MANAGEMENT OF A SURGICAL PATIENT

REYNALDO O. JOSON, MD, MS Surg 1998; 1999;2001

MANAGEMENT OF A SURGICAL PATIENT Re !"#$% O. J%&%!, MD, MS Surg

TA'LE OF CONTENT

Preface Introduction ..................................................................................................................... Objectives ........................................................................................................................ Recommended Preparations .............................................................................................. Options in Learning the Program ........................................................................................ Authors Approach to the Topic ......................................................................................... A arration of a !ho"e #ase $anagement inc"uding %urgica" Aspect &o' I (sua"") *o It $anagement of a Patient 'ith a Preauricu"ar $ass .............................................................. . $anagement of a %urgica" Patient in an Out"ine ,orm ......................................................... %teps in the $anagement of a Patient ................................................................................. $a.ims/ Ru"es/ and 0uides in the $anagement of a Patient ................................................. Advising Patients and Re"atives .......................................................................................... 2no'ing !hen and To !hom To Refer ............................................................................ ,ormative and %ummative 4va"uation ................................................................................. Ans'ers to ,ormative and %ummative 4va"uation ............................................................... Recommended ,o""o'6up .................................................................................................. References ....................................................................................................................... About the Author ..............................................................................................................
1 1 2 2 2

+ 1+ 221 21 23 25 +2 ++ ++ ++

Primar) Intended (sers 6 %tudents of medicine and primar) hea"th care ph)sicians 4stimated %tud) Time 6 2 hours

Pre(")e *ear Learner/

M"*u+" , !e"come to a "earning e.perience in becoming a hea"th professiona". This program has been especia"") designed 'ith )ou/ the "earner/ and the princip"es of effective teaching and "earning in mind. As )ou go through this "earning program/ p"ease bear in mind the fo""o'ing7 1. I am treating )ou as an adult learner 'hich 1.1 Assumes )ou have "earning aspirations and e.pectations and therefore/ are motivated8 1.2 0ives )ou the privi"ege to use other "earning strategies in achieving the objectives in this program8 1.+ !e"comes )ou to go be)ond the "earning pac9age as )ou so desire8 and 1.1 4.pects discip"ine/ honest)/ and maturit) in fu"fi""ing )our "earning activities. 2. !e sha"" define learning as a positive observab"e change :for the better or improvement; in human behavior/ disposition/ attitude/ performance/ or capabi"it) 'hich persists over a period of time. +. Active "earning strategies and activities 'i"" be uti"i<ed as much as possib"e. 1. The program 'i"" contain "earning materia"s 'hich I thin9 'i"" be relevant to )our being an effective, efficient, and humane hea"th professiona". =. The u"timate goa" of the "earning program is to produce hea"th professiona"s 'ho 'i"" contribute to the health development in the Philippines. 3. !hen I made this program/ I tried m) best to facilitate )our "earning. >ear in mind/ ho'ever/ that I am not infallible. Thus/ ana")<e carefu"") ever)thing in this program. *ont hesitate to offer disagreements and constructive criticisms for o'n "earning and for the improvement of the program. 'e&- ./&+e& (%r " (ru/-(u# #e"r!/!g ./-+ -+e +e#0 %( -+/& 0r%gr"1. Re !"#$% O. J%&%!, MD, MS Surg 1??@81???82--182-11
M"!"ge1e!- %( " Surg/)"# P"-/e!Re !"#$% O. J%&%!, MD, MS Surg

INTRODUCTION

The practice of medicine is essentia"") management of a patient/ a person 'ith a hea"th prob"em. A surgica" patient is a person 'ith a surgica" disorder. A surgica" disorder is a hea"th prob"em or condition that is treated b) surger) or an operation. A nonsurgica" patient is one 'ith a nonsurgica" disorder. Regard"ess of t)pe of patient or disorder/ 'hether surgica" or nonsurgica"/ the basic processes in the management are essentia"") simi"ar. The on") difference "ies in the specific treatment moda"it) and procedure emp"o)ed/ 'hether surgica" or nonsurgica" means. A"" primar) hea"th care ph)sicians are e.pected at "east to 9no' the basic processes in the management of a surgica" patient. Thus/ this se"f6instructiona" program intended for primar) hea"th care ph)sicians and 'hich 'i"" give an overvie' of the processes invo"ved in the management of a surgica" patient. O'JECTI2ES (pon comp"etion of this program/ the user is e.pected to be ab"e to7 1. %tate the overa"" goa"s in the management of a patient :'hether surgica" or not;. 2. 4numerate the four functions of a ph)sician in the management of a patient :'hether surgica" or not;. +. *escribe the c"inica" diagnostic process. 1. *escribe ho' to determine the indication for a parac"inica" diagnostic procedure. =. *escribe ho' a parac"inica" diagnostic procedure shou"d be se"ected among severa" options. 3. *escribe ho' to interpret resu"ts of a parac"inica" diagnostic procedure to come out 'ith a pretreatment diagnosis. 5. *escribe ho' a treatment moda"it) shou"d be se"ected among severa" options. @. 4numerate at "east 1 essentia" items in the preoperative preparation of a surgica" patient. ?. 4numerate in correct chrono"ogica" order 5 phases in the intraoperative management starting from the incision to 'ound c"osure. 1-. 4numerate at "east 1 items in the immediate postoperative care of a surgica" patient. 11. 4numerate the t'o objectives of a fo""o'6up p"an after treatment of a patient :'hether surgica" or not;. 12. *escribe ho' to advice patients on c"inica" diagnosis/ parac"inica" diagnostic procedures/ treatment/ fo""o'6up/ and hea"th promotion and maintenance. 1+. *escribe 'hen and to 'hom to refer. 1

RECOMMENDED PREPARATIONS There are no specific recommended preparations needed for the user to gain benefit from this program. !hat is just reAuired is a motivation to "earn the processes invo"ved in the management of a surgica" patient.

OPTIONS IN LEARNING T3E PROGRAM Bou ma) start 'ith the C,ormative 4va"uationD%ummative 4va"uationE at the end of this program to se"f6eva"uate )ourse"f prior to reading the main te.t or )ou can read the te.t first. The choice is )ours. AUT3OR4S APPROAC3 TO T3E TOPIC I have decided to approach the topic b) giving )ou first a comp"ete b"o'6b)6b"o' account or narration of ho' I usua"") manage a patient. A"though the e.amp"e given is a patient 'ith a preauricu"ar mass/ the processes i""ustrated here 'i"" be app"icab"e to and are the same for an) 9ind of patient 'ith an) 9ind of hea"th prob"em. !hen )ou read the narration/ tr) to identif) the processes invo"ved. &ave the "earning objectives b) )our side to remind )ou on 'hat things to "oo9 for in the narration. !hen )ou finish reading the narration/ I e.pect )ou to have the appropriate ans'ers to the first 11 "earning objectives. The ne.t thing that )ou 'i"" encounter in this program after the narration is the C$anagement of a %urgica" Patient in an Out"ine ,ormE. Reading this out"ine 'i"" he"p )ou further in "earning the first 11 objectives. After the out"ine/ )ou 'i"" see a diagram or a"gorithm on C%teps in the $anagement of a PatientE fo""o'ed b) 'rite6ups 'ith the fo""o'ing tit"es7 C$a.ims/ Ru"es/ and 0uides in the $anagement of a PatientE8 CAdvising Patients and Re"ativesE8 and C2no'ing !hen and To !hom To Refer.E %tud)ing the diagram and the 'rite6ups 'i"" comp"ete )our "earning of a"" the stated objectives.

