and physical exam. Sometimes, most of the workup has been done by your primary care doctor, and this has been relayed to the surgeon. Nevertheless, between the two of them a complete history and physical must be done. Briefly, this consists of a description of the present illness (“I have a pain or a lump or a hernia”), the length of duration, and/or how it happened. There must be a past history including allergies, medications you are taking, previous surgeries (such as breast biopsies, hernias, hysterectomy, heart transplants , including complications or drug reactions), and a list of all your medical problems (such as heart disease, diabetes mellitus, high blood pressure, and AIDS). Note must be made of your social history (married, single, divorced, widowed, children, significant other), whether you smoke, and how much alcohol you drink. A review of systems is included, which consists of questions about general health, cardiorespiratory system (heart and lungs i.e., shortness of breath, chest pains, palpitations, coughing up blood), gastrointestinal system (such as nausea, vomiting, constipation, diarrhea, vomiting up blood, black or bloody stools, ulcer history), and genitourinary system (problems with the kidneys, ureters, bladder or other genitalia). This review also includes a gynecological history for women including age at first menarche (menstrual period), age at first pregnancy, whether you're still having periods and their regularity, age of menopause (when you stopped having periods), and whether you're using birth control or hormones. Then there are questions about neurological (nerve problems) and psychiatric history, as well as any orthopedic and skin problems.
By then your physician should have a pretty good history about your risks, and this will be followed by a complete physical examination. Naturally, a specialist such as a heart doctor, urologist or gynecologist will tend to focus more on his/her area of expertise, but a brief physical exam is always needed. This will include a general description of you (young, elderly, weak, in pain, thin, obese, etc.) followed by an exam of the head, eyes, ears, nose, mouth, and throat. Then the neck exam is done, looking for stiffness, lymph nodes, thyroid gland enlargement, and abnormal sounds from your carotid arteries, which supply the brain. General examinations of the chest, breasts of both men and women, lungs, and heart sounds are done, followed by abdominal and flank exams for tenderness, masses, and hernias, to name a few.
A woman should have a regular gynecological exam every year after age 21, and males should have a testicular and rectal exam by their family doctor every year. A limited exam of the arteries and veins in the arms and legs, as well as a neurological evaluation, is recommended. The examining physician will also want to give his impression of the patient from an emotional and psychiatric point of view to help in alleviating fears and misunderstandings. The physician must be sure that the patient comprehends what is being said and the nature of the surgery that is going to be performed.
This is a brief list of what is expected in a history and physical examination, and it should be completed to some degree before a patient has any major surgery.
Obviously, if someone is going to have a minor procedure, such as a lymph node biopsy or removal of a skin tumor under local anesthesia, the physical may not need to be as comprehensive at the time of the surgery. But everyone needs a good, complete H&P (History and Physical) on a regular basis (every 13 years).
Okay. So now that's done. Next, the doctor will need to order some special studies to help in assessing your physical condition and risk for surgery and to further evaluate a condition which he has already diagnosed. I will list a few of the more common studies: chest x-ray, electrocardiogram (EKG = heart evaluation), and a series of blood tests among which may be CBC, which means a complete blood count, including hematocrit and hemoglobin, to determine how much blood you have and whether you have been secretly bleeding. There are the electrolytes, Na (Sodium), K (Potassium), Cl (Chloride) and CO2 (carbon dioxide); these are measures of the chemistry of the blood and can tell a lot about the status of your health. Blood sugar is measured to determine if you have diabetes mellitus; BUN or blood urea nitrogen and Creatinine to evaluate kidney function; and the clotting factors PT (protime), PTT (partial thromboplastin time) and platelet count, a measure of how well your blood clots. Another study is the urinalysis checking for problems with the kidneys and infections in the urine. These are the basics, but there are a myriad of other blood and urine tests your doctor may order. You can ask him about these and how they apply to your specific problem.
The pre-op tests may cause the surgeon to delay your surgery until certain things have been corrected or rechecked. I always say that when a blood test comes back very abnormal and doesn't make sense...repeat the test! If your EKG is abnormal, you may be referred to a cardiologist for further studies, including a stress test, where you walk on a moving platform while your heart function is monitored to evaluate for coronary artery problems. This, in turn, may lead to the need for coronary angiography, which is an xray with dye, of the arteries to your heart.
An abnormal chest xray may lead to getting a CAT scan (computerized axial tomography) of your chest to rule out cancer, tuberculosis, or other problems.
Be aware that, as we increase in age, the chance for abnormalities in the preoperative workup also increases, and your physician may need further studies to get you cleared for surgery.
This brings up one further issue. If the surgery is an emergency, then obviously it cannot be delayed by laboratory values, but these values will help the doctor to correct problems just prior to or during the surgery itself. If the surgery is elective (does not have to be done NOW!), then the patient should be made as healthy as possible before being brought to the operating room. This means that your surgeon must use common medical sense and never rush anyone into elective surgery without a proper workup.
Sometimes, the patient is such a poor surgical risk that alternative and second best options for treatment must be considered. The adage, “The operation was a success but the patient died,” is a hard one to explain to a family and for the surgeon to explain to himself.
That is the preoperative workup in a nutshell. Arranging for these studies, getting them done, evaluating them and getting surgery scheduled appropriately takes time and usually involves multiple phone calls by an office staff person. And this doesn't include the ins and outs of getting permission from an insurance company or a managed care group. Multiply this situation by ten or twenty in a surgeon's office, and you will understand why getting a surgery scheduled may not be as easy as it seems. Be patient and understanding...eventually, everything will get done safely and completely.
Chapter 10
TALKING TO YOUR SURGEON
Second Opinions, Credentials and Qualifications
You can bet your britches, and I can bet mine too,
That if you become a surgeon, you may rue the day you do.
'Cause every time you do a case someone will go inspect
The whole shebang to see if you have done the thing correct.
I mean, does every workman and contractor have to prove
That every corner done has just a perfect tongue in groove?
So what if you forget to tie a vessel off or two?
Why should everyone come out and point a thumb at you?
In what other profession do we ask for 100 percent?
Why can't these stringent rules, just a little bit, be bent?
Then I could advertise in public and the daily press.
I'm a real surgeon and guarantee 80% success.
Now if you were in school an 80% would be a solid B
Enough
