Chapter IX. GUIDELINES FOR PREOPERATIVE CARE

A comprehensive and thorough examination of a surgical patient is a prerequisite for making the definitive diagnosis. The purposes of the preoperative diagnostic workup are therefore as follows:

1) to define the organ affected;

2) to find out the aetiology and pathogenesis of the disease;

3) to identify the complications, if any, of the condition.

It is noteworthy that the results of each of the three stages do influence the therapeutic plan.

All the pertinent findings, both positive and negative, of physical examination and laboratory investigations are to be recorded in the patient's medical record. This is a document with medical, research and legal purposes; thus it should be written clearly, accurately and be free of non-conventional abbreviations.

A standard outline for history-taking and physical examination in surgery, alongside with specific patterns, whenever necessary, follows.

The chief complaints in detail, history of the present illness, as well as results of the comprehensive physical examination with an emphasis on the organ(s) affected (Latin status localis) are the mainstays of the patient's medical record.

Taking the medical history. Trying to find out the patient's life events associated with the problem that has made them seek out the medical aid, the physician will interview the patient in a standardised sequence. Putting questions in simple nontechnical words is a prerequisite as this ensures that the patient understands what he/she is meant to talk about. The chief purpose of the history to furnish clues for diagnosis, which implies that only relevant data are to be considered seriously. The value of interrogation can be sometimes undermined when the patient is not able to present the complaints well and explain the chief complaints despite the fact that the question has been put correctly.

It is sometimes hard to establish contact with the patient if, for instance, they are in severe pain during the interrogation. This makes the surgeon arm himor herself with patience and be considerate so as to be able to obtain the information required for the diagnosis to be made. Occasionally, patients deliberately exaggerate their complaints (which is referred to as aggravation) or present non-existent symptoms (the phenomenon known as simulation). At the same time, dissimulation, or concealing the symptoms because of the fear of surgery or for some other reason, has also to be born in mind.

When it is impossible to take the history from the patient him-/herself, other informants (e.g. next of kin) will be involved in the interrogation.

The history of symptoms starts with the chief complaints, abbreviated CC. Each complaint must both be clarified and quantified. If, for example, the patient complains of pain, its localisation and irradiation have to be specified, and so do the time of its onset, persistence, intensity and the character, its recurrence, the relation of the pain to physical activity, trauma, physiological functions, its association with dizziness, loss of consciousness or temperature changes.

Or, if the patient complains of vomiting, it is important to ascertain the nature of vomitus, frequency of vomiting and specify other complaints that accompany it, if any. Further, it has to be found out whether the patient feels better after vomiting or not.

As was mentioned above, in taking the history of the present illness (PI; Latin anamnesis morbi) it is necessary to clarify the time of onset of the symptoms and their progression. Also, the type and results of previous hospitalisations and therapy (surgical, conservative or sanatorium) have to be ascertained. The relevant medical documents have to be scrutinised as well, such as referral notes, discharge summaries, and the results of laboratory and X-ray investigations; all these are subject to registration in the patient's medical record.

Past medical history (Latin anmnesis vitae) is a short biographical narrative of the patient that comprises the information on the following:

1) hospitalisation(s) (date, duration, and diagnosis);

2) operations;

3) childhood illnesses;

4) injuries;

5) illnesses requiring physician's attention;

6) family history with specific mentioning the data on parents (age and health status) and any disease in which congenital factors may play a role (e.g. TB, hypertension, coronary heart disease, anaemia, diabetes, blood dyscrasia, cancer, migraine);

7) social history (residences and education; all jobs and posts held and military service with a description of occupational hazards; tobacco, alcohol, and other drugs);

8) allergies, particularly those to antibiotics and previous blood transfusions or blood substitutes in female patients, gynaecologic conditions.

The next step in making the diagnosis is the physical examination of the patient, which implies utilisation of the following methods: inspection, thermometry, palpation, percussion and auscultation.

Inspection. Of the several methods of examination, inspection yields the most of clinical signs in surgery, and not infrequently it provides a valuable clue to the diagnosis.

