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Management of a Patient [Process]
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 disorderSurgical disorder - health problem or condition that
is treated by surgery or an operationNonsurgical patient - one with a nonsurgical
disorder
Management of a 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
Management of a Patient [Process]
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.
Management of a Patient [Process]
Learning Objectives1. 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.
Management of a Patient [Process]
Learning Objectives6. 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.
Management of a Patient [Process]
Learning ObjectivesFor 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.
Management of a Patient [Process]
Learning ObjectivesFor 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.
10. Enumerate at least 2 items in the immediate posttreatment care of a nonsurgical patient.
Management of a Patient [Process]
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.
Management of a 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.
MANAGEMENT OF A PATIENTPROBLEM-SOLVING AND DECISION-MAKING
GOALS
RESOLUTION OF HEALTH PROBLEM
LIVE PATIENT
NO COMPLICATION
NO DISABILITY
SATISFIED PATIENT
NO MEDICOLEGAL SUIT
MANAGEMENT OF A PATIENTPROBLEM-SOLVING AND DECISION-MAKING
TASKS
RAPPORT
DIAGNOSIS
ADVICE
TREATMENT
ADVICE
Quality Standards: Rational, effective, efficient, humane
G
O
A
L
S
Management of a 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
Management of a Patient [Process]
Rapport
Some ways of establishing rapport with patient and his/her relatives:
1. Being courteous2. Showing respect to person and beliefs 3. Giving honest and clear advice on diagnosis,
paraclinical diagnostic procedures,and treatment
4. Demonstrating humaneness and compassion
Management of a 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 expenses8. Making the patient and relatives feel that you are
approachable and easy to talk to
Management of a 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).
Management of a 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
CLINICAL DIAGNOSTIC PROCESS
DATA NEEDED
SYMPTOMS (from interview or history)SIGNS (from physical examination)PERSONAL DATA OF PATIENT
CLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
PATTERN RECOGNITION-realization that the patient’s presentationconforms 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
CLINICAL DIAGNOSTIC PROCESS
OUTPUT EXPECTED
RATIONAL
-PRIMARY CLINICAL DIAGNOSIS-SECONDARY CLINICAL DIAGNOSIS
CLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
PATTERN RECOGNITION-realization that the patient’s presentationconforms 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
CLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
Knowing the common manifestations of 5 different diseases as follows:
Disease A - abcd (manifestations)Disease B - fghiDisease C - klmnDisease D - pqrsDisease E - uvwx
Given a patient manifesting with pqrs, your diagnosis is Disease D. What is the process used?
Pattern Recognition
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 commonDisease 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
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
CLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
PATTERN RECOGNITION-realization that the patient’s presentationconforms 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
Management of a Patient [Process]
Paraclinical Diagnostic ProcessIndication - to be more definite on the clinical diagnosis
Selection
Interpretation
Management of a Patient [Process]
Paraclinical Diagnostic Process - Indication
DATA NEEDED
PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS
Management of a 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 DxDifferent Sameneeded not needed
Management of a Patient [Process]
Paraclinical Diagnostic Process - Indication
OUTPUT EXPECTED
DIAGNOSTIC PROCEDURE NEEDED orNOT NEEDED
Management of a Patient [Process]
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 98% SurgicalSecondary 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)
Management of a Patient [Process]
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 60% SurgicalSecondary clinical diagnosis 40% Nonsurgical
Is a paraclinical diagnostic procedure needed?
YES
Management of a Patient [Process]
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 60%Surgical ExcisionSecondary 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)
Management of a Patient [Process]
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 90% Mutilating OpSecondary clinical diagnosis 10%
Nonmutilating Op
Is a paraclinical diagnostic procedure needed?
YES unless there is a strong reason NOT to do so (exception to the rule)
Management of a Patient [Process]
Paraclinical Diagnostic Process - Indication
Certainty Plan of Treatment
Primary clinical diagnosis 70% ChemotherapySecondary clinical diagnosis 30%
Radiotherapy
Is a paraclinical diagnostic procedure needed?
