect surgical result (unsuspected anemia or diabetes) • ⑵Appraisal of diseases that may contraindicate elective surgery or require treatment before surgery (diabetes, heart failure) • ⑶Diagnosis of disorders that require surgery ( hyperparathyroidism, pheochromocytoma) • ⑷Evaluation of the nature and extent of metabolic or septic complications

Laboratory examinations • A complete blood and urine examination is necessary. • A history of renal, hepatic, or heart disease requires detailed studies.

Laboratory examinations • Medical consultation required in total appraisal • The total management must be surgeon’s responsibility and is not to be delegated.

Imaging studies • To avoid serious mistakes ← closest cooperation between the radiologist and the surgeon • Surgeon should provide an adequate account of the history and physical findings, especially in emergency

Imaging studies • Radiologic diagnosis (not definitive) →repeated examination in history and P.E. • Negative X-ray, doesn’t exclude ulcer or neoplasm. Such as small lesion in right colon • Clear diagnosis with history and P.E., operation despite negative imaging studies

Special examinations • • • • • •

Cystoscopy Gastroscopy Esophagoscopy Colonoscopy Angiography bronchoscopy

Special examinations • Be familiar with indications and limitations • Make good use for diagnostic appraisal of surgical disorders