2 A NARRATION 53OLE CASE MANAGEMENT INCLUDING SURGICAL ASPECT 3O5 I USUALLY DO IT M"!"ge1e!- %( " P"-/e!- ./-+ " Pre"ur/)u#"r M"&& E6PECTATIONS

#onfronted 'ith a patient 'ith a preauricu"ar mass/ I have to be first reminded of the fo""o'ing7 1. I am to manage this patients hea"th prob"em. 2. $anaging a patients hea"th prob"em is essentia"") a prob"em6so"ving and decision6ma9ing activit). +. $) goa" in the management of this patient is to reso"ve the patients hea"th prob"em in such a 'a) that I dont end up 'ith a dead or disab"ed patient nor a dissatisfied patient/ and 0od forbid/ a medico"ega" suit. 1. $) tas9s consist of the fo""o'ing7 1.1 4stab"ishing rapport initia"") and then maintaining it throughout the course of patient management8 1.2 ,ormu"ating a c"inica" diagnosis fo""o'ed b) an advice to the patient on m) findings and diagnosis8 1.+ *eciding on 'hether I need a parac"inica" diagnostic procedure and/ if I need one/ se"ecting the most cost6effective procedure/ to be fo""o'ed b) an informed consent on the part of the patient8 if parac"inica" diagnostic procedures are done/ I need to interpret the resu"ts and corre"ate them 'ith the c"inica" findings to come out 'ith a pretreatment diagnosis/ again to be fo""o'ed b) an advice to the patient8 and "ast")/ 1.1 I need to decide on the most cost6effective treatment procedure for the patient. 1.= $) tas9s can be summari<ed b) the fo""o'ing diagram7 Rapport 666666666666666666666666666666666666666666666666666666666666666666666666F *iagnosis 6666666666666666666666666666666666666666666666666666666666666666666F Advice 66666666666666666666666666666666666666666666666666666F Treatment 66666666666666666666666666666666666666F Advice 666666666666666666666666666F =. The outcome of m) prob"em6so"ving and decision6ma9ing 'i"" be judged b) the fo""o'ing criteria7 =.1 rationa" =.2 effective =.+ efficient =.1 humane

+ RAPPORT 4stab"ishing rapport 'ith the patient and hisDher re"atives is m) best strateg) for obtaining satisfaction from m) patient and hisDher re"ative. It is a"so m) strongest strateg) in the prevention of medico"ega" suit in case I commit errors of commission and omission. &ere are some 'a)s in 'hich I tr) to estab"ish rapport 'ith m) patient and hisDher re"atives7 1. >eing courteous

2. %ho'ing respect to person and be"iefs +. 0iving honest and c"ear advice on diagnosis/ parac"inica" diagnostic procedures/ and treatment 1. *emonstrating humaneness and compassion =. >eing gent"e in 'ords and deeds :ph)sica" e.amination/ procedure; 3. %ho'ing the patient and re"atives that I am tr)ing m) ver) best 5. >eing he"pfu" 'hen it comes to medica" e.penses @. $a9ing the patient and re"atives fee" that I am approachab"e and eas) to ta"9 to CLINICAL DIAGNOSIS In formu"ating the c"inica" diagnosis/ I first verif) the e.pressed chief comp"aint of the patient. In this particu"ar patient/ the e.pressed chief comp"aint is a preauricu"ar mass. To verif)/ I "oo9 at and pa"pate the area pointed to b) the patient :"ets sa)/ the "eft preauricu"ar area;. I see and fee" a = cm mass in front of the "eft ear. !ith this/ I conc"ude that there is rea"") a preauricu"ar mass on the "eft side of the face. Initia" impression of the patients hea"th prob"em/ therefore/ is a "eft preauricu"ar mass. I need to be more specific than just sa)ing there is a mass. Thus/ the ne.t thing that I shou"d do is determine the organ or tissue of origin of the preauricu"ar mass. >) the "ocation/ the mass can come from an) of the fo""o'ing organs or tissues7 1. %9in of the face 2. %oft tissue +. Parotid g"and 1. L)mph node =. $andib"e :ascending ramus; I 'i"" sa) the mass is originating from the s9in of the face if I see a superficia" "esion on the s9in surface. In this patient/ there is no brea9 or "esion on the s9in. The mass is underneath the s9in. I conc"ude/ therefore/ that this mass is most "i9e") OT a s9in tumor.

1 I 'i"" sa) the mass is originating from the mandib"e if I fee" the mass is a bon) tumor. In this patient/ the mass does not fee" bon). I conc"ude/ therefore/ that this mass is most "i9e") OT a mandibu"ar tumor. The "eft preauricu"ar mass is beneath the s9in and not a bon) tumor. The considerations on the tissue or organ of origin are no' trimmed do'n to the fo""o'ing7 1. %oft tissue 2. Parotid +. L)mph node At this point/ after finishing m) inspection and pa"pation of the "eft preauricu"ar mass/ I have gotten the fo""o'ing data7

Left preauricu"ar mass/ beneath the s9in/ not a bon) tumor/ = cm in si<e/ not hard/ movab"e/ nontender/ border 'e""6defined. I 9no' m) priorit) at this point is sti"" to first determine 'hether the mass is a soft tissue tumor/ parotid tumor/ or a ")mph node before I decide on the 9ind of disease. I fee" I shou"d investigate first the ")mph node possibi"it) because of the presence of a c"inica" investigative path'a) for ")mph node. If the mass is a ")mph node/ it is most "i9e") secondar) or metastatic. The primar) "esion can be found in the upper part of the head :sca"p and face; or in the naso6oropharn.. If there is a "esion in an) of these areas/ then the preauricu"ar mass is most "i9e") a metastatic ")mph node. I e.amine/ therefore/ the upper part of the head and the orophar)n.. There is no evident "esion in these areas. I as9 for an) s)mptoms referab"e to the nasophar)n. "i9e nasa" stuffiness and b"eeding. There are none. !ith these data/ I p"ace ")mph node in o. + in the "ine6up of possibi"it) of sources of tissue or organ of origin. The consideration is no' centered on soft tissue and parotid tumors. %ince there are no c"inica" features that 'i"" differentiate the t'o tumors/ I no' have to re") on preva"ence data to choose 'hich one is more "i9e") to be the case. I choose parotid tumor because this is ver) much more common than soft tissue tumor in the preauricu"ar area. At this point/ m) impression is a "eft preauricu"ar mass/ most "i9e") arising from the parotid g"and. I need to be more specific to inc"ude the possib"e disorder/ 'hether inf"ammator)/ ma"ignant or nonma"ignant. Thus/ the ne.t thing I 'i"" do is "oo9 for signs for inf"ammation "i9e pus/ er)thema/ tenderness/ and 'armth. If there are signs of inf"ammation/ then m) diagnosis 'i"" be either parotitis or parotid abscess/ depending on 'hether there is f"uctuanc) or not. = In this patient/ there are no signs of inf"ammation. I conc"ude that most "i9e") the mass is OT inf"ammator). The ne.t thing I 'i"" do is "oo9 for signs of ma"ignanc) 'hich inc"ude a hard nonosseous so"id tumor/ fi.ation/ invasion of the s9in/ facia" paresis or para")sis/ ipsi"atera" nec9 nodes/ and a distant mass suspicious for metastasis. If an) of these signs is present/ then m) diagnosis 'i"" be a parotid cancer. In this patient/ there are no signs of ma"ignanc). I conc"ude/ therefore/ that most "i9e") the mass is OT ma"ignant. !ith no signs of inf"ammation and ma"ignanc)/ I am "eft 'ith a non6ma"ignant tumor consideration. >efore I sett"e for this consideration/ I 'i"" "oo9 for signs and other c"ues of benignit). As for signs of benignit)/ a re"iab"e cue 'i"" be a c)stic nature of the mass. If the mass is c)stic/ most "i9e") the parotid mass is benign/ a parotid c)st. As for other c"ues of benignit)/ the

