A PRIMER FOR THIRD YEAR SURGICAL CLERKSHIP
Written by Farhood Farjah, MD
Edited by Lorrie Langdale, MD
2003
Introduction
While course objectives provide you with the philosophical goals of a clerkship, seldom does anyone tell the student how to achieve such goals. Furthermore, other than talking to other students previously on service, incoming students rarely obtain a vision of what a service is like. Thus, the purpose of this manuscript is to provide you with several tips based on my experience as both a student and resident. The surgery clerkship is unlike any other third year medical school rotation. Although the information here is geared towards the surgery rotation, many tips are also relevant on other in-patient services.
Dailey Routine
Your priorities on the clerkship are:
- your education - attend all scheduled conferences
- the operating room
- the clinic
- the ward
You will begin your day by collecting overnight events, vitals, and examinations on your assigned patients, usually 3 per student (up to 5 as you become more experienced). Next, you will round with your team (residents only, attendings rarely round in the morning) on all patients (i.e.. both wards and ICU). Either OR cases, clinic, or both follow rounds. Your chief resident or site schedule will tell where you should be. Between cases or morning and afternoon clinic, you will need to complete remaining notes and accomplish any assigned ward tasks. Most teams round a second time in the afternoon/evening. Therefore attempt to pre-round half-an-hour in advance. Check the labs, results of any diagnostic procedure and consults for your patients. Since every day is a little different and depends on when cases or clinics are finished, you will rarely receive prior notification of when evening rounds will occur. After rounds, you will need to complete any additional assigned ward tasks. Check the following day's OR schedule for a list of cases and identify which cases you will attend (ask the chief resident which case is yours; you will need to read up on these cases for the following day since the attendings and residents may quiz you on points of anatomy, physiology, the primary disease and patient prognosis). Finally, ask any team members still remaining in the hospital if they need any help. Also remember that certain days of the week will be interrupted with grand rounds, morbidity and mortality conference, and other teaching sessions (attend all that you can).
Interactions with Others
Your interaction with other medical students should always be the same regardless of the clerkship. While evaluators applaud teamwork and respect, they shun competitive attitudes and behaviors.
Arguably, you will learn the most from your residents. Interns are useful for questions regarding the peri-operative management of patients, the daily routine, and any other basic questions (i.e. where is the bathroom?). Junior residents are quite wise, however they seem to be stretched the thinnest because of their new found responsibility of running the entire service. Give them some space and patience. The chief resident is the primary teaching resident, however his/her level of responsibility also limits the time available to sit down with you. You can often learn a lot more by simply observing residents rather than firing off multiple questions.
Surgery attendings, like all attendings, are variable in their expectations, teaching style, and willingness to interact directly with students. Therefore, it may be helpful to ask other students and perhaps the intern about each attending. For certain, you will encounter attendings most often in the OR, clinic, and during dedicated teaching sessions. On the surgery rotation, you are expected to complete 4 complete histories and physicals plus a review of an article in the literature that is relevant to one of your patients - turn one of these in each week and schedule a sit-down discussion with the attending who gets the write-up or review. This is your time for direct feedback from faculty.
Be respectful of all nurses, secretaries, and other non-physician medical staff. Nurses, in particular, spend more time with your patients than you do, and therefore they can be valuable resources for information. Moreover, most staff members have spent more time on the floor than both the students and residents on service, and thus they are better acquainted with protocols, procedures, and the whereabouts of specific items (i.e. gauze, scissors, forms, etc.). As a rite of passage, some non-physician staff may test your willingness to learn from individuals who are not doctors. I would advise you to demonstrate humility at all times. Finally, a well known fact among interns is that if you make one nurse angry then you have made all the nurses on that particular floor angry.
Clinic
The clinic is where patients receive their initial surgical consultation, routine post-operative assessment, or non-emergent evaluation of a new post-operative problem.
Initial surgical consultation is to determine whether the patient actually has a surgical problem, and if so, whether or not they are likely to survive and have a meaningful life after an operation. Such evaluations begin with a complete history and physical (see Appendix A). Be prepared to review or propose laboratory tests and imaging to help further evaluate a patient. If an operation is deemed appropriate, then the resident or attending will obtain consent.
Post-operative evaluations and the non-urgent evaluation of potential complications are identical in that they are both focused visits centered on issues such as identification of case-specific complications, wound checks, pain control, stitch/suture removal, prescription refill, and instructions for further follow-up. Notes should be in a SOAP format and presentations should be very brief (see Appendix B and C for examples of notes and presentations).
