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Management of a Surgical Patient (Process) - 2014

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2014-updated slide presentation.

2014-updated slide presentation.

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  • 1. Management of a Surgical Patient [Process] Reynaldo O. Joson, MD, MS Surg 1998; 2001; 2003; 2004;2014
  • 2. Management of a Surgical Patient [Process] Introduction
  • 3. 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 disorder Surgical disorder - health problem or condition that is treated by surgery or an operation Nonsurgical patient - one with a nonsurgical disorder
  • 4. 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
  • 5. 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.
  • 6. Management of a Surgical Patient [Process] Learning Objectives
  • 7. 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). 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.
  • 8. Management of a Surgical Patient [Process] Learning Objectives 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 management starting from the incision to wound closure.
  • 9. Management of a Surgical Patient [Process] Learning Objectives 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.
  • 10. 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
  • 11. Facilitator’s Approach to Learning Session Management of a Surgical Patient [Process]
  • 12. 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.
  • 13. Management of a Surgical Patient [Process] Goals
  • 14. MANAGEMENT OFA PATIENT PROBLEM-SOLVING AND DECISION-MAKING
  • 15. 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
  • 16. Management of a Surgical Patient [Process] MD’s Tasks
  • 17. MANAGEMENT OF A PATIENT PROBLEM-SOLVING AND DECISION-MAKING TASKS RAPPORT DIAGNOSIS ADVICE TREATMENT ADVICE Quality Standards: Rational, effective, efficient, humane G O A L S
  • 18. Management of a Surgical Patient [Process] Rapport
  • 19. 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
  • 20. Management of a Surgical Patient [Process] Rapport Some ways of establishing rapport with patient and his/her relatives: 1. Being courteous 2. Showing respect to person and beliefs 3. Giving honest and clear advice on diagnosis, paraclinical diagnostic procedures, and treatment 4. Demonstrating humaneness and compassion
  • 21. 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 expenses 8. Making the patient and relatives feel that you are approachable and easy to talk to
  • 22. 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).
  • 23. Management of a Surgical Patient [Process] Clinical Diagnostic Process
  • 24. 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
  • 25. CLINICAL DIAGNOSTIC PROCESS DATA NEEDED SYMPTOMS (from interview or history) SIGNS (from physical examination) PERSONAL DATA OF PATIENT
  • 26. CLINICAL DIAGNOSTIC PROCESS PROCESSING OF DATA PATTERN RECOGNITION -realization that the patient’s presentation conforms 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
  • 27. CLINICAL DIAGNOSTIC PROCESS OUTPUT EXPECTED RATIONAL -PRIMARY CLINICAL DIAGNOSIS -SECONDARY CLINICAL DIAGNOSIS
  • 28. CLINICAL DIAGNOSTIC PROCESS PROCESSING OF DATA PATTERN RECOGNITION -realization that the patient’s presentation conforms 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
  • 29. CLINICAL DIAGNOSTIC PROCESS PROCESSING OF DATA Knowing the common manifestations of 5 different diseases as follows: Disease A - abcd (manifestations) Disease B - fghi Disease C - klmn Disease D - pqrs Disease E - uvwx Given a patient manifesting with pqrs, your diagnosis is Disease D. What is the process used? Pattern Recognition
  • 30. 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 common Disease 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
  • 31. 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
  • 32. CLINICAL DIAGNOSTIC PROCESS PROCESSING OF DATA PATTERN RECOGNITION -realization that the patient’s presentation conforms 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
  • 33. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process
  • 34. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process Indication - to be more definite on the clinical diagnosis Selection Interpretation
  • 35. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Indication DATA NEEDED PRIMARY CLINICAL DIAGNOSIS SECONDARY CLINICAL DIAGNOSIS
  • 36. 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 Dx Different Same needed not needed