duration of the mass ma) he"p. If the mass has been present for a "ong duration of time 'ithout causing s)mptoms and there are no signs of ma"ignanc)/ most "i9e") the parotid mass is benign. In this patient/ the mass is not c)stic and it 'as noted + )ears ago. These data do not support the diagnosis of benignit) but the) a"so do not negate it. Thus/ in the absence of inf"ammation and ma"ignanc) and considering benign parotid neop"asms are more common than ma"ignant ones :@-G vs 2-G;/ m) c"inica" diagnosis/ therefore/ is a benign parotid mass/ "eft/ most "i9e")/ p"eomorphic adenoma. The basis for sa)ing most "i9e") p"eomorphic adenoma is the preva"ence of this disease. It is the most common benign parotid neop"asm. As an added investigation to the parotid mass/ beside the onset/ the other pertinent Auestions to as9 are 'hether there are associated s)mptoms and 'hether there is a histor) of previous medica" consu"tation and treatment. To these Auestions/ the ans'ers are negative. In formu"ating the c"inica" diagnosis of a preauricu"ar mass/ the signs/ s)mptoms/ and persona" data of the patient are needed. In this particu"ar patient/ the age is 3= and the se. is fema"e. These persona" data as 'e"" as other persona" data "i9e civi" status/ occupation/ and menopausa" status 'i"" not ma9e me change the diagnosis that I arrive at using pattern recognition :based on signs and s)mptoms; and preva"ence. The output e.pected in c"inica" diagnosis is a rationa" primar) c"inica" diagnosis as 'e"" as a secondar) diagnosis. The primar) c"inica" diagnosis is a parotid tumor/ "eft/ benign p"eomorphic adenoma. I have presented the bases that ma9es m) diagnosis rationa". As to the secondar) c"inica" diagnosis/ I 'i"" consider a ma"ignant parotid tumor.

3 I am confident of the choice of organ or tissue of origin of the preauricu"ar mass/ that is/ the parotid g"and. If I am not/ then I have to ma9e soft tissue tumor as m) secondar) diagnosis/ rather than a ma"ignant parotid tumor. As I have said I am confident of the parotid tumor. !hat I am not ver) confident of is 'hether the parotid tumor is benign or ma"ignant. The main basis for choosing benign parotid tumor over ma"ignanc) is preva"ence/ 'hich is a 'ea9er basis compared to one that is based on both pattern recognition and preva"ence. PARACLINICAL DIAGNOSTIC PROCEDURE *o I need a parac"inica" diagnostic procedureH $) primar) c"inica" diagnosis is parotid tumor/ benign. $) secondar) c"inica" diagnosis is parotid tumor/ ma"ignant. $) basis for choosing benign over ma"ignant is preva"ence. That ma9es m) diagnosis not Auite certain. >eing uncertain/ theoretica"") spea9ing/ I need a parac"inica" diagnostic procedure. I need to consider another factor in deciding 'hether I rea"") need a diagnostic procedure.

The treatment for both primar) and secondar) diagnosis is operative e.tirpation. !hether the tumor be benign or ma"ignant/ m) operative procedure 'i"" be e.tirpation of a"" gross tumors. %ince m) treatment p"an and procedure 'i"" be the same for both m) primar) and secondar) c"inica" diagnosis/ then I decide that I dont need parac"inica" diagnostic procedure. ote7 4.tirpation of a"" gross tumors ma) range from subtota" parotidectom) to tota" parotidectom). %ubtota" parotidectom) ma) range from partia" superficia" parotidectom)/ tota" superficia" parotidectom)/ partia" superficia" and tota" deep parotidectom)/ and partia" superficia" and partia" deep parotidectom). TREATMENT $) pretreatment diagnosis is parotid tumor/ "eft/ benign. The goa" and objective of treatment 'i"" be to comp"ete") e.tirpate a"" gross") evident tumor in such a 'a) that there 'i"" be no "oca" recurrence and no comp"ications/ particu"ar")/ facia" nerve para")sis. The most cost6effective treatment is an operative e.tirpation. *rugs are ineffective.

5 PREOP PREP Preoperative")/ I 'i"" 1. %ecure an informed consent after I have e.p"ained the diagnosis and proposed treatment to the patient and her re"atives. 2. Provide ps)chosocia" support to a""a) fear and an.iet). +. If there is a co6e.isting disorder/ optimi<e the patients ph)sica" hea"th so that she can 'ithstand the operative procedure. 1. %creen the patient for an) hea"th condition that ma) interfere 'ith the outcome of the treatment. =. Prepare the materia" needs for the operation/ if these are not avai"ab"e in the p"ace of treatment :hospita";. INTRAOPERATI2E MANAGEMENT

I!)/&/%!7 Objectives7 Long enough to faci"itate accurate intraoperative eva"uation and comp"ete e.tirpation of parotid tumor 'ithout comp"ications P"ace it at an area that 'i"" faci"itate achievement of treatment goa" P"ace it at an area that 'i"" be cosmetica"") acceptab"e to the patient P"anning and e.ecution of incision 'i"" be based on the above objectives. E80%&ure7 Objectives7 To faci"itate accurate intraoperative eva"uation To faci"itate comp"ete e.tirpation of the parotid tumor 'ithout comp"ication 4.ecution7 #reate f"aps to such an e.tent that 'i"" faci"itate accurate intraoperative eva"uation and comp"ete e.tirpation of parotid tumor 'ithout comp"ications #reate f"aps not be)ond the anterior border of the parotid g"and so as to avoid injur) to the branches of the facia" nerve #reate viab"e f"aps @ I!-r"%0er"-/9e E9"#u"-/%!7 Objectives7 To determine the e.act diagnosis To determine the e.tent of the tumor To faci"itate decision on specific operative procedure and maneuvers 4.ecution7 Inspect and pa"pate to determine 'hether mass is rea"") parotid in origin if parotid in origin/ determine 'hether benign or ma"ignant/ e.tent of tumor/ superficia" or deep/ inferior po"e/ superior po"e/ 'ho"e g"and/ etc *ecide on e.tent of parotidectom) Tota" parotidectom) %ubtota" parotidectom) Tota" superficia" parotidectom) Partia" superficia" parotidectom) Partia" superficia" and partia" deep parotidectom) *ecide on operative maneuvers

