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patient
History
Physical examination
Differential diagnosis
Investigations, if required, to confirm your diagnosis
Treatment
Observation of the effects of treatment
Re-evaluation of the situation, the diagnosis and the treatment.
The History
A full medical history includes the following:
Allergies
Medications, including non-prescription and locally obtained drugs
Immunizations
Use of tobacco and alcohol
Family history
Social history
Functional inquiry which reviews all systems
Investigations: general
principles
The decision to operate must often be made on
purely clinical grounds,
even
though
investigations provide additional information
and further support for the diagnosis and
management plan
Only ask for an investigation if:
You know why you want it and can interpret the
result
Your management plan depends on the result.
Decision making
Your clinical assessment of the patient may
indicate that surgery is required.
If so, consider the following important issues.
Can we do the procedure here?
Is the operating room safe and fit for use?
Are the necessary equipment and drugs available?
Are all members of the team available?
Do I have the knowledge and skill to perform the
necessary procedure?
Decision making.
Can we manage this patient?
Is there back up or extra support available, if required?
Can we manage the potential complications if problems
arise?
Do we have nursing facilities for good postoperative care?
Preoperative note
The preoperative note should:
Document:
Demonstrate:
The thought process leading to the decision to operate
That you have considered possible alternatives and the risks and
benefits of each.
Operative Note
After an operation, an operative note must be
written in the patients clinical notes.
It should include at least:
Names of persons in attendance during the
procedure
Pre- and postoperative diagnoses
Procedure carried out
Findings and unusual occurrences
Length of procedure
Estimated blood loss
Operative Note
Anaesthesia record (normally a separate sheet)
Fluids administered (may also be on anaesthesia record)
Specimens removed or taken
Complications, including contamination or potential for
infection
Method of closure or other information that will be
important to know before operating again (for example,
the type of incision on the uterus after Caesarean
section)
Postoperative expectations and management plan
Presence of any tubes or drains.
Aftercare
Prevention of complications
Encourage early mobilization:
Discharge note
On discharging the patient from the ward,
record in the notes:
Diagnosis on admission and discharge
Summary of course in hospital
Instructions about further management, including
drugs prescribed.
PHYSIOLOGICAL CONSIDERATIONS
Vital signs
Infants and children have a more rapid metabolic
rate than adults.
This is reflected in their normal vital signs.
Blood volume
Children have smaller blood volumes than adults:
Even small amounts of blood loss can be life
threatening
Intravenous fluid replacement is needed when blood
loss exceeds 10% of the total blood volume
Chronic anaemia should be slowly corrected before
elective operations with iron, folic acid or other
supplements, as appropriate
Make sure that safe blood will be available in the
operating room if blood loss is anticipated during
surgical procedures
Blood volume.
Paediatric blood volumes
Blood volume ml/kg body weight
Neonates : 85 90
Children: 80
Adults : 70
100 120ml/day
90 120ml/day
5090ml/day
Plus
Second 10 kg
Plus
Thereafter
Pain Mgt
Children suffer from pain as much as adults, but
may show it in different ways.
Make surgical procedures as painless as possible:
Oral paracetamol can be given several hours prior to
operation
Local anaesthetics (bupivacaine 0.25%, not to
exceed 1 ml/kg) administered in the operating room
can decrease incisional pain
Pain Mgt
Paracetamol (1015 mg/kg every 46 hours)
administered by mouth or rectally is a safe and
effective method for controlling postoperative pain
Intravenous narcotics
morphine sulfate 0.05 0.1 mg/kg IV) every 2 4 hours.
For more severe pain,
Intestinal obstruction
Hypertrophic pyloric stenosis
Esophageal atresia
Abdominal wall defects
Anorectal anomalies
NTD/ spina bifida
Cleft lip and palate
Club foot/ talipus equinovarus
Hip dislocation
Injury
Burn
Surgical infection
Acute abdomen
Abdominal pain
Bowel obstruction
Appendicitis
Hernia