Focusing observation on a single anatomic region it is required that the former be well exposed. Position patient so that the part under examination is sufficiently lighted. During inspection, compare the symmetrical sites and structures of the body (e.g. the affected part with the intact one on inspection of an injured knee). The position, form, size, mobility, changes in skin colour, folds and normal lines, the change in the axis of an organ, and its transparency should also be noted.

From the position of an organ one can infer not only the type of disease but also its duration and severity. For example, a stiff vertebral column, especially in the patient supporting the trunk or head with their hands, suggests spondylitis. On the other hand, the unusual positioning of an organ can result from skeletal changes, muscle contractions and palsy, acquired and congenital diseases and other deformities. It is necessary that a would-be surgeon make it a rule to examine each patient both supine and standing, with the exception of critically ill patients. This is particularly pertinent to conditions of the lower extremities, spine or genitals (e.g. in congenital hydrocele of the testes and spermatic cord, when fluid can flow from the abdominal cavity into the scrotum or the inguinal region on standing and go back into the abdomen in the patient being supine).

Bone deformities may occur either rapidly, as is the case in bone fractures, dislocations and ligamental straining or gradually, resulting from osseous or articular infections.

When inspecting a limb consider the possibility of axial deformities that occur in fractures, dislocations or joint or diaphysis deformity. The axis of the upper limb is a line passing through the centre of the humeral head and the heads of the radius and ulna, while that of the lower limb is the line connecting the anterior superior spine of the iliac bone, the centre of the patella and the space between the first and second toes.

A change in the shape of the part under examination is the first to attract the surgeon's attention. In this case the commonest conditions identified are swelling and tumours (the terms which are frequently confused). A swelling can be due to inflammation, oedema or neoplasm, while a tumour is an overgrowth of the new tissue which is visualised by its location, form and partly its mobility (e.g. the movement of a thyroid tumour on swallowing). A tumour can be spherical, eggor pear-shaped, oblong, cylindrical, irregular etc. It will be noted that spherical, or round-shaped, tumours are typically cysts, atheromas, etc. A tumour on a stalk is mostly benign (e.g. polyposis); alternatively, malignant tumours have commonly wide bases and often an almost invisible stalk with changes in the overlying skin.

The size of a tumour is usually assessed by comparing it to a well-known object (e.g. a tumour of a size of a nut, bean, orange, hen or goose egg). Tumour can occasionally be as huge as a child's or even adult's head. To obtain the size more accurately (in cm) the tumour has to be measured with a tape.

Skin changes can offer diagnostic clues as well. The colour helps both assess the patient's general condition and gain the information about the local process. The skin can be pinkish or pale, and the patients with debilitating disease may have sallow complexion.

Generalised straw-yellow skin discolouration of a patient with a malignant tumour suggests an advanced stage of the condition resulting in severe intoxication and cachexia. In contrast, localized skin discolouration depends on the extent of circulatory disorder or disturbance in pigmentation.

Local skin pallor may serve as evidence of severe defect in arterial blood circulation, cyanosis - insufficient oxygen saturation of arterial blood or venous stasis. The skin changes such as peeling, wasting or alopecia (i.e. hair loss) are commonly found in chronic circulatory insufficiency of the affected area. Cutaneous hyperaemia may be caused by inflammation, pathological dilation or an increase in the amount of blood vessels (e.g. teleangioctasic, varicose veins). Pigmentation disorders occur as a result of excessive accumulation of the pigment (e.g. venous dilation, melanosis) or its insufficient production (leucodermia in syphilis or vitiligo in white leprosy). Skin rash can also be encountered: macules (spots), papules, nodules or nodes, vesicles or bullae filled with pus or fluid, blisters, erythaema, crusts, fissures, ulcers, erosions.

Scarring can result from vaccinations, chicken pox, lupus erythematosus, trophic ulcers (on the leg), tuberculous lymphadenitis (on the neck), syphilis or surgery. The size, location, mobility (i.e. the degree of attachment to the underlying tissue, bone) and the colour (pigmented or depigmented) of the scar have to be noted. Transparency is one of the characteristics of tumour-like structures that consist of the sac containing fluid (e.g. scrotal hydrocele). Transparent fluid suggests the serous nature of the fluid.