O0er"-/9e Pr%)e$ure Pr%0er7 Objectives7 To comp"ete") e.tirpate a"" gross") evident tumor in such a 'a) that there 'i"" be no "oca" recurrence and no comp"ications/ particu"ar")/ facia" nerve para")sis. $aneuvers7 Identif) facia" nerve main trun9 to branches :usua""); branches to main trun9 :if main trun9 cannot be identified first; 4.tirpate a"" gross parotid tumor 'ith a rim of norma" parotid tissue :adeAuate"); Avoid cutting or entering into the tumor :c"ean"); Avoid injur) to the facia" nerve 'hi"e e.tirpating 'hich can occur either b) cutting/ burning :'ith cauter); or traction Attac9 tumor initia"") through areas of "esser difficu"t) before entering through dense and difficu"t areas >e gent"e >e meticu"ous and precise 4ver) move must have a reasonI ? 3e1%&-"&/& C+e):7 Objectives7 To avoid b"eeding and hematoma To avoid injur) to facia" nerve during hemostasis chec9 4.ecution7 #hoice of suture6"igature and cauteri<ation Avoid injur) to the facia" nerve during c"amping/ t)ing/ and cauteri<ation b) right choice of hemostatic method and b) being meticu"ous and precise Dr"/!7 Objectives7 To prevent un'anted accumu"ation of f"uid :serum and sa"iva; in the 'ound space To drain continuous sa"ivar) secretion into the 'ound site after a subtota" parotidectom)

4.ecution7 #hoice of tube drain or rubber drain Remove 'hen drain is not needed an)more C%rre)- C%u!-7 Objective7 To avoid "eaving surgica" instruments and sponges in the 'ound site 4.ecution7 4nsure correct instrument and gau<e count before 'ound c"osureI

15%u!$ C#%&ure7 Objective7 To repair the s9in incision used to remove the parotid tumor To repair the s9in incision in such a 'a) that a cosmetica"") acceptab"e scar is effected and that 'i"" promote patient comfort :e.g. pain of s9in suture remova"; 4.ecution7 (se absorbab"e suture to avoid pain on suture remova" :if nonabsorbab"e ones are used; Appose 'ound edges precise") to promote a cosmetica"") acceptab"e scar POSTOP CARE Objectives7 %upp") basic needs of patient #omfort Ana"gesics ,"uids and 4"ectro")tes utrition !ound care $onitoring for comp"ications and treat as indicated

Advice on home care of 'ound Advice on fo""o'6up p"an FOLLO5;UP PLAN7 Objectives7 4va"uate resu"ts of treatment Provide ps)chosocia" support $onitoring guide"ines7 Ph)sica" e.amination %)mptom6directed investigation

11 ,reAuenc) of ,o""o'6up 0uide"ines7 #onsider (sua" course of disease :recurrence probabi"it) and incidence; Persona"it) of patient Patients convenience OUTCOME OF MANAGEMENT If at the end of the treatment/ I have achieved a"" the fo""o'ing7 Reso"ution of the hea"th prob"em Parotid tumor e.tirpated 'ith no recurrence Live patient o facia" para")sis %atisfied patient o medico"ega" suit Then/ I can consider m)se"f to be successfu" in m) prob"em6so"ving and decision6ma9ing in the management of the patient.

12 MANAGEMENT OF A SURGICAL PATIENT IN AN OUTLINE FORM

MANAGEMENT OF A PATIENT PROBLEM-SOLVING AND DECISION-MAKING GOALS RESOLUTION OF 3EALT3 PRO'LEM LI2E PATIENT NO COMPLICATION NO DISA'ILITY SATISFIED PATIENT NO MEDICOLEGAL SUIT TAS<S

RAPPORT ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;= DIAGNOSIS ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;= AD2ICE ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;= TREATMENT ;;;;;;;;;;;;;;;;;;;;;;;;;;;;= AD2ICE ;;;;;;;;;;;;;;;;= >u"#/- S-"!$"r$&7 R"-/%!"#, e((e)-/9e, e((/)/e!-, +u1"!e
1+

CLINICAL DIAGNOSIS DATA NEEDED SIGNS SYMPTOMS PERSONAL DATA OF PATIENT PROCESSING OF DATA PATTERN RECOGNITION -realization that the patient pre entation !on"or# to a pre$io% l& learne' pi!t%re or pattern o" 'i ea e PREVALENCE - !hoi!e o" a 'ia(no i i )a e' on the "re*%en!& o" o!!%rren!e o" the 'i ea e in a !ertain lo!alit&+ in a !ertain a(e an' e, (ro%p+ an' in the a""e!te' or(an an' & te# OUTPUT E6PECTED

RATIONAL ;PRIMARY CLINICAL DIAGNOSIS ;SECONDARY CLINICAL DIAGNOSIS

11

PARACLINICAL DIAGNOSTIC PROCEDURE INDICATION DATA NEEDED PRIMARY CLINICAL DIAGNOSIS SECONDARY CLINICAL DIAGNOSIS PROCESSING OF DATA CERTAINTY OF CLINICAL D8 1O D8 1? ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; 99? !ee$e$;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;!%- !ee$e$ TREATMENT PLAN FOR 1O @ 2O D8 D/((ere!- ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;S"1e !ee$e$ ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;!%- !ee$e$ OUTPUT E6PECTED DIAGNOSTIC PROCEDURE NEEDED %r NOT NEEDED

1=

PARACLINICAL DIAGNOSTIC PROCEDURE SELECTION DATA NEEDED OPTIONS OF DIAGNOSTIC PROCEDURES SELECTION PROCESS O0-/%!& 1 2 A 'e!e(/- R/&: C%&- A9"/#"*/#/-

OUTPUT E6PECTED MOST COST;EFFECTI2E DIAGNOSTIC PROCEDURE

13

TREATMENT SELECTION DATA NEEDED PRETREATMENT DIAGNOSIS SE2ERITY OR STAGE GOALS AND O'JECTI2ES TREATMENT OPTIONS SELECTION PROCESS O0-/%!& 1 2 A 'e!e(/- R/&: C%&- A9"/#"*/#/-