The Wards
The ward is where patients receive peri-operative care or non-surgical management of surgical complications. Most of your patient care activities will occur on the wards. Refer to the peri-operative care section for general guidelines on how to manage ward patients. As a medical student, you should always pre-round on your patients. Pre-rounding includes finding out the previous night's events (i.e. from the nurse and patient), any new complaints, important subjective data (i.e. flatus), vitals, physical examination, and labs (rarely back that early in the morning). This process should take no more than 30 minutes. If you are coming to the hospital at 4 AM to do this, you need to work on your organizational skills! After you see your patients, you should help collect every patient's chart and have it available on a cart for rounds. Furthermore, make sure that the order book(s) is/are also on the cart. As hospitals continue to move toward a paperless system, the "chart cart" may be replaced by a "computer cart." Finally, ensure that you or the cart has dressing supplies, such as gauze, kerlex, abdominal pads (aka ABD pads), tape, scissors, and sterile cotton tips. If you are not presenting, then you should be either writing a note (if your team writes notes on rounds), writing orders, or performing a dressing change. However, always keep a mindful ear towards each patient's general condition and plan, even those you are not directly responsible for.
As time allows throughout the day, check to see if the orders that were written in the morning have actually been fulfilled. Follow-up on any imaging studies that were ordered. Make sure you have the lab results that were unavailable earlier in the day. Pull drains and tubes as directed. Check the patient's chart for notes from the following people: your attending, consulting teams, social work, and physical therapy/occupational therapy. Do not forget to re-assess the patient in the afternoon, which includes obtaining a history, vitals, and physical examination. Prepare a plan for your patient and re-collect the order book(s), but not the patient chart, for afternoon/evening rounds.
If you are asked to do something that you have not done before and need help, say so. Patients deserve the best of care from everyone involved.
Emergency Department
The emergency department (ED) is where surgeons provide initial evaluation and care for patients with acute surgical problems or acute complications of a prior operation.
While caring for the hemodynamically unstable patient (trauma or non-trauma), your primary goal should be to carry out all tasks delegated by the most senior resident. Little to no time will be available to answer your questions or to provide you with an explanation of the situation and plan of action. Watch and learn. An explanation can follow at a later time. Even though such situations can be quite stressful, it is usually very exciting and rewarding to have a role in the care for such patients.
Intensive Care Unit
The intensive care unit is where critically ill patients receive hemodynamic and respiratory monitoring and support. Your role will be limited to listening, observing, performing a physical examination, helping with wound care, and writing orders. Despite your limited role, you should be familiar with how residents approach ICU patients in order to enhance your educational experience. We address problems by systems, namely neurologic, pulmonary, cardiovascular, renal, FEN (fluids, electrolytes, and nutrition), gastrointestinal, hematologic, and infectious disease. Presentations typically occur in the following order: 1) overnight events, 2) subjective (rare because many patients are often intubated or sedated), 3) vitals, 4) ventilator settings, 5) arterial blood gas data, 6) swan-ganz catheter data, 7) ins and outs, 8) physical examination, 9) laboratory, 10) imaging (almost always a daily chest x-ray), 11) lines and drains, and 12) the plan by systems. Finally, the resident should state the patient's disposition (i.e. remain in ICU, transfer to floor, or to OR).
The ICU is a place where much teaching occurs. As such, you may be asked questions in this setting. Although anything goes, much of the focus is on basic physiology, pharmacology, and pathophysiology. Whereas the surgical treatment of patients is often underemphasized in this setting, the impact of surgical and non-surgical trauma on human physiology is heavily emphasized.
Operating Room
Obviously, the operating room is where patients undergo surgical procedures. In preparation for a case you must know the patient's history, relevant physical exam findings, diagnosis, treatment options, and proposed operation. With respect to the region or organ involved, know the physiology, pathophysiology, anatomy, and proposed operation. Think about how the operation solves the problem. Also, think about how the operation, whether successful or unsuccessful, could cause problems for the patient. If you do not know the answer to a question, it is better say, "I don't know, but I will look it up." Some people suggest stating everything you know about the general topic. In my experience, most people don't have the attention span or patience for this approach. Also, never make up an answer. You will be setting yourself up for heavier interrogation.