Thermometry. Increased body temperature, or fever, is a characteristic sign of an inflammation; pyogenic infections, for example, produce fever of the alternating pattern. On the other hand, a fall in body temperature previously raised and its normalisation may be well suggestive of a favourable outcome of the condition. Further, fever accompanied by chills is a sign of purulent infection that may result in septicaemia. Of the important aspects of fever is the relationship between a rise in body temperature and the pulse rate: tachycardia with a fall in temperature tends to imply worsening the patient's condition and, therefore, be a prognostically unfavourable sign.

To check the local skin temperature the physician places the dorsum of the hand on the site examined. If, for example, the local temperature is found to be higher compared with that in the symmetrical site, an inflammation may probably be found either in the skin or the underlying tissues (phlegmon, osteomyelitis, arthritis, etc.), as may a malignancy (benign tumours are very unlikely to increase the local skin temperature). In contrast, gangrene, occlusion of arterial branches and spasm of small arteries commonly cause a reduction in the local temperature.

Measurement of organs or parts of the body. Measurement of an organ or tumour-like structure yields valuable clues that help make the diagnosis. The circumference of the abdomen should be measured if an intra-abdominal condition (e.g. ascitis, tumour) is suspected; the measurement of the extremities aids to recognise a reduction in their size in muscular atrophy or an increase in their oedema. Equally, an increase in the size of a limb can be a sign of venous or lymphatic stasis. Measurement of the circumference and length of a limb is to be performed both on the affected and intact sides, the results obtained being compared. A tape measure is applied to measure the circumference and length of the limb in cm.

To perform the procedure, place the patient comfortably: the pelvis should not be distorted, the line joining the two anterior iliac spines must be perpendicular to the mid-sagittal plane of the pelvis. The length of the upper arm is regarded as the distance from the acromion to the olecranon or the lateral humeral epicondyle, while the length of the forearm is the distance from the olecranon to ulnar styloid process of the. The length of the lower limb is measured from the superior anterior iliac spine to the medial malleolus; the length of the thigh - the distance between the major trochanters and the knee joint space; the length of the shin (i.e. the distance between the knee joint space and the lateral malleolus). The shortening or lengthening of the limb may result from a number of causes.

Abnormal joint movements can be identified by inspection. These are usually classified into active, or voluntary, and passive, or involuntary (i.e. performed by the examiner). Absolute or almost absolute limitation of both active and passive movements is encountered in ankylosis of the joints. Conversely, excessive movements in the joints are characteristic of «the dangling joint», as is the case in a ligament tear. Suppleness along the length of a long bone suggests a fracture. The absence of activity and the ability to passive movements of a limb may serve as evidence of palsy.

The amplitude of motion in a joint is evaluated with an angle gauge whose sides are placed in the direction opposite to the segments that form the joint. The angles are measured from the initial position of the limb (i.e. the one of the joint when the trunk and limbs are in the vertical position).

When examining the limbs, their muscle power (i.e. the counteractive motion of the patient in various directions) is also assessed. The reverse effect on the examiner is compared to the power in the symmetrical muscles. The application of dynamometer provides more precise information about the muscle power.

Palpation. Palpation is preferably performed with warm hands and the patient made to take various positions. Start palpating from the areas far-off from the pain-causing site, moving gradually and carefully towards it. Careful superficial palpation evolving into a deeper one is advisable.

Palpation adds to the information obtained through inspection, namely, that about the position, shape and size of a tumour or swelling. Further, the consistency of the organ or swelling under examination is determined. Some conditions can cause the accumulation of dense products identified by the change in consistency. The accumulation of fluid in tissues can either account for infiltration or cavity full of fluid. The consistency can be either woody-or stone-hard; it can also be soft, for example, jellylike (i.e. the finger embedded on pressing leaves a dimple) or elastic (e.g. like a plastic ball).

