Symposium on Surgical Techniques in Small Animal Practice
Presurgical Evaluation of the Surgical Patient William B. Henry, Jr., D.V.M.*
Presurgical evaluation of the patient is necessary for many reasons. This evaluation may be needed to determine whether the patient has a surgical problem or a medical problem. The presurgical evaluation may indicate that surgical intervention may not be necessary or must be delayed until a course of medical therapy has been instituted and later reevaluated. The presurgical examination may indicate that surgical intervention is the best method of treatment. The depth of presurgical examination is governed by many variables. The age of the patient is a prime consideration regardless of whether a major or minor surgical procedure is to be done. The available time prior to surgery may be limited because of a life-threatening problem that limits the thoroughness of the presurgical evaluation. In veterinary medicine there are frequently financial limitations that the client places on the doctor. This is common but should not be used as as an excuse. The doctor should equip himself and his hospital well, and then offer his client the best possible care for the animal so that the client must make the compromising decision.
PHYSICAL EXAMINATION The first and most important initial portion of the presurgical evaluation of the patient is the physical examination. The clinician must develop a thorough physical examination procedure and not vary from it, unless, of course, the patient is in a state of respiratory or cardiac collapse. In such instances portions of the physical examination must be omitted and emergency resuscitation procedures initiated. Every surgeon has his favorite area; however, interest in areas of specialty must be suppressed so that the patient may be evaluated as a whole. *Director of Surgery, South Shore Veterinary Associates, Inc., South Weymouth, Massachusetts Veterinary Clinics of North America- Vol. 5, No.3, August 1975
317
318
WILLIAM
B.
HENRY, JR.
The best way to avoid making mistakes by overlooking something and to provide a permanent record is to use a physical examination checklist. This checklist is broken down according to systems of the body in the order that the physical examination is carried out from the oral and ocular area to the extremities (Fig. l.). For individual reference, and especially when there are many people involved in a practice, there must be some standard written communication. Physical examination sheets are helpful when the initial physical examination is done by associates, thus providing a quick review of findings and comments. The checklist is beneficial as a permanent record for legal reasons and facilitates follow-up examinations. In the order of their priority, the age, breed, sex of the patient, the owner's complaint, and duration of the problem should be noted on the record. A brief history should be recorded regarding appetite, stool consistency, and the presence of vomiting, polydipsia, or polyuria. We all may find ourselves cutting corners in this portion of presurgical evaluation because we are in a hurry for various reasons. If the surgeon rushes through the physical examination or takes short cuts by not obtaining a good history, he may waste a great deal of his own time, his client's money, and even his patient's life. As a surgeon, one is most interested in perfusing the surgical patient's tissues with oxygenated blood and anesthetic during surgery, and quick elimination of the anesthetic postoperatively without insulting the patient's tissues to the point that they are incapable of recovery. The patient's age, physical status, and type of surgical procedure contemplated must be considered when determining which anesthetic agent would be most satisfactory. Gas anesthesia would be used in most patients undergoing major· surgery because its rapid evacuation from the body results in less tissue insult. One therefore must critically evaluate the cardiopulmonary system, the kidneys, and the liver in that order.
PREOPERATIVE CONSIDERATIONS Prior to, during, or following the surgeon's physical examination of the patient, there are three basic considerations that affect his recommendations to the client. These three factors, as well as the results of the physical examination, are the basis for the course of action from that moment. The first factor to be considered is the age of the patient. In the younger patient there are fewer chances for complications so that the surgeon is less concerned with the patient's cardiopulmonary, renal, or hepatic function. Therefore the presurgical evaluation is often less involved for the surgeon and the patient, and in turn less expensive for the client. The second consideration is determination of whether surgery will
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Presurgical Evaluation of the Surgical Patient William B. Henry, Jr., D.V.M.*
Presurgical evaluation of the patient is necessary for many reasons. This evaluation may be needed to determine whether the patient has a surgical problem or a medical problem. The presurgical evaluation may indicate that surgical intervention may not be necessary or must be delayed until a course of medical therapy has been instituted and later reevaluated. The presurgical examination may indicate that surgical intervention is the best method of treatment. The depth of presurgical examination is governed by many variables. The age of the patient is a prime consideration regardless of whether a major or minor surgical procedure is to be done. The available time prior to surgery may be limited because of a life-threatening problem that limits the thoroughness of the presurgical evaluation. In veterinary medicine there are frequently financial limitations that the client places on the doctor. This is common but should not be used as as an excuse. The doctor should equip himself and his hospital well, and then offer his client the best possible care for the animal so that the client must make the compromising decision.
PHYSICAL EXAMINATION The first and most important initial portion of the presurgical evaluation of the patient is the physical examination. The clinician must develop a thorough physical examination procedure and not vary from it, unless, of course, the patient is in a state of respiratory or cardiac collapse. In such instances portions of the physical examination must be omitted and emergency resuscitation procedures initiated. Every surgeon has his favorite area; however, interest in areas of specialty must be suppressed so that the patient may be evaluated as a whole. *Director of Surgery, South Shore Veterinary Associates, Inc., South Weymouth, Massachusetts Veterinary Clinics of North America- Vol. 5, No.3, August 1975
317
318
WILLIAM
B.
HENRY, JR.
The best way to avoid making mistakes by overlooking something and to provide a permanent record is to use a physical examination checklist. This checklist is broken down according to systems of the body in the order that the physical examination is carried out from the oral and ocular area to the extremities (Fig. l.). For individual reference, and especially when there are many people involved in a practice, there must be some standard written communication. Physical examination sheets are helpful when the initial physical examination is done by associates, thus providing a quick review of findings and comments. The checklist is beneficial as a permanent record for legal reasons and facilitates follow-up examinations. In the order of their priority, the age, breed, sex of the patient, the owner's complaint, and duration of the problem should be noted on the record. A brief history should be recorded regarding appetite, stool consistency, and the presence of vomiting, polydipsia, or polyuria. We all may find ourselves cutting corners in this portion of presurgical evaluation because we are in a hurry for various reasons. If the surgeon rushes through the physical examination or takes short cuts by not obtaining a good history, he may waste a great deal of his own time, his client's money, and even his patient's life. As a surgeon, one is most interested in perfusing the surgical patient's tissues with oxygenated blood and anesthetic during surgery, and quick elimination of the anesthetic postoperatively without insulting the patient's tissues to the point that they are incapable of recovery. The patient's age, physical status, and type of surgical procedure contemplated must be considered when determining which anesthetic agent would be most satisfactory. Gas anesthesia would be used in most patients undergoing major· surgery because its rapid evacuation from the body results in less tissue insult. One therefore must critically evaluate the cardiopulmonary system, the kidneys, and the liver in that order.
PREOPERATIVE CONSIDERATIONS Prior to, during, or following the surgeon's physical examination of the patient, there are three basic considerations that affect his recommendations to the client. These three factors, as well as the results of the physical examination, are the basis for the course of action from that moment. The first factor to be considered is the age of the patient. In the younger patient there are fewer chances for complications so that the surgeon is less concerned with the patient's cardiopulmonary, renal, or hepatic function. Therefore the presurgical evaluation is often less involved for the surgeon and the patient, and in turn less expensive for the client. The second consideration is determination of whether surgery will
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