Before any treatment can be intelligently rendered a patient, the physician must know to what end his treatment is directed. In short, the first step in any treatment plan is to establish a diagnosis. In some cases this is easily accomplished. Often the first examination reveals the diagnosis; moreover, the patient may know pretty well his own diagnosis before submitting himself for treatment. For example, a man with a hernia (or “rupture”) may be quite certain of his diagnosis before seeking surgical advice. Also patients with burns, scars, warts, and a host of other conditions may know their diagnosis before consulting the surgeon.
In many cases, however, the diagnosis is not easily established. Often it takes repeated examinations and special studies to determine the exact nature of a disease process. Many of the procedures are performed to ascertain the diagnosis in difficult cases. Frequently patients are admitted to the hospital without an exact diagnosis, so that it may be established by special procedures and then the indicated treatment given. Occasionally a patient thought to be suffering from a medical illness is found to have a condition correctable by operation when the final diagnosis is determined. In this event the patient is transferred to the surgical service if already in the hospital and a surgeon called into consultation.
In a few eases the diagnosis may be impossible to completely establish, even after all the diagnostic aids and procedures have been exhausted. Under such circumstances the judgment of the surgeon plays an all-important role. The signs and symptoms and results of special studies and tests may suggest that operation is indicated, for the condition may be correctable by such. An example is the exploratory laparotomy (exploring-abdominal operation), where the diagnosis is not known for certain before operation, but rather is determined at the time of operation and the necessary alterations made. In other cases the diagnosis may be known in part but not in detail. For example, in the case of intestinal obstruction, this part of the diagnosis may be readily apparent, but the exact cause of the obstruction may rest with several possibilities. This does not constitute a great problem, however, as operation is indicated to relieve the obstruction regardless of the specific cause. Also, in the case of a tumor, the exact nature of the tumor may be unknown without analyzing a portion of it microscopically; but usually the fact that it is a tumor is indication enough for operation, so nothing is lost by not knowing the complete diagnosis.
In some cases a minor operation is performed to ascertain the diagnosis of a certain abnormality. This is called a biopsy, and entails the actual removal of a small piece of tissue, or an entire lesion, for the purpose of studying it to determine the exact nature of the disease. A common example of this is a lump in the breast, where other diagnostic measures may be inconclusive and yet the treatment of each of the possible causes of the lump radically different. The biopsy is also used for many other swellings and many chronic surface lesions. A special type of biopsy is the punch biopsy, where an instrument is inserted into an oragn or part to get a bit of tissue for study. Also certain body fluids are often withdrawn for analysis; these in effect are minor surgical procedures, so are frequently classed as biopsies.
There is a multitude of other tests and procedures at the surgeon’s disposal to add to his own diagnostic acumen. But fortunately the diagnosis of most cases is readily apparent after taking the history of the patient’s symptoms and physical examination; or if not, after one or two of the commoner diagnostic procedures in conjunction with the history and physical.
In some emergency situations time may not be afforded for complete diagnostic procedures. The history, complete physical examination, and necessary tests may be precluded by lack of time as efforts to save life or alleviate suffering are begun immediately. Yet, even in these situations the physician has to have some idea of what is wrong before he may instigate emergency treatment in an effective manner. In shock, for example, even though its cause is unknown, cursory examination may reveal the condition so treatment may be initiated. In these emergency situations the diagnosis is incomplete, or tentative. Then, as the situation allows, the necessary diagnostic measures may be performed. For definitive treatment a full diagnosis must be reached.
The import of the diagnosis is that on it the treatment plan is predicated. In cases where more than one disease state exists, there will have to be more than one diagnosis, of course, and treatment must be directed at each.
As the patient’s condition changes, so changes the diagnosis. The physician must seek diagnostic signs continually throughout the course of a disease. As a patient passes from one stage of a disease to another, the diagnosis changes. Often the major diagnosis must be changed completely, or another added. Actually the diagnostic phase of patient care never ceases. Examinations and tests may be repeated and new tests performed as the diagnosis is kept current. A constant watch is made for signs of complications which might ensue, and the general progress of the patient is followed. The physician’s impression of his patient’s course is as much a part of the diagnosis as the words used to formally designate it. Variations in the initial treatment plan will have to be made from time to time in many cases.
In cases where treatment involves operation, the diagnosis is definite in almost all cases. This is the preoperative diagnosis and is recorded by the surgeon just prior to operation. In a few situations, however, such as those mentioned above, the exact diagnosis has not been ascertained but rather rests with two or more possibilities. In such circumstances the surgeon records the most likely diagnosis but bears in mind the other possibilities, so the operative procedure may be directed at the most likely condition yet modified to correct another disease state if found. In this instance the precise diagnosis is actually made at the operating table. Such cases are not common, it is to be emphasized, for in almost all cases the preoperative diagnosis is unique and definite.