The accumulation of fluid (pus in an abscess, serous fluid in a cyst or blood in haematoma) in a cavity or sac-like tumour is characterised by fluctuation, and occasionally a tense elasticity is identified. Fluctuation is accounted for by the transfer of waves of liquid vibration caused by a special type of pressure applied to the cavity wall. It is performed the following way: one or two fingers of one hand are placed on one side of the swelling, and the fingers of the other hand are used to perform a short and fast tappings on the opposite side; the first hand receives the jolts being transmitted. This manipulation has to be repeated several times to obtain more precise and clear information. This method is used to estimate the volume of fluid accumulated in suppurative focus, the abdominal cavity or elsewhere in the body. In huge cysts, a modified form of the method is used, in which the palm of one hand is placed on the side of the swelling and the other hand is used to tap from the opposite side. The resultant vibrations are felt by the first hand. It is noteworthy that pseudo fluctuations can be encountered and should not be confused with authentic ones. Pseudo fluctuations can be found in lipomas, myxomas or fungating masses of joints and tendons. On the other hand, fluctuation may be overlooked if the accumulation of fluid is deep-sited (e.g. beneath the greater muscles) or the cavity containing the fluid is formed by rigid tissues, in which case the consistency resembles that of a blown balloon.

The lymph nodes are to be palpated in a careful circular manner using fingers 2-4, the size, consistency, and mobility of the nodes being examined. Their relationship with each other and the surrounding tissues (lying free, being grouped in packets), tenderness should also be specified.

The point of maximum tenderness on palpation indicates the site of the disease which is liable to scrutiny (e.g. in felon or phlegmon). The place of maximum tenderness identified with a probe may help localise the site of accumulation of pus, while the place of maximum tenderness found with the finger passing along a bone in case of trauma points to the fractured site). Similarly, identification of abdominal tenderness points facilitates the diagnosis, for example, of acute appendicitis.

Palpation is also practical in evaluating changes in the size of a swelling (e.g. hernias) and tumour (e.g. angiomata, or in vascular tumours). Pressing on angiomata, or varices often yields their emptying of the blood which flows into the vessels. Equally, the contents of a reducible hernia (abdominal or cerebral) move back either to the abdominal cavity or skull when pressure is applied.

The mobility of a tumour is also assessed by way of palpation which helps identify the origin of the tumour (the skin, muscle or bone). In fact, malignant tumours tend to be fixed, while benign masses are commonly mobile and therefore can be displaced in relation to the surrounding tissues. Technically, holding it at its base and moving upwards, downwards and laterally checks the mobility of the tumour.

Pulsation is known to be typical of vascular tumours and aneurysms. Arteriovenous aneurysms produce specific vibration - a hum murmur, while a vibration synchronous with the heartbeat is characteristic of pulsating haematomas.

The pulse rate should be evaluated at specific sites as follows:

• the radial artery - on the palmar aspect of the outer border of the forearm, about 2-3 cm above the wrist joint;

• the humeral artery - on the medial aspect of the biceps brachii muscle;

• the femoral artery - below the Pourpart's ligament, about 1, 5-2 cm medial from its midpoint;

• the popliteal fossa - with the patient lying on the abdomen and their knee joint bent at the angle of 120°;

• the posterior tibial artery - between the posterior inferior aspect of the medial malleolus and the Achilles tendon;

• the dorsalis pedis artery - along the line drawn between toes 1 and 2 towards the ankle joint;

• the temporal artery -about 1 cm anterior to the auricle.

Palpation can also be used to identify crackles, snap, and crepitations, which may serve as a sign of accumulation of air (e.g. subcutaneous emphysema) or gas (e.g. anaerobic infections). Crepitations are recognised by a slight tap or pressure on the skin. Accumulation of blood mixed with blood clots produces a mild crackle felt by the fingers, which resembles that of snow. On the other hand, fibrin deposits in the tendon sheets of the fingers may cause specific snap audible with the fingers bent in the joints. In fractures of long bones clear crepitation sounds are elicited as a result of the friction of the bone fragments against each other. Parchment crackles are typical of central bone cysts, myelogenic sarcoma and fibrous ostitis if the thin plate of the cortical bone substance is pressed upon.