YES unless there is a strong reason NOTto do so (exception to the rule)
Management of a 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 diagnosisB. You want to confirm a clinical diagnosis which are certain ofC. You want to document a clinical diagnosis which you are certain
ofD. When you are not certain of your clinical diagnosis
Best Answer is D
Management of a Patient [Process]
Paraclinical Diagnostic Process - Selection
DATA NEEDED
OPTIONS OF DIAGNOSTIC PROCEDURES
Management of a Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability123
Management of a Patient [Process]
Paraclinical Diagnostic Process - Selection
OUTPUT EXPECTED
MOST COST-EFFECTIVEDIAGNOSTIC PROCEDURE
Management of a Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions1 most direct acceptable 1000 available2 indirect acceptable 1500 available3 indirect acceptable 1000 available
Which is the most cost-effective procedure?
Option 1
Management of a Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions
1 accuracy 99% acceptable 5000 available2 accuracy 90% acceptable 3000 available3 accuracy 50% acceptable 1000 available
Which is the most cost-effective procedure?
Option 2 or Option 1?
Management of a Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions
1 accuracy 95% acceptable 5000 available2 accuracy 90% acceptable 3000 available3 accuracy 50% acceptable 1000 available
Which is the most cost-effective procedure?
Option 2 or Option 1?
Management of a Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions
1 yield greatest acceptable 4000 available2 yield 90% acceptable 4000 available3 yield 80% acceptable 3000 available
Which is the most cost-effective procedure?
Option 1
Management of a Patient [Process]
Paraclinical Diagnostic Process - Interpretation
DATA NEEDED
PRIMARY CLINICAL DIAGNOSISSECONDARY CLINICAL DIAGNOSIS
RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE
Management of a Patient [Process]
Paraclinical Diagnostic Process - Interpretation
INTERPRETATION PROCESS
CORRELATE RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE
WITH PRIMARY AND SECONDARY CLINICAL DIAGNOSIS
CONGRUENT - ACCEPTINCONGRUENT - MAKE A DECISION!
(Accept or Hold!)
Management of a 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
diagnosis7.3 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
Management of a 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.
Management of a Patient [Process]
Learning Objectives7. Describe how a treatment modality should be selected
among several options.
For surgical patient8. 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.
Management of a Patient [Process]
Learning ObjectivesFor 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.
10. Enumerate at least 2 items in the immediate posttreatment care of a nonsurgical patient.
Management of a Patient [Process]
Learning Objectives 11. Enumerate the two objectives of a follow-up plan after
treatment of a patient (whether surgical or not).
Management of a Patient [Process]
Treatment Process - Selection
DATA NEEDED
PRETREATMENT DIAGNOSISSEVERITY OR STAGE
GOALS AND OBJECTIVESTREATMENT OPTIONS
Management of a Patient [Process]
Treatment Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability123
Management of a Patient [Process]
Treatment Process - Selection
OUTPUT EXPECTED
MOST COST-EFFECTIVETREATMENT PROCEDURE
ACHIEVEMENT OF GOALS OF PATIENT MANAGEMENT!
Management of a Patient [Process]
Treatment Process - Selection
SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions
1 greatest surv rate acceptable 5000 available2 rate < 1 > 3 acceptable 4000 available3 least surv rate acceptable 3000 available
Which is the most cost-effective treatment option?
Option 1
Management of a Patient [Process]
Treatment Process - Selection
SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions
1 SR1 = SR2 lesser 5000 available 2 SR2= SR1 more 5000 available
Which is the more cost-effective treatment option?
Option 1
Management of a Patient [Process]
Treatment Process - Selection
SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions
1 as effective as 2 acceptable 8000 available2 as effective as 1 acceptable 4000 available
Which is the more cost-effective treatment option?