  • 37. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Indication OUTPUT EXPECTED DIAGNOSTIC PROCEDURE NEEDED or NOT NEEDED
  • 38. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Indication Certainty Plan of Treatment Primary clinical diagnosis 98% Surgical Secondary 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)
  • 39. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Indication Certainty Plan of Treatment Primary clinical diagnosis 60% Surgical Secondary clinical diagnosis 40% Nonsurgical Is a paraclinical diagnostic procedure needed? YES
  • 40. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Indication Certainty Plan of Treatment Primary clinical diagnosis 60% Surgical Excision Secondary 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)
  • 41. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Indication Certainty Plan of Treatment Primary clinical diagnosis 90% Mutilating Op Secondary 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)
  • 42. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Indication Certainty Plan of Treatment Primary clinical diagnosis 70% Chemotherapy Secondary clinical diagnosis 30% Radiotherapy Is a paraclinical diagnostic procedure needed? YES unless there is a strong reason NOTto do so (exception to the rule)
  • 43. 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 diagnosis B. You want to confirm a clinical diagnosis which are certain of C. You want to document a clinical diagnosis which you are certain of D. When you are not certain of your clinical diagnosis Best Answer is D
  • 44. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Selection DATA NEEDED OPTIONS OF DIAGNOSTIC PROCEDURES
  • 45. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Selection SELECTION PROCESS Options Benefit Risk Cost Availability 1 2 3
  • 46. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Selection OUTPUT EXPECTED MOST COST-EFFECTIVE DIAGNOSTIC PROCEDURE
  • 47. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Selection SELECTION PROCESS Procedure Benefit Risk Cost (PhP) Availability Options 1 most direct acceptable 1000 available 2 indirect acceptable 1500 available 3 indirect acceptable 1000 available Which is the most cost-effective procedure? Option 1
  • 48. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Selection SELECTION PROCESS Procedure Benefit Risk Cost (PhP) Availability Options 1 accuracy 99% acceptable 5000 available 2 accuracy 90% acceptable 3000 available 3 accuracy 50% acceptable 1000 available Which is the most cost-effective procedure? Option 2 or Option 1?
  • 49. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Selection SELECTION PROCESS Procedure Benefit Risk Cost (PhP) Availability Options 1 accuracy 95% acceptable 5000 available 2 accuracy 90% acceptable 3000 available 3 accuracy 50% acceptable 1000 available Which is the most cost-effective procedure? Option 2 or Option 1?
  • 50. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Selection SELECTION PROCESS Procedure Benefit Risk Cost (PhP) Availability Options 1 yield greatest acceptable 4000 available 2 yield 90% acceptable 4000 available 3 yield 80% acceptable 3000 available Which is the most cost-effective procedure? Option 1
  • 51. Management of a Surgical Patient [Process] Paraclinical Diagnostic Process - Interpretation DATA NEEDED PRIMARY CLINICAL DIAGNOSIS SECONDARY CLINICAL DIAGNOSIS RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE
  • 52. 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 - ACCEPT INCONGRUENT - MAKE A DECISION! (Accept or Hold!)
  • 53. 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 diagnosis 7.3 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
  • 54. 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.
  • 55. Management of a Surgical Patient [Process] Learning Objectives 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.
  • 56. Management of a Surgical Patient [Process] Learning Objectives 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).
  • 57. Management of a Surgical Patient [Process] Treatment Process
  • 58. Management of a Surgical Patient [Process] Treatment Process - Selection DATA NEEDED PRETREATMENT DIAGNOSIS SEVERITY OR STAGE GOALS AND OBJECTIVES TREATMENT OPTIONS
  • 59. Management of a Surgical Patient [Process] Treatment Process - Selection SELECTION PROCESS Options Benefit Risk Cost Availability 1 2 3
  • 60. Management of a Surgical Patient [Process] Treatment Process - Selection OUTPUT EXPECTED MOST COST-EFFECTIVE TREATMENT PROCEDURE ACHIEVEMENT OF GOALS OF PATIENT MANAGEMENT!
