Management of a Patient (All Types) - ROJoson

Management of a Patient
[Process]
Reynaldo O. Joson, MD, MS Surg
2001;2002

Management of a Patient [Process]
Introduction

Introduction
Practice of medicine - essentially management of a patient,
a person with a health problem
Patient – surgical and nonsurgical
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

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

Introduction
All primary health care physicians are expected at least to
know the basic processes in the management of a
patient.
This learning session gives an overview of the processes
involved in the management of a patient.

Learning Objectives

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.

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.

Learning Objectives
For surgical patient
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.
10. Enumerate at least 4 items in the immediate
postoperative care of a surgical patient.

Learning Objectives
For nonsurgical patient
8. Enumerate the essential items in the pretreatment
preparation of a nonsurgical patient.
9. Enumerate in correct chronological order phases in
the intratreatment management of a nonsurgical
patient.
posttreatment care of a nonsurgical patient.

Learning Objectives
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.

Facilitator’s
Approach to
Learning Session

• 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.

Goals

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

MD’s Tasks

TASKS
RAPPORT
DIAGNOSIS
ADVICE
TREATMENT
ADVICE
Quality Standards:
Rational, effective, efficient, humane
G
O
A
L
S

Rapport

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

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

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

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).

Clinical Diagnostic
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

CLINICAL DIAGNOSTIC PROCESS
DATA NEEDED
SYMPTOMS (from interview or history)
SIGNS (from physical examination)
PERSONAL DATA OF PATIENT

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

OUTPUT EXPECTED
RATIONAL
-PRIMARY CLINICAL DIAGNOSIS
-SECONDARY CLINICAL DIAGNOSIS

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

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

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

Paraclinical
Diagnostic Process

Paraclinical Diagnostic Process
Indication - to be more definite on the clinical diagnosis
Selection
Interpretation

Paraclinical Diagnostic Process - Indication
DATA NEEDED
PRIMARY CLINICAL DIAGNOSIS
SECONDARY CLINICAL DIAGNOSIS

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

OUTPUT EXPECTED
DIAGNOSTIC PROCEDURE
NEEDED or
NOT NEEDED

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)

Primary clinical diagnosis 60% Surgical
Secondary clinical diagnosis 40% Nonsurgical
YES

Primary clinical diagnosis 60%Surgical Excision
Secondary clinical diagnosis 40%Surgical Excision
NO unless there is a strong reason to do so (exception to
the rule)

Primary clinical diagnosis 90% Mutilating Op
Secondary clinical diagnosis 10%
Nonmutilating Op
YES unless there is a strong reason NOT to do so
(exception to the rule)

Primary clinical diagnosis 70% Chemotherapy
Secondary clinical diagnosis 30%
Radiotherapy
YES unless there is a strong reason NOTto do so
(exception to the rule)

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

Paraclinical Diagnostic Process - Selection
DATA NEEDED
OPTIONS OF
DIAGNOSTIC PROCEDURES

SELECTION PROCESS
Options Benefit Risk Cost Availability
1
2
3

OUTPUT EXPECTED
MOST COST-EFFECTIVE

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

SELECTION PROCESS
Options
1 accuracy 99% acceptable 5000 available
Option 2 or Option 1?

SELECTION PROCESS
Options
Option 2 or Option 1?

SELECTION PROCESS
Options
1 yield greatest acceptable 4000 available
2 yield 90% acceptable 4000 available
3 yield 80% acceptable 3000 available
Option 1

Paraclinical Diagnostic Process - Interpretation
DATA NEEDED
PRIMARY CLINICAL DIAGNOSIS
SECONDARY CLINICAL DIAGNOSIS
RESULT OF PARACLINICAL

INTERPRETATION PROCESS
CORRELATE
RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE
WITH
PRIMARY AND SECONDARY CLINICAL DIAGNOSIS
CONGRUENT - ACCEPT
INCONGRUENT - MAKE A DECISION!
(Accept or Hold!)

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

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.

Learning Objectives
7. Describe how a treatment modality should be selected
among several options.
For surgical patient
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.
postoperative care of a surgical patient.

Learning Objectives
For nonsurgical patient
8. Enumerate at least 4 essential items in the pretreatment
preparation of a nonsurgical patient.
9. Enumerate in correct chronological order phases in
the intratreatment management of a nonsurgical
patient.
posttreatment care of a nonsurgical patient.

