Clinical presentation of patients

Patients may present in two ways:

  • electively, with chronic symptoms of variable duration;
  • acutely, with life-threatening disorders.

The pathways involved in management of the two are quite different.

In the elective (cold) situation, the surgeon proceeds as shown in way 1. If surgical treatment is required, the patient is usually put on the waiting list or is given a date for the operation at the time of the outpatient interview. A priority system based on disease severity is adopted in deciding which patients are operated on soon after the diagnosis is confirmed. Thus a patient with cancer takes precedence over a patient with an uncomplicated inguinal hernia. Cancer patients undergo a process of staging by appropriate investigations based on the TNM (tumour, regional nodes, distant metastases) system before the relevant treatment is selected. This staging process influences management in several ways. In some patients, the disease is found to be inoperable, when non-surgical treatment (chemotherapy, radiotherapy) may be employed. In others, the disease, though operable, is advanced and adjuvant therapy (endocrine, chemotherapy, radiotherapy) before or after surgery is needed in addition to surgical extirpation of the primary tumour. Staging (clinical and pathological) is also the best overall guide to prognosis in the individual patient.

Acute patients are admitted as emergencies with life-threatening disorders or trauma. The pathway of management in these patients is shown in way 2. Frequently, resuscitation and diagnosis go hand in hand in the seriously ill or injured patient. Prompt and efficient resuscitation of seriously ill patients, which necessitates an understanding of the underlying pathological mechanisms, is crucial to the survival of these patients. Not all acute conditions need surgical intervention and some are managed conservatively in the first instance, with recourse to surgery if progress is not made or the clinical condition deteriorates. The relief of acute pain by appropriate analgesia is a very important part of the clinical management of acutely ill patients, whether they need emergency surgery or not.

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