Palpation of the abdomen is indispensable in examining abdominal organs, especially in the presence of inflammation. The abdomen must be fully relaxed during this procedure. For this, the patient should be placed on a firm couch without a pillow, their legs bent in the knee joint. The patient will be asked to breathe evenly but not very deeply, since during the forceful deep breathing the abdomen is rather drawn in, which impedes the overcoming of the resistance of abdominal muscles.

The examiner has to use their both hands, placing the palms on the abdominal wall in a way that the fingers are slightly bent, and gradually pressing deep. The hands are then moved in a sliding manner, perpendicular to the axis of the organ being examined. The location of the organ or tumour, its size and form and mobility with breathing are thus noted. Abdominal tenderness is assessed during palpation as well as by reflective resistance of the abdominal muscles. Palpation is used to reveal specific pain signs (Blumberg's, Rovsing's, Obraztsov's etc.). The findings obtained by palpation of the abdomen are usually supplemented by auscultation.

Percussion. In physical diagnosis, percussion is the method of examination in which the surface of the body is struck to emit sounds that vary in quality according to the density of the underlying tissues. It is very informative in the examination of many diseases of the viscera. Percussion is employed to determine the borders of the heart and lungs, as well as the presence of fluid (e.g. pus) in the pleural cavity or pericardial sac. The pleural fluid, for instance, is detected by the presence of an oblique line (Damoiseau's line) whose apical point is situated on the posterior axillary line. The fluid level can sometimes be horizontal, as is the case in pyopneumothorax when, apart from the fluid, the pleural cavity contains air. Besides, percussion helps locate the heart: cardiac displacement resulting from accumulation of fluid and gas in the pleural cavity.

Percussion of the abdomen allows verifying a decrease or even absence of hepatic dullness, the presence of fluid in the abdominal cavity, and the extent of abdominal distension as well. Also, it helps elicit local tenderness. Fluid accumulation is known to be typical of peritonitis in which case the dull percussion sound is heard over the areas of fluid accumulation in the abdominal cavity; this changes with a change in the patient's position. To elicit the clinical sign, abdominal percussion will be started with the patient lying on the back; then without changing the location of the physician's hands placed on the patient's abdomen they are asked to turn aside, after which percussion is continued. Fluid accumulation, along with dullness of the percussion sound, is revealed on the side the patient is lying on. The sound on the opposite side that has initially been dull on percussion evolves into a tympanic one.

Percussion can also be used to determine intestinal distension resulting from peritonitis and other abdominal inflammatory conditions.

Auscultation is the method of listening to and interpreting the meaning of sounds produced within the body:

1) heart sounds (clear/dull/accentuated, etc.) and murmurs (systolic/diastolic, etc.);

2) breath sounds (vesicular/bronchovesicular/ bronchial, etc.) and crackles (rales, crepitations, moist sounds);

3) bowel sounds.

• the absence of bowel sounds on abdominal auscultation may be well suggestive of severe peritonitis in which peristaltic intestinal movements are unlikely to be audible;

• sound of «falling drops» (is abscence of peristatic ones peristalsis) is often found in intestinal obstruction etc.

Auscultation of the skeleton is generally of limited value. In some cases, however, local auscultation can be helpful (e.g. intra-articular injuries; aneurysms; long bone fractures in which crepitations can be heard, etc.) In fractures there is no sound conduction through a bone.

Arterial auscultation is to be performed in each patient with arteriosclerosis. In health, a characteristic conductivity tone is heard from the pulsating waves of major arteries during auscultation, while in vascular pathologies various auscultation signs may be found:

• systolic murmur in constricted or dilated arteries;

• systolic-diastolic murmur when blood is being pumped from an artery into the vein.

Based on the physical findings an initial impression, or the preliminary diagnosis, is made; this includes the main disease and its complications, and concurrent conditions. The preliminary diagnosis dictates further workup. The diagnostic algorithm implies that more sophisticated and invasive investigations should follow simpler and non-invasive ones if only the latter appeared inconclusive.

The results obtained through the physical examination and additional investigations are used to make the final, or definitive, diagnosis.This should comprise the confirmed major disease and, if any, its complications and all the concurrent conditions.