Prior to the case, go to the bathroom and eat if you can. Then, introduce yourself to the patient. Next, go to the OR and introduce yourself to the circulating and scrub nurses. Write your name and rank on a white board. Get your gloves and give them to the scrub nurse in a sterile fashion (ask how if you don't know how). Ask the scrub nurse if he or she has enough gowns for you. Obtain eye protection. Turn off your pager or don't wear it. If you have never scrubbed, ask a resident or nurse to show you how. Ask someone where you should stand. Never reach for instruments on the mayo stand. Always say please and thank you. When cutting suture, ask whether you should cut it long or short (long = 1cm, short = cut on top of the knot, but not the knot). If the attending offers the resident to feel something, ask if you can (don't be disappointed if you can't). If you have to sneeze or cough, don't turn your head, just step back and face forward. If you are light-headed or nauseated say so and then sit down or scrub out (no one wants to deal with a head injured medical student). At the end of the case, help transfer and transport the patient to the recovery room. Help the resident write a brief operative report and the admission or discharge orders. If you don't scrub on a case but are in the operating room, remember that everything light blue is sterile and thus you should not touch it!
Go into as many cases as you can. There is no limit to the number of students who may observe a case. There are some cases that are so unusual that you may never have the opportunity to see it again - ever - so look at the OR board and explore. There should be at least one student at every case (including weekends and nights).
Diagnosing and Treating Surgical Problems
READ. Knowledge of surgically amenable diseases accumulates differently for each person. Thus, my only recommendation is to use your favorite strategies and tactics to learn about topics as you encounter them in your patients. This approach promotes efficiency, motivation, and recall. To optimize this approach, diversify the problems you encounter by choosing a wide variety of patients.
Peri-Operative Mgmt of Surgical Patients
You will notice on this rotation that it is basically a Medicine clerkship with Surgery added on. All the medical problems that the patient had before the operation need to be taken into account, both in the pre-operative evaluation and in post-operative care.
Pre-operative care is directed towards preparing the patient for surgery the next day. Such care includes, making the patient NPO at midnight, starting maintenance intravenous fluids while NPO, ordering and reviewing the relevant labs, CXR, and/or EKG if indicated, typing and crossing for blood if necessary, ordering pre-operative antibiotics, and ensuring that consent is available. For bowel surgery, many patients require a special bowel preparation.
Post-operative care is directed towards preparing the patient for discharge from the hospital. In general, the patient should be tolerating a regular diet, ambulating independently, and with adequate pain control in order to go home. Immediately post-op, the patient will generally be NPO, have IVFs running, and require IV narcotics. As bowel function returns (i.e. manifested by flatus), you can advance the patient's diet. If they tolerate liquids sufficiently to hydrate themselves, then they can have their IVFs turned off. If they are tolerating a diet, then should have their IV narcotics changed to oral narcotics. Furthermore, they should be started on their home medications, assuming no contraindications (i.e. resuming anti-coagulants in a fresh post-op patient) exist. Patients should be encouraged to ambulate as soon as possible to stimulate the earlier return of bowel function and to expand the lungs in an effort to avoid atelactasis (collapsed alveoli) and subsequent pneumonia. Ambulating is much easier without IVFs running, a foley catheter, and drains/tubes. The foley may come out as soon as the patient can ambulate. Drains serve different purposes and thus you should check with your resident for the criteria of a particular drain. Finally, patients need somewhere to go and someone to assist them after leaving the hospital. Involve social work early for patients who are homeless or those that require assistance.
Management of a complication is dependent on the particular surgery, the complication, and the attending (style counts here). Therefore, your ability to generate a daily plan hinges on a thorough understanding of the complication and the attending's proposed strategy (ask the residents).
Common Post-Operative Problems
Common post-operative issues include pain control, prolonged ileus, fever, urinary retention, and management of pre-existing medical problems (i.e. diabetes, HTN, etc.).
Although IV narcotics provide faster relief of pain, oral narcotics offer longer lasting relief. Therefore, transition the patient to oral narcotics as soon as possible. Tylenol is an excellent adjunct to narcotics for pain control. Toradol is another outstanding adjunct to narcotics, although this NSAID can cause renal insufficiency and possibly bleeding secondary to platelet dysfunction. When the above measures fail, a pain service consult may be indicated.
Prolonged ileus is manifest by the inability to pass gas, abdominal distention, and possibly vomiting. A plain film of the abdomen may substantiate the clinical findings. Treatment involves making the patient NPO, giving IVFs, and placing a NGT. The NGT helps decompress the stomach and prevents aspiration. Deranged electrolytes and narcotics can lead to or exacerbate an ileus. Thus, check and replace electrolytes, and limit narcotic use. Prolonged ileus may be a sign of intra-abdominal abscess after an operation.
