“How to…” for the surgical clerkship

Report
“How to…” for the surgical
clerkship
Sean Monaghan, MD
[email protected]
Morning rounds
• Note significant overnight events
– talk to your patient’s nurse
• Ask patients relevant questions
– pain control
– flatus or bowel movements after abdominal surg.
– tolerating diet
– nausea/vomiting
– ambulation
Recording and reporting vitals
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Consistency in reporting is important
TmaxTcurrent, HR, BP, RR, O2 saturation
Get current vitals and 24 hour range
Make mental note of time and events
surrounding any significant abnormalities
Ins and Outs
• “Total in and Total out” is not sufficient
• Urine output
– output over 24 hrs and past 8 hour shift
– Foley or voiding
• IV fluids
– Type of fluid and hourly rate
– Blood products given in past 24 hrs
– IVF boluses given overnight
• PO intake
– amount and type of diet
Drains
• NG tubes, JP drains, chest tubes, etc.
• Report output over past 24 hours and quality
• QUALITY
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serous – pale yellow, translucent
sanguineous – bloody
serosanguineous (SS) – mixture
purulent
bilious
• If multiple drains, know where they are and which
drain is doing what
Example
• Tmax 101.8, currently 100.4, 60-80, 110130/60-70, 14, 98% 2L NC
• UOP 2200/24h, 400/last shift , IVF – D5
1/ NS 20K @ 125/h, no BM, +flatus
2
• NGT – 550/24h bilious, JP – 180/24h
serosang
Physical Exam
• Should be very FOCUSED exam based on patient’s disease and
surgical procedure
• Heart sounds
– regular vs. irregular, obvious murmurs
• Lung sounds
– clear, decreased, course, crackles, etc.
• Abdominal exam
– Softness/tenderness/distension
• rate tenderness or distension as “mild, moderate, or severe”
• is the tenderness appropriate for a post-op patient?
• Incisions
– look for erythema, or drainage
– is incision intact?
Dressings
• Unless otherwise specified, dressings should be
taken down on POD#2 morning rounds
• before removing a dressing, make sure you have
what you need to re-dress the wound
• make sure a resident sees the wound before you
re-dress it
• If dressing change is painful (open wounds), will
the patient need pre-medication with IV
narcotics?
– if YES then find your resident first
Assesment and Plan
• Age, POD#, procedure, reason for procedure
• Make a problem list
• Prioritize the list
A/P: 55M POD#6 s/p sigmoid colectomy for perforated
diverticulitis.
1. fever – send BCx, CT abdomen for possible abscess
2. oliguria – bolus 1L LR, increase IVF to 150/h
3. post op ileus – continue NPO, NGT
4. pain control – IV morphine prn
Pre-op Note
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Pre-op dx
Procedure
Pre-op lab work
Blood
Pre-op imaging
EKG
Consent
A/P: 55M with perforated sigmoid diverticulitis
– to OR for sigmoid colectomy (if it has a side, specify and
spell out)
– IV cipro/flagyl
– NPO, IVF
Brief Operative Note
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pre-op dx
post-op dx
procedure
surgeon
assistant
anesthesia
IVF (crystalloid, colloid, blood products)
EBL
urine
findings (discuss with resident/attending)
specimen (to pathology?)
complications (discuss with resident/attending)
drains
condition/disposition
Post-op Note
• Procedure
• continue with a traditional SOAP note, PLUS
– lab work since surgery
– imaging studies since surgery
– post-op EKG (if needed)
• A/P – pay particular attention to
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pain control
urine output
IVF rate
diet advancement
activity status
prophylaxis

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