Specific laboratory techniques can occasionally be associated with complications. The invasive methods such as diagnostic punctures, laparoscopy, thoracoscopy, biopsy, etc. may result in bleeding, damage to the internal organs or infections. Thus, in prescribing any of the special investigations one should bear in mind the following principles.

• The investigation must never be more dangerous than the disease itself.

• Contraindications to the investigation must always be considered.

• Safer but as effective techniques must be preferred.

Making the diagnosis the physician inevitably assesses the severity of the patient's condition. This is more objective if the scoring system is applied.

The Glasgow Coma Scale is widely used (tab. 4).

Table 4. Glasgow Coma Scale

Condition	Score	Maximum Value
Eye opening (E)
Spontaneous	4
To speech	3
To pain	2
No response	1	4
Verbal response (V)
Orientated	5
Confused conversation	4
Inappropriate words	3
Incomprehensible sounds	2
No response	1	5
Motor response (M)
Obeys	6
Localizes pain stimulus	5
Withdraws extremities as a reaction to pain	4
Flexion pathological	3
Extension pathological	2
No response	1
Glasgow Coma Scale = E + V + M
GCS minimum	3
GCS maximum	15

The Glasgow scale is used to assess the functional state of the central nervous system in disturbed consciousness, particularly in head injury, cerebrovascular disease, poisoning and endogenous intoxication. Patients with scores above 9 are likely to recover. The Glasgow score has been incorporated into the Simplified Acute Physiology Score (SAPS) as part of evaluation of the patient's general condition and estimation of the overall prognosis by adding up the points. The SAPS is based on the deviation from the norm of each of its fourteen parameters (tab. 5).

Table 5. Simplified Acute Physiology Score (SAPS)

Clinical signs	Scores
and laboratory fidings	+ 4	+ 3	+ 2	+1	0	+1	+2	+3	+4
1	2	3	4	5	6	7	8	9	10
Age, yrs					< 45	46-55	56-65	66-75	> 75
Pulse rate, min-1	> 180	140-179	110-139		70-109		55-69	40-54	< 40
Systolic BP, mm Hg	> 190		150-189		80-149		55-79		< 55
T, °C	> 41	39, 040, 9		38, 538, 9	36, 038, 0	34, 035, 9	32, 033, 9	30, 031, 9	< 30
Respiratory rate, min-1	> 50	35-49		25-34	12-24	10-11	6-9		< 6
Mechanical ventilation	-	-	-	-	-	-	-		-
Urea, mmol/l	> 55, 0	36, 054, 9	29, 035, 9	7, 528, 9	3, 5-7, 4	< 3, 5
Haematocrit (PCV) %	> 60, 0		50, 059, 9	46, 049, 9	30, 045, 9		20, 029, 9		< 20, 0
WBC, x109/l	> 40, 0		20, 039, 9	15, 019, 9	3, 014, 9		1, 0-2, 9		< 1, 0
Glucose, mmol/l	> 44, 5	27, 844, 4		1427, 7	3, 913, 9		2, 8-3, 8	1, 6-2, 7	< 1, 6

Tab. 5. Contd.

1	2	3	4	5	6	7	8	9	10
Potassium, meq/l (mmol/l)	> 7, 0	6, 0-6, 9		5, 5-5, 9	3, 5-5, 4	3, 0-3, 4	2, 5-2, 9	2, 0-2, 4	< 2, 0
Sodium, meq/l (mmol/l)	> 180, 0	161179	156160	151155	130150		120129	110119	< 110
Bicarbonate, meq/l (mmol/l)		> 40, 0		30, 039, 9	20, 029, 9	10, 019, 9		5, 0-9, 9	< 5, 0
Glasgow Coma Scale (score)	13-15	10-12	7-9	4-6	3

Table 6. The prognostic probability of a lethal outcome using the SAPS system of scores

Score	Lethal prognosis (%)
4	-
5-6	10, 7
7-8	13, 3
9-10	19, 4
11-12	24, 5
13-14	30, 0
15-16	32, 1
17-18	44, 2
19-20	50, 0
20	81, 1

Chapter X. TRAUMA

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