  • 61. Management of a Surgical Patient [Process] Treatment Process - Selection SELECTION PROCESS Treatment Benefit Risk Cost (PhP) Availability Options 1 greatest surv rate acceptable 5000 available 2 rate < 1 > 3 acceptable 4000 available 3 least surv rate acceptable 3000 available Which is the most cost-effective treatment option? Option 1
  • 62. Management of a Surgical Patient [Process] Treatment Process - Selection SELECTION PROCESS Treatment Benefit Risk Cost (PhP) Availability Options 1 SR1 = SR2 lesser 5000 available 2 SR2= SR1 more 5000 available Which is the more cost-effective treatment option? Option 1
  • 63. Management of a Surgical Patient [Process] Treatment Process - Selection SELECTION PROCESS Treatment Benefit Risk Cost (PhP) Availability Options 1 as effective as 2 acceptable 8000 available 2 as effective as 1 acceptable 4000 available Which is the more cost-effective treatment option? Option 2
  • 64. Management of a Surgical Patient [Process] Treatment Process - Selection SELECTION PROCESS Treatment Benefit Risk Cost (PhP) Availability Options 1 most effective acceptable 2000 available 2 effectivity <1 >3 acceptable 3000 available 3 least effective acceptable 4000 available Which is the most cost-effective treatment option? Option 1
  • 65. Management of a Surgical Patient [Process] Surgical Treatment Process PREOP PREPARATION
  • 66. Management of a Surgical Patient [Process] Surgical Treatment Process - Preop Preparation INFORMED CONSENT PSYCHOSOCIAL SUPPORT OPTIMIZATION SCREENING OPERATIVE MATERIALS
  • 67. Management of a Surgical Patient [Process] Surgical Treatment Process INTRAOP MANAGEMENT
  • 68. Management of a Surgical Patient [Process] Surgical Treatment Process - Intraop Mgt PHASES INCISION EXPOSURE INTRAOP EVALUATION OPERATIVE PROCEDURE PROPER HEMOSTASIS CHECK CORRECT COUNT WOUND CLOSURE
  • 69. Management of a Surgical Patient [Process] Surgical Treatment Process - Intraop Mgt Quality Standards: GENTLE METICULOUS and PRECISE NO IATROGENIC INJURIES NO UNNECESSARY MOVES EVERY MOVE HAS A REASON!
  • 70. Management of a Surgical Patient [Process] Surgical Treatment Process POSTOP CARE
  • 71. Management of a Surgical Patient [Process] Surgical Treatment Process - 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
  • 72. Management of a Surgical Patient [Process] Surgical Treatment Process POSTOP FOLLOW-UP PLAN
  • 73. Management of a Surgical Patient [Process] Surgical Treatment Process - Postop Follow-up Plan OBJECTIVES: EVALUATE TREATMENT OUTCOME PROVIDE PSYCHOSOCIAL SUPPORT MONITORING GUIDELINE: PHYSICAL EXAMINATION SYMPTOM-DIRECTED INVESTIGATION
  • 74. Management of a Surgical Patient [Process] Surgical Treatment Process - Postop Follow-up Plan FF-UP FREQUENCY GUIDELINES: CONSIDER USUAL COURSE OF DISEASE PERSONALITY OF PATIENT PATIENT’S CONVENIENCE
  • 75. Management of a Surgical Patient [Process] Learning Objectives 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.
  • 76. Management of a Surgical Patient [Process] Learning Objectives 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).
  • 77. 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.
  • 78. Management of a Surgical Patient [Process] HOW TO GIVE ADVICES
  • 79. 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.
  • 80. 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.
  • 81. Management of a Surgical Patient [Process] REFERRAL WHEN TO WHOM
  • 82. 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.
  • 83. 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.
  • 84. Management of a Surgical Patient [Process] Learning Objectives
  • 85. 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). 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.
  • 86. Management of a Surgical Patient [Process] Learning Objectives 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 management starting from the incision to wound closure.
  • 87. Management of a Surgical Patient [Process] Learning Objectives 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.
  • 88. Management of a Surgical Patient [Process] HOPE u have enjoyed this learning session! Text or email me for any feedback and questions: 0918-804-03-04 rjoson2001@yahoo.com
  • 89. 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: 0918-804-03-04 rjoson2001@yahoo.com