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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 • Formally
confidence structured
• Convey the • Avoid
assurance of overstructuring
available help and leading
• Patient is a person questions
who need help • novice
• not only a “case”
• Gentle
• considerate
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 No evidence
Has not
every detail of external
lost
Of an Injury
consciousness
accident to head
Trauma
Gunshot
and
stab
wound

The
Nature Size
Probable position
of and
trajectory of patient
weapon shape
when hit
Family History

polyposis
Other
Endocrine diabetes
abnormalities
Family
history Peutz-
cancer related Jeghers
syndromes

Multiglandular
Chronic
syndromes
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-to-
mouth 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