OUTPUT E6PECTED MOST COST;EFFECTI2E TREATMENT PROCEDURE AC3IE2EMENT OF GOALS OF PATIENT MANAGEMENT,

15

SURGICAL TREATMENT PREOP PREPARATION INFORMED CONSENT PSYC3OSOCIAL SUPPORT OPTIMIBATION SCREENING OPERATI2E MATERIALS

SURGICAL TREATMENT INTRAOP MANAGEMENT P3ASES INCISION E6POSURE INTRAOP E2ALUATION OPERATI2E PROCEDURE PROPER 3EMOSTASIS C3EC< CORRECT COUNT 5OUND CLOSURE

>u"#/- S-"!$"r$&7 GENTLE

METICULOUS "!$ PRECISE NO IATROGENIC INJURIES NO UNNECESSARY MO2ES EVER- MOVE .AS A REASON/
1@

SURGICAL TREATMENT POSTOP CARE SUPPLY 'ASIC NEEDS OF PATIENT COMFORT ANALGESICS FLUID AND ELECTROLYTES NUTRITION SUPPORT ORGAN FUNCTION 5OUND CARE MONITORING FOR COMPLICATIONS AD2ICE ON 3OME CARE FOLLO5;UP PLAN SURGICAL TREATMENT 0OLLO1-2P PLAN O'JECTI2ES7 E2ALUATE TREATMENT OUTCOME PRO2IDE PSYC3OSOCIAL SUPPORT MONITORING GUIDELINE7 P3YSICAL E6AMINATION SYMPTOM;DIRECTED IN2ESTIGATION

FF;UP

FRE>UENCY GUIDELINES7 CONSIDER USUAL COURSE OF DISEASE PERSONALITY OF PATIENT PATIENT4S CON2ENIENCE
1? STEPS IN T3E MANAGEMENT OF A PATIENT

M.D. C C 9 PATIENT;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;GOALS C C C I!-er9/e. ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;C;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;P+ &/)"# e8"1 D& 10-%1&E C D&/g!&E C C#/!/)"# D/"g!%&-/) Pr%)e&& C P"--er! re)%g!/-/%! C Pre9"#e!)e C C#/!/)"# D/"g!%&/& ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;A$9/)e C C C P"r")#/!/)"# D/"g!%&-/) C Pr%)e$ure ;;;;;;;;;;;;;;;;;;;;;;;;;A$9/)e C C C C ; I!$/)"-/%! C C ; Se#e)-/%! D*e!e(/-Fr/&:F)%&-F"9"/#E C C ; I!-er0re-"-/%! C C Pre-re"-1e!- D/"g!%&/& ;;;;;;;;;;;;;;;;;;;;;;;;;;;;A$9/)e C C C Se#e)-/%! %( Tre"-1e!- ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;A$9/)e D'e!e(/-Fr/&:F)%&-E C C C Tre"-1e!- ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;A$9/)e C C C 3e"#-+ Pr%1%-/%! "!$ M"/!-e!"!)e ;;;;;;;;;;;;;;;;;;;;;;A$9/)e

2MA6IMS, RULES, AND GUIDES IN T3E MANAGEMENT OF A PATIENT 'ASIC MA6IMS 1. othing is abso"ute in medicine. 1.1 There are e.ceptions to the ru"es. 1.2 An)thing is possib"e. 1.+ There are more than one 'a) of doing things in medicine. 1.1 There is no such thing as abso"ute") certain diagnosis/ 'hether it be c"inica"/ parac"inica"/ histopatho"ogic/ or postmortem diagnosis. 2. The on") routine in medicine is a rationa" decision6ma9ing in the management of a patient 'ith a hea"th prob"em. 2.1 Rationa" decision6ma9ing 'eighs the probabi"it) of being successfu" in the achievement of the goa"s in the management of a patient. 2.2 Rationa" decision6ma9ing re"ies more on genera" ru"es than on the e.ceptions. 2.+ Rationa" decision6ma9ing ban9s on the more common rather than on the "east common or rare events. 2.1 Rationa" decision6ma9ing uses processes rather than gut6fee". 2.= A rationa" decision6ma9ing ma) not a"'a)s be correct. As "ong as the decision6 ma9ing is rationa"/ it is acceptab"e. A rationa" decision6ma9ing is more often correct than 'rong compared to an irrationa" decision6ma9ing. 2.3 A decision6ma9ing is deemed correct on") after its imp"ementation has resu"ted in the achievement of the goa"s in the management of a patient. T3E DIAGNOSTIC PROCESS AND T3E DIAGNOSIS 1. The diagnostic process starts from the time a ph)sician sees the patient up to after treatment. 2. A diagnosis is an identification "abe" of the patients hea"th prob"em. +. The diagnostic process must be rationa" for it to be acceptab"e. 1. A diagnosis that is based on a rationa" process is not a"'a)s correct. &o'ever/ a diagnosis is more often correct than 'rong if it is rationa"") arrived at. =. A diagnosis is a"most a"'a)s an educated guess. INTER2IE5 AS A DIAGNOSTIC TOOL 1. Identif) the chief comp"aint or main prob"em of the patient. Once identified/ use it as the steering 'hee" in the diagnostic investigation of the patient. 1.1 InAuire on the circumstances associated 'ith the chief comp"aint. 1.2 InAuire on s)mptoms. %)mptoms are those manifestations perceived b) the patient. 1.+ 0et c"ues from the Ccircumstances and s)mptomsE to be used in the diagnosis of the patient. 2. >e effective. >e comp"ete. >e efficient. >e re"evant.

+. 2no' ho'

to get cues from data. to interpret data. 21

1. 2no' 'hich data

to pursue. to put in the bac9ground. to use in the diagnosis. not to use in the diagnosis.

P3YSICAL E6AMINATION AS A DIAGNOSTIC TOOL 1. (se the identified chief comp"aint or main prob"em of the patient as a guide on 'hat to e.amine. 1.1 Loo9 for signs. %igns are those manifestations perceived b) the ph)sicians. 1.2 0et c"ues from the signs to be used in the diagnosis of the patient. 2. >e effective. >e accurate. >e comp"ete. >e efficient. >e re"evant. +. 2no' ho' to get cues from data. to interpret data. 1. 2no' 'hich data to pursue. to put in the bac9ground. to use in the diagnosis. not to use in the diagnosis. INTER2IE5 AND P3YSICAL E6AMINATION 1. Intervie' and ph)sica" e.amination can be done in an) order as dictated b) the circumstances. 2. Intervie' and ph)sica" e.amination can be done simu"taneous"). +. The goa" of intervie' and ph)sica" e.amination is diagnosis. 1. #orre"ate data from intervie' and ph)sica" e.amination to come out 'ith a rationa" c"inica" diagnosis. =. If there is a Auestion on 'hich data to put more re"iance on/ choose the CsignE data over Cs)mptomE data. Remember/ ho'ever/ that for the CsignE data to be re"iab"e/ the) must be accurate. CLINICAL DIAGNOSTIC PROCESS 1. A c"inica" diagnosis is one that is derived from the intervie' and ph)sica" e.amination/ or put in another 'a)/ it is one that is derived from the s)mptoms and signs. 2. After the intervie' and ph)sica" e.amination/ the s)mptoms and signs are ana")<ed to come out 'ith a c"inica" diagnosis. 4ssentia"")/ t'o processes are used in coming out 'ith a c"inica" diagnosis. These t'o processes are pattern recognition and preva"ence. +. Pattern recognition means the rea"i<ation that the patients presentation conforms to a previous") "earned picture or pattern of disease. 1. Preva"ence means the choice of a diagnosis is based on the freAuenc) of occurrence of the disease in a certain "oca"it)/ in a certain age and se. group/ and in the affected organ and s)stem. =. 4"ementa" steps in ma9ing a diagnosis7 =.1 Identif) 'hich organ or tissue or s)stem is invo"ved. =.2 Then/ identif) the disease in genera" terms/ such as inf"ammation/ infection/ tumor/ trauma/ endocrine/ etc.