Learning Objectives
11. Enumerate the two objectives of a follow-up plan after
treatment of a patient (whether surgical or not).

Treatment Process

Treatment Process - Selection
DATA NEEDED
PRETREATMENT DIAGNOSIS
SEVERITY OR STAGE
GOALS AND OBJECTIVES
TREATMENT OPTIONS

SELECTION PROCESS
Options Benefit Risk Cost Availability
1
2
3

OUTPUT EXPECTED
MOST COST-EFFECTIVE
TREATMENT PROCEDURE
ACHIEVEMENT OF GOALS OF
PATIENT MANAGEMENT!

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

SELECTION PROCESS
Options
1 SR1 = SR2 lesser 5000 available
2 SR2= SR1 more 5000 available
Which is the more cost-effective treatment option?
Option 1

SELECTION PROCESS
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

SELECTION PROCESS
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

Surgical Treatment Process
PREOP PREPARATION

Surgical Treatment Process - Preop Preparation
•INFORMED CONSENT
•PSYCHOSOCIAL SUPPORT
•OPTIMIZATION
•SCREENING
•OPERATIVE MATERIALS

Nonsurgical Treatment
Process
PRETREATMENT
PREPARATION

Nonsurgical Treatment Process - Pretreatment
Preparation
•INFORMED CONSENT
•PSYCHOSOCIAL SUPPORT
•OPTIMIZATION
•SCREENING
•NONSURGICAL TREATMENT
MATERIALS

INTRAOP
MANAGEMENT

Surgical Treatment Process - Intraop Mgt
PHASES
•INCISION
•EXPOSURE
•INTRAOP EVALUATION
•OPERATIVE PROCEDURE PROPER
•HEMOSTASIS CHECK
•CORRECT COUNT
•WOUND CLOSURE

Surgical Treatment Process - Intraop Mgt
Quality Standards:
GENTLE
METICULOUS and PRECISE
NO IATROGENIC INJURIES
NO UNNECESSARY MOVES
EVERY MOVE HAS A REASON!

Process
INTRATREATMENT
MANAGEMENT

Nonsurgical Treatment Process - Intratreatment
Mgt
PHASES
Example: Intramuscular Administration of Drugs
• Prepping of needle puncture site
• Insertion of needle
• Administration of parenteral drugs
• Removal of needle
• Pressure to control and stop bleeding

Nonsurgical Treatment Process - Intratreatment
Mgt
PHASES
Example: Oral Administration of Drug
• Prepare water to be used to swallow drug
• Open the wrapper of the drug
• Examine the drug
• Patient places drug inside mouth
• Patient places water inside mouth
• Patient swallows water with drug

POSTOP CARE

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

Process
POSTTREATMENT CARE

Nonsurgical Treatment Process - Posttreatment
Care
•SUPPLY BASIC NEEDS OF PATIENT
•COMFORT
•ALLAYANCE OF FEAR
•MONITORING FOR COMPLICATIONS
•ADVICE ON
•HOME CARE
•FOLLOW-UP PLAN

POSTOP FOLLOW-UP
PLAN

Surgical Treatment Process - Postop Follow-up
Plan
OBJECTIVES:
•EVALUATE TREATMENT OUTCOME
•PROVIDE PSYCHOSOCIAL SUPPORT
MONITORING GUIDELINE:
PHYSICAL EXAMINATION
SYMPTOM-DIRECTED
INVESTIGATION

Surgical Treatment Process - Postop Follow-up
Plan
FF-UP FREQUENCY GUIDELINES: CONSIDER
•USUAL COURSE OF DISEASE
•PERSONALITY OF PATIENT
•PATIENT’S CONVENIENCE

Process
POSTTREATMENT
FOLLOW-UP PLAN

Follow-up Plan
OBJECTIVES:
•EVALUATE TREATMENT OUTCOME
•PROVIDE PSYCHOSOCIAL SUPPORT
MONITORING GUIDELINE:
PHYSICAL EXAMINATION
SYMPTOM-DIRECTED
INVESTIGATION

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

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.

HOW TO GIVE
ADVICES

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 advise. 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.

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.

REFERRAL
WHEN
TO WHOM

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.

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.

HOPE
u have enjoyed this
learning session!

Management of a Patient (All Types) - ROJoson

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