Option 2
Management of a Patient [Process]
Treatment Process - Selection
SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions
1 most effective acceptable 2000 available2 effectivity <1 >3 acceptable 3000 available3 least effective acceptable 4000 available
Which is the most cost-effective treatment option?
Option 1
Management of a Patient [Process]
Surgical Treatment Process - Preop Preparation
•INFORMED CONSENT•PSYCHOSOCIAL SUPPORT•OPTIMIZATION•SCREENING•OPERATIVE MATERIALS
Management of a Patient [Process]
Nonsurgical Treatment Process - Pretreatment Preparation
•INFORMED CONSENT•PSYCHOSOCIAL SUPPORT•OPTIMIZATION•SCREENING•NONSURGICAL TREATMENT MATERIALS
Management of a Patient [Process]
Surgical Treatment Process - Intraop Mgt
PHASES
•INCISION•EXPOSURE•INTRAOP EVALUATION•OPERATIVE PROCEDURE PROPER•HEMOSTASIS CHECK•CORRECT COUNT•WOUND CLOSURE
Management of a Patient [Process]
Surgical Treatment Process - Intraop Mgt
Quality Standards:
GENTLE
METICULOUS and PRECISE
NO IATROGENIC INJURIES
NO UNNECESSARY MOVESEVERY MOVE HAS A REASON!
Management of a Patient [Process]
Nonsurgical Treatment Process - Intratreatment Mgt
PHASESExample: 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
Management of a Patient [Process]
Nonsurgical Treatment Process - Intratreatment Mgt
PHASESExample: 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
Management of a 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
Management of a Patient [Process]
Nonsurgical Treatment Process - Posttreatment Care
•SUPPLY BASIC NEEDS OF PATIENT•COMFORT•ALLAYANCE OF FEAR
•MONITORING FOR COMPLICATIONS
•ADVICE ON •HOME CARE •FOLLOW-UP PLAN
Management of a Patient [Process]
Surgical Treatment Process - Postop Follow-up Plan
OBJECTIVES:
•EVALUATE TREATMENT OUTCOME •PROVIDE PSYCHOSOCIAL SUPPORT
MONITORING GUIDELINE:
PHYSICAL EXAMINATIONSYMPTOM-DIRECTED
INVESTIGATION
Management of a Patient [Process]
Surgical Treatment Process - Postop Follow-up Plan
FF-UP FREQUENCY GUIDELINES: CONSIDER•USUAL COURSE OF DISEASE•PERSONALITY OF PATIENT•PATIENT’S CONVENIENCE
Management of a Patient [Process]
Nonsurgical Treatment Process - Posttreatment Follow-up Plan
OBJECTIVES:
•EVALUATE TREATMENT OUTCOME •PROVIDE PSYCHOSOCIAL SUPPORT
MONITORING GUIDELINE:
PHYSICAL EXAMINATIONSYMPTOM-DIRECTED
INVESTIGATION
Management of a Patient [Process]
Nonsurgical Treatment Process - Posttreatment Follow-up Plan
FF-UP FREQUENCY GUIDELINES: CONSIDER•USUAL COURSE OF DISEASE•PERSONALITY OF PATIENT•PATIENT’S CONVENIENCE
Management of a 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.
Management of a Patient [Process]
Learning Objectives7. Describe how a treatment modality should be selected
among several options.
For surgical patient8. 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.
Management of a Patient [Process]
Learning ObjectivesFor 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.
10. Enumerate at least 2 items in the immediate posttreatment care of a nonsurgical patient.
Management of a 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.
Management of a 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 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.
Management of a 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.
Management of a 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.
Management of a 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.
Management of a Patient [Process]
Learning Objectives1. 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.
Management of a Patient [Process]
Learning Objectives6. 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.
Management of a Patient [Process]
Learning ObjectivesFor 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.
Management of a Patient [Process]
Learning ObjectivesFor 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.
10. Enumerate at least 2 items in the immediate posttreatment care of a nonsurgical patient.
Management of a Patient [Process]
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.