22 =.+ Then/ tr) to be more specific in identif)ing the disease/ if possib"e/ such as ma"ignant neop"asm/ abscess/ etc. 3. 2no'ing the nomenc"ature of diseases faci"itates diagnostic "abe"ing. PARACLINICAL DIAGNOSTIC PROCESS 1. After the c"inica" diagnosis/ the ne.t step to do is to determine 'hether a parac"inica" diagnostic procedure is needed or not. A parac"inica" diagnostic procedure is a diagnostic procedure that is done after the c"inica" diagnosis is arrived at and its objective is to ma9e the diagnosis more definite. 2. To decide 'hether a parac"inica" diagnostic procedure is needed or not/ a ph)sician shou"d consider the fo""o'ing factors7 2.1 &o' certain he is 'ith the c"inica" diagnosis. If he is Auite certain or ver) certain/ in genera"/ a parac"inica" diagnostic procedure is not needed. The Auite certain c"inica" diagnosis becomes automatica"") the pretreatment diagnosis. If he is not Auite certain or uncertain/ in genera"/ a parac"inica" diagnostic procedure is needed. In genera"/ a c"inica" diagnosis is said to be Auite certain if it is based primari") on signs that are reinforced b) the s)mptoms and preva"ence data. A c"inica" diagnosis is said to be uncertain if it is based primari") on s)mptoms or on preva"ence data. 2.2 !hether a more definite diagnosis is needed or not for some reasons or another. If the contemp"ated treatment procedure is muti"ating/ ris9)/ etc./ then a more definite diagnosis is needed. If the treatment for the differentia" diagnosis is the same as that for the primar) c"inica" diagnosis/ then a parac"inica" diagnostic procedure ma) not be needed. If it is different/ then a more definite diagnosis is indicated. +. Once a decision is made that a parac"inica" diagnostic procedure is needed/ the ne.t step is to choose the most cost6effective procedure for the patient b) considering the various factors :tabu"ate/ compare/ and ana")<e;7 Procedures Option1 Option2 Option+ >enefit :goa"; Ris9 #ost Avai"abi"it)

1. After the parac"inica" diagnostic procedure has been done/ the ne.t step is to interpret the resu"t. The resu"t of the parac"inica" diagnostic procedure must be corre"ated 'ith the signs and s)mptoms of the patient to come out 'ith a pretreatment diagnosis. SELECTION OF TREATMENT 1. %e"ection of treatment procedure is based primari") on the pretreatment diagnosis. 2+

2. %e"ect the most cost6effective treatment for the patient after considering the various factors :tabu"ate compare/ and ana")<e;7 Treatment >enefit :goa"; Ris9 #ost Option1 Option2 Option+ +. The fina" decision on the t)pe of treatment to institute 'i"" rest on the patient. 1. 2no' 'hen and to 'hom to refer. AD2ICE AND INFORMED CONSENT 1. After the intervie' and ph)sica" e.amination and after the ph)sician has arrived to a c"inica" diagnosis/ the ne.t step is to advise the patient on the nature of his hea"th prob"em. 2. After the c"inica" diagnosis has been e.p"ained to the patient andDor his re"atives/ the ne.t step is to advise 'hether a parac"inica" diagnostic procedure is needed or not. If a parac"inica" diagnostic procedure is needed/ the patient is informed of the various options. &e is advised on the most cost6effective option. Performing the parac"inica" diagnostic procedure can on") be carried out after the ph)sician has secured an informed consent from the patient. +. After the parac"inica" diagnostic procedure has been performed/ the ne.t step is to advise the patient on the resu"ts. 1. After a pretreatment diagnosis has been gotten/ the ne.t step is to inform the patient on the various options of treatment. &e is advised on the most cost6effective treatment option. #arr)ing out the treatment procedure can be done on") after the ph)sician has secured an informed consent from the patient. =. After treatment/ the patient shou"d be advised on the resu"ts and subseAuent management/ specifica"") fo""o'6up. The patient shou"d a"so be given advice on hea"th maintenance. Avai"abi"it)

21 AD2ISING PATIENTS AND RELATI2ES

A ph)sician dea"s 'ith both patients and their re"atives or guardians. A successfu" ph)sician6patient6re"ative re"ationship is based on the estab"ishment and maintenance of good rapport initiated and accomp"ished b) the ph)sician. A good rapport basica"") emanates from the trust and confidence given b) the patient6re"ative to the ph)sician. This trust and confidence can be gained b) the ph)sician through man) 'a)s. The fo""o'ing are some Aua"ities of the ph)sician that 'i"" promote trust and confidence of the patient6re"ative7 #ompetent ph)sician &onest 0ent"e #ompassion and sho's concern #ourteous Patient/ persevering/ and understanding Advising a patient and his re"atives is a major path'a) through 'hich a rapport can be estab"ished and maintained b) the ph)sician. In managing a patient/ advising is usua"") needed on7 1. c"inica" diagnosis 2. need for a parac"inica" diagnostic procedure +. nature of a parac"inica" diagnostic procedure 1. resu"ts of a parac"inica" diagnostic procedure =. p"an of treatment 3. outcome of treatment 5. prognosis of the disease @. maintenance of hea"th after treatment Advising a patient and his re"atives on an) matter can ma9e or brea9 the ph)sician6patient6 re"ative re"ationship. Thus/ it is important that the ph)sician 9no's ho' to advise. The fo""o'ing are tips in advising7 1. A"'a)s inc"ude the re"atives of the patient in the advising/ if the) are avai"ab"e. 2. Assess the ps)cho"ogica" ma9e6up/ the hea"th be"iefs/ and the "eve" of competenc) of the patient and the re"atives before ma9ing an) advice. $a9e strategies that 'i"" promote rapport. 2.1 >e honest but not bruta"") fran9. ,or e.amp"e/ s"o'") divu"ge the diagnosis of an incurab"e disease or a frightening disease. 2.2 (se termino"ogies or e.p"anations that can be easi") understood b) the patient and his re"atives. +. (se a"" 9inds of strategies that 'i"" ma9e the patient and his re"atives "i9e )ou. 1. 4.p"ain to the patient and re"atives the processes )ou use in arriving to a diagnosis/ recommendation for a parac"inica" diagnostic procedures and treatment. 2= <NO5ING 53EN AND TO 53OM TO REFER There 'i"" a"'a)s be patients 'hose hea"th prob"ems 'i"" be be)ond a ph)sicians e.isting competencies.

