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 T max T current, HR, BP, RR, O 2 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 T max 101.8, currently 100.4, 60-80, 110- 130/60-70, 14, 98% 2L NC UOP 2200/24h, 400/last shift, IVF – D5 1 / 2 NS 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