“How to…” for the surgical clerkship

1. “How to…” for the surgical clerkship Sean Monaghan, MD Smonaghan@lifespan.org

2. 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

3. Recording and reporting vitals • 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

4. 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

5. Drains • NG tubes, JP drains, chest tubes, etc. • Report output over past 24 hours and quality • QUALITY • serous – pale yellow, translucent • sanguineous – bloody • serosanguineous (SS) – mixture • purulent • bilious • If multiple drains, know where they are and which drain is doing what

6. Example • Tmax 101.8, currently 100.4, 60-80, 110-130/60-70, 14, 98% 2L NC • UOP 2200/24h, 400/last shift , IVF – D5 1/2NS 20K @ 125/h, no BM, +flatus • NGT – 550/24h bilious, JP – 180/24h serosang

7. 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?

8. 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

9. 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

10. Pre-op Note • 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

11. Brief Operative Note • 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

12. 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 • pain control • urine output • IVF rate • diet advancement • activity status • prophylaxis