%uch patients ma) have a ver) unusua" hea"th prob"em 'hose diagnosis is e.treme") difficu"t. %uch patients ma) have usua" hea"th prob"ems but 'hose treatment is be)ond a ph)sicians e.isting competencies :e.amp"e 6 a primar) hea"th care ph)sician 'ho has not been trained to do a surgica" operation;. !hether a person is sti"" in medica" schoo" or has graduated/ there 'i"" a"'a)s be patients 'hose hea"th prob"ems are be)ond his present e.isting competencies. 5+e! -% re(erG A## 0+ &/)/"!&, *%-+ )er-/(/e$ "!$ !%- e- )er-/(/e$, 1u&- :!%. -+e/r #/1/-"-/%!&. O!# -+e -+e1&e#9e& )"! $e-er1/!e -+e/r %.! #/1/-"-/%!&. T+e 1u&- re"#/He -+e/r #/1/-"-/%!& &% -+"- -+e $% !%- )"u&e u!$ue +"r1 -% -+e/r 0"-/e!-& "!$ &% -+"- -+e :!%. .+e! -% re(er -% )%##e"gue&. Refer means as9ing for he"p from and conferring 'ith co""eagues. Referring a patient to a co""eague ma) mean tota"") transferring the care of a patient to him or continuing to manage the patient 'ith his he"p. A proper communication either ora" or 'ritten is in order. T% .+%1 -% re(erG Re(err"# 1u&- *e 1"$e -% &%1e*%$ .+% 1" %r )"! &%#9e -+e 0"-/e!-4& +e"#-+ 0r%*#e1 r"-/%!"## , e((e)-/9e# , e((/)/e!-# , "!$ +u1"!e# , "!$ .+% +"& " g%%$ -r"): re)%r$ %( +"!$#/!g -+e :/!$ %( 0r%*#e1 %! +"!$.

23
M"!"ge1e!- %( " Surg/)"# P"-/e!Re !"#$% O. J%&%!, MD, MS Surg

F%r1"-/9e E9"#u"-/%!FSu11"-/9e E9"#u"-/%!

:>ased on Learning Objectives;

I. Ans'er as concise") as )ou can.

1. %tate the overa"" goa"s in the management of a patient :'hether surgica" or not;. 2. 4numerate the four functions of a ph)sician in the management of a patient :'hether surgica" or not;. +. *escribe the c"inica" diagnostic process. 1. *escribe ho' to determine the indication for a parac"inica" diagnostic procedure. =. *escribe ho' a parac"inica" diagnostic procedure shou"d be se"ected among severa" options. 3. *escribe ho' to interpret resu"ts of a parac"inica" diagnostic procedure to come out 'ith a pretreatment diagnosis. 5. *escribe ho' a treatment moda"it) shou"d be se"ected among severa" options. @. 4numerate at "east 1 essentia" items in the preoperative preparation of a surgica" patient. ?. 4numerate in correct chrono"ogica" order 5 phases in the intraoperative management starting from the incision to 'ound c"osure. 1-. 4numerate at "east 1 items in the immediate postoperative care of a surgica" patient. 11. 4numerate the t'o objectives of a fo""o'6up p"an after treatment of a patient :'hether surgica" or not;. 12. *escribe ho' to advice patients on c"inica" diagnosis/ parac"inica" diagnostic procedures/ treatment/ fo""o'6up/ and hea"th promotion and maintenance. 1+. *escribe 'hen and to 'hom to refer.

JThe ans'ers can easi") be found in the te.t of this se"f6instructiona" program. II. #hoose the best ans'erDAna")<e and decide as instructed7 1. The most cost6effective 'a) of managing the prob"em of a "ega" suit :potentia" and actua"; in a medica" practice is7 A. Ordering a"" possib"e screening "aborator) e.aminations >. 4stab"ishing good rapport 'ith the patient and his re"atives #. As9ing a"" patients to sign a 'aiver of ph)sicians "iabi"ities *. %ecuring a ma"practice insurance

25 2. A patient 'a"9s into )our hea"th c"inic to consu"t )ou. Bou shou"d initia"") estab"ish 'hich of the functions of a ph)sicianH A. *iagnosis >. Treatment #. Advice *. Rapport +. *etermine the c"inica" diagnostic process used in the various scenarios. A. Pattern recognition

>. Preva"ence #. Pattern recognition and preva"ence +.1 2no'ing the common manifestations of = different diseases as fo""o's7 *isease A 6 abcd :manifestations; *isease > 6 fghi *isease # 6 9"mn *isease * 6 pArs *isease 4 6 uv'. 0iven a patient manifesting 'ith pArs/ )our diagnosis is *isease *. +.2 2no'ing the common manifestations 'ith its usua" tempora" seAuence of + different diseases as fo""o's7 *isease A 6 a6b6c6d :manifestations; *isease > 6 b6c6d6a *isease # 6 a6b6d6c 0iven a patient manifesting 'ith a6b6c6d/ )our diagnosis is *isease A. +.+ 2no'ing the common manifestations of + different diseases and re"ative freAuenc) of each as fo""o's7 *isease A 6 abcd :manifestations; Least common *isease > 6 abcd *isease # 6 abcd $ost common 0iven a patient manifesting 'ith abcd/ )our diagnosis is *isease #. +.1 2no'ing the common manifestations of + different diseases and re"ative freAuenc) of each as fo""o's7 *isease A 6 abcd :manifestations; Least common *isease > 6 abde *isease # 6 abdf $ost common 0iven a patient manifesting 'ith abcd/ )our diagnosis is *isease A. +.= 2no'ing the most common diagnosis of a th)roid nodu"e is a benign co""oid adenomatous goiter/ given a patient 'ith a th)roid nodu"e/ )ou gave the abovementioned diagnosis. 2@ 1. *etermine 'hether a parac"inica" diagnostic procedure is indicated or not in the various scenarios. !rite :I; if indicated and : I; if not indicated. #ertaint) 1.1 Primar) c"inica" diagnosis %econdar) c"inica" diagnosis 1.2 Primar) c"inica" diagnosis %econdar) c"inica" diagnosis 1.+ Primar) c"inica" diagnosis 3-G %urgica" e.cision 3-G 1-G %urgica" onsurgica" ?@G 162G %urgica" onsurgica" P"an of Treatment

%econdar) c"inica" diagnosis 1.1 Primar) c"inica" diagnosis %econdar) c"inica" diagnosis 1.= Primar) c"inica" diagnosis %econdar) c"inica" diagnosis

1-G ?-G 1-G 5-G 1-G

%urgica" e.cision $uti"ating operation onmuti"ating operation #hemotherap) Radiotherap)

