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The interchange between physicians discussing a patient’s
case has been mentioned in written history since ancient
Greece. From the time of Hippocrates, physicians have been
encouraged to seek consultation on difficult cases when they
were in doubt. They were urged not to be jealous of one
another but to realize their own limitations and to use the
knowledge of their colleagues to help. “Nor, among physicians,
do those who treat by diet envy those who employ
surgery, but they even call each other into consultation and
commend one another.” It is clear, however, that there were
disagreements in those days: “Physicians who meet in consultation
must never quarrel or jeer at one another.” There
were also “wretched quarrelsome consultations at the bedside
of the patient, with no consultant agreeing with another,
fearing he might acknowledge a superior.”
Over the next 25 centuries, consultation has had its ups and
downs. Much of what was written had to do with the etiquette
and ethics of the interaction. In medieval Europe, little
changed from ancient times. Physicians were encouraged to
ask colleagues for help if needed and to refrain from criticizing
each other in front of non-physicians.
Now in its fifth edition, Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine has been fully revised and updated and continues to provide an authoritative account of all aspects of perioperative care for surgical patients. Including recommended plans which aid accurate treatment of patients, it provides an evidence-based approach for consulting physicians to care for patients with underlying medical conditions that will affect their surgical management. The latest minimally invasive surgical techniques are included, with new chapters on thoracic aortic disease, reconstruction after cancer ablation, lung transplantation, esophagomyotomy, vasectomy and thyroid malignancies, amongst others. With detailed descriptions of nearly one-hundred operations, highlighting their usual course as well as their common complications, the book encourages learning from experience. This definitive account includes numerous contributions from leading experts at national centers of excellence. It will continue to serve as a significant reference work for internists, hospitalists, anesthesiologists and surgeons.
The acute confusional state known as delirium is the most common cause of altered mental status in surgical patients. The cardinal feature of delirium is an alteration in the level of consciousness that fluctuates over time. Despite its common occurrence delirium can often go unrecognized, leading to delays in treatment. This can have significant implications as patients with delirium suffer from higher postoperative complication rates, longer lengths of stay, and delayed functional recovery .
Delirium is usually acute in onset but may develop gradually. It can persist for hours to days and can fluctuate throughout the course of a day. A clouding of consciousness is most common but patients can also show hyperalert, irritable, or agitated behavior. The sleep–wake cycle is often markedly disrupted. Sleep is usually fragmented, with restlessness and agitation. Psychomotor abnormalities may range from hyperactivity to lethargy, stupor, obtundation, and catatonia. Most cases of delirium improve or resolve within 1–4 weeks if sufficient attention is given to correcting the underlying disorder causing the cerebral dysfunction. However, the development of delirium, particularly in frail, elderly patients is a marker for progressive decline .