The differential for fever in a post-operative patient is limited. A popular pneumonic includes the five "Ws": w ind (atelactasis or pneumonia), w ater (UTI), w ound (wound infection or abscess), w alking (DVT), and w onder drug (drug reaction/allergy). The standard work-up for a fever is a CXR, two blood cultures, urine analysis, gram stain, and culture, and CBC. Fever within the first forty-eight hours of surgery is most likely secondary to atelactasis. In general, such fevers are not worked-up. Instead, the patient is encouraged to perform incentive spirometry, get out of bed to a chair, and/or ambulate.
The diagnosis of pneumonia depends on several clinical findings consistent with the diagnosis, for example infiltrate on CXR, leukocytes, fever, increased sputum production, and/or increased oxygen requirement.
Urinary tract infections are common in surgical patients because catheters are conduits for bacterial growth in the bladder. If a patient has a UTI and requires a foley catheter, then replace the old one with a new one. Wound infections and abscesses typically do not manifest themselves until post-operative day four or five. Urinary retention may result from pre-existing bladder outlet obstruction, bladder atony secondary to prolonged foley drainage, medications, or a combination of the above. A bladder scan (bedside ultrasound performed by nursing) finding of greater than 300cc of urine is generally diagnostic. Patients may undergo two rounds of straight in and out catheterization prior to re-insertion of an indwelling foley catheter. Those that require re-catheterization may be sent home with leg bag and follow-up with urology.
Wound infections, heralded by tumor, calor, dolor, and rubor, are treated by opening the skin incision and performing twice daily wet-to-dry dressing changes. After an abdominal operation, an abscess should be suspected in patients with fever (in the absence of another obvious source), prolonged ileus, and/or persistent or increasing leukocytosis. CT scan of the abdomen with PO and IV contrast is diagnostic. Treatment is often by interventional radiologic percutaneous drainage but may require a return to the operating room with open irrigation and debridement.
DVTs may or may not have signs and symptoms. Therefore, a high index of suspicion must exist to rule them out with a lower extremity duplex. "Treatment" with anti-coagulation prevents further clot formation rather than resolving the offending clot. However, consideration as to timing after a recent operation may make other methods to prevent pulmonary embolization.
Finally, medications may cause fever prompting substitution or their removal if possible. Missing from the classic five W's, is line infection and superficial thrombophlebitis. Prevention of line sepsis includes removing any central catheters or peripheral IVs. Diagnosing an infected line includes findings of fever, leukocytosis, bacteremia, and a positive culture from a line tip. The treatment is line removal. If fevers and bacteremia persist, IV antibiotics become necessary. Furthermore, the presence of pre-existing valvular disease or new onset murmur should prompt an aggressive work-up to rule-out endocarditis. Treatment of superficial thrombophlebitis involves removing the peripheral IV, warm compress, and NSAIDS.
Management of pre-existing medical issues, most commonly HTN and diabetes, in post-operative patients can be challenging because patients do not eat and cannot take medications orally. Diabetes is managed either by an insulin drip (for the ICU patient on TPN or tube feeds) or insulin sliding scale. The patient's pre-operative regimen should be resumed when the patient is taking oral medications and eating (so that they do not undergo a hypoglylcemic crisis). Escalating or uncontrollable hyperglycemia may be an early indicator of sepsis. HTN can be managed by IV nitrates (hydralazine or nitropaste), although a known and occasional unwanted response is reflex tachycardia. IV metoprolol is an outstanding anti-hypertensive drug that requires telemetry or ICU monitoring for administration. Thus, it is not available for use on the wards. Escalating or new onset HTN may indicate hypoxia, alcohol or benzodiazapene withdrawl, or pain.
Procedures
Students' procedural experiences vary greatly and depend on the student's prior experience and the resident's comfort level in teaching the procedure. It is highly unlikely that you will be "doing surgery". Would your Mom want the third year student doing her operation? However, on your own time, you should at the very least learn to perform a simple interrupted and continuous skin closure, instrument tie, and two-handed tie. You will likely remove many drains (i.e. JPs and Penroses) while on service. The steps are as follows: 1) lay the patient flat, 2) release any suction (i.e. wall suction or bulb suction), 3) cut the skin stitch or remove the tape, 4) pull the drain swiftly, and 5) dress the wound.
Books
READ. To be successful, you will need multiple books during your surgery