=. !hich of the fo""o'ing statements is the strongest indication for a parac"inica" diagnostic procedureH A. Bou can never be abso"ute") certain of )our c"inica" diagnosis >. Bou 'ant to confirm a c"inica" diagnosis 'hich are certain of #. Bou 'ant to document a c"inica" diagnosis 'hich are certain of *. !hen )ou are not certain of )our c"inica" diagnosis 3. *etermine 'hat parac"inica" diagnostic procedure shou"d be se"ected in the various scenarios. !rite )our choice in term of the option number enc"osed in parenthesis/ "i9e so :K;. Procedure Options 3.1 1 2 + 3.2 1 2 + accurac) ?=G accurac) ?-G accurac) =-G acceptab"e acceptab"e acceptab"e =--+--1--avai"ab"e avai"ab"e avai"ab"e most direct indirect indirect acceptab"e acceptab"e acceptab"e 1--1=-1--avai"ab"e avai"ab"e avai"ab"e >enefit Ris9 #ost :PhP; Avai"abi"it)

2? 3. *etermine 'hat parac"inica" diagnostic procedure shou"d be se"ected in the various scenarios. !rite )our choice in term of the option number enc"osed in parenthesis/ "i9e so :K;. Procedure Options 3.+ 1 2 + 3.1 1 2 + )ie"d ?-G )ie"d ?-G )ie"d ?=G acceptab"e acceptab"e acceptab"e 2--2=-1--avai"ab"e avai"ab"e avai"ab"e )ie"d greatest )ie"d ?-G )ie"d @-G acceptab"e acceptab"e acceptab"e 1--1--+--avai"ab"e avai"ab"e avai"ab"e >enefit Ris9 #ost :PhP; Avai"abi"it)

5. *etermine 'hich parac"inica" diagnosis shou"d be accepted as the pretreatment diagnosis and 'hich one shou"d be put on ho"d for further decision6ma9ing. !rite :A; for accept and :&; for ho"d. 5.1 5.2 5.+ 5.1 Parac"inica" diagnosis Parac"inica" diagnosis Parac"inica" diagnosis Parac"inica" diagnosis is the same as the primar) c"inica" diagnosis. is the same as the secondar) c"inica" diagnosis is a c"inica" diagnosis "east considered. does not jibe 'ith the c"inica" picture or diagnosis.

@. *etermine 'hat treatment moda"it) shou"d be se"ected in the various scenarios. !rite )our choice in term of the option number enc"osed in parenthesis/ "i9e so :K;. Procedure @.1 1 2 + @.2 1 avai"ab"e @.+ 1 2 @.1 1 2 + most effective effectivit) L1 F+ "east effective acceptab"e acceptab"e acceptab"e +2--+--1--avai"ab"e avai"ab"e avai"ab"e as effective as 2 as effective as 1 acceptab"e acceptab"e @--1--avai"ab"e avai"ab"e %R1 M %R2 2 %R2M %R1 "esser more =--=--avai"ab"e greatest surviva" rate acceptab"e rate L 1 F + acceptab"e "east surviva" rate:%R; acceptab"e =--1--+--avai"ab"e avai"ab"e avai"ab"e >enefit Ris9 #ost :PhP; Avai"abi"it)

?. To 'hom 'i"" )ou refer )our patient for further managementH %omebod) 'ho is A. 'e""69no'n because of his freAuent e.posure in the media. >. 'e""69no'n because of his e.tensive research. #. a certified specia"ist b) both American and Phi"ippine medica" societies. *. 9no'n for his good outcome in management. 4. a 'e""69no'n academician in the premier medica" schoo" in the Phi"ippines %ee ans'ers on the ne.t page.

+1

M"!"ge1e!- %( " Surg/)"# P"-/e!Re !"#$% O. J%&%!, MD, MS Surg

A!&.er& F%r1"-/9e E9"#u"-/%!FSu11"-/9e E9"#u"-/%!

:>ased on Learning Objectives;

I. %ee ans'ers in the te.t. II. #hoose the best ans'erDAna")<e and decide as instructed7 1. > 2. * +. +.1 A +.2 A

+.+ # +.1 A +.= > 1. 1.1 : I; 1.2 :I; 1.+ : I; 1.1 :I; 1.= :I; =. * 3. 3.1 :1; 3.2 :2; 3.+ :1; 3.1 :1; 5. 5.1 :A; 5.2 :A; 5.+ :&; 5.1 :&; @ @.1 :1; @.2 :1; @.+ :2; @.1 :1; ?. *

+2

RECOMMENDED FOLLO5;UP Learning shou"d not stop after reading this se"f6instructiona" program. I strong") advise )ou to app") 'hat )ou "earned in this program to actua" patients. Remember there are so man) 'a)s of doing things and there is the option to refer. Remember 'hat counts in the end is a reso"ution of the hea"th prob"em in such a 'a) that the patient does not end up dead or disab"ed and in such a manner that the patient and his re"atives are satisfied and )ou dont have a medico"ega" suit in )our hand. Last")/ remember a"so that )our prob"em6so"ving and decision6ma9ing 'i"" be judged b) the fo""o'ing criteria7 Rationa" 6 'ith basis 4ffective 6 achievement of goa"s 4fficient 6 achievement of goa"s in "east time/ cost/ and effort

&umane or 'ith compassion 6 )ou are guided b) the go"den ru"e T+e 1"8/1&, ru#e&, "!$ gu/$e& /! -+/& &e#(;/!&-ru)-/%!"# 0r%gr"1 )"! *e "00#/e$ -% "! :/!$ %( 0"-/e!- "!$ I -+/!: -+e ./## ./-+&-"!$ -+e -e&- %( -/1e. S%, 1"&-er /-. REFERENCES There are no specific references that I used for this program. I did not refer to an) boo9s/ manua"s/ or journa"s 'hen I 'rote this program. !ith the intended readers and objectives in mind/ I made a topic out"ine and then deve"oped each topics. I incorporated m) past 'ritings. I re"ied heavi") on m)se"f/ especia"")/ on m) 1? )ears of e.perience in medica" education and 2= )ears of e.perience as a surgeon. A'OUT T3E AUT3OR *r. Re)na"do O. Noson is present") an associate professor at the *epartment of %urger) of the (niversit) of the Phi"ippines/ #o""ege of $edicine. &e 'as previous") the #hief of the *ivision of the &ead and ec9/ >reast/ 4sophagus/ and %oft Tissue %urger) of the *epartment of %urger) at the Phi"ippine 0enera" &ospita" :1??162---;. &e is current") the chair of the *epartment of %urger) of Ospita" ng $a)ni"a $edica" #enter :2--16;. &e finished his residenc) in genera" surger) at the Phi"ippine 0enera" &ospita" in 1?@1. &e is a dip"omate of the Phi"ippine >oard of %urger). &e obtained his $aster of %cience in 0enera" %urger) from the (niversit) of the Phi"ippines #o""ege of $edicine in 1??@. &e is a"so a ho"der of $aster in &ospita" Administration and $aster in &ea"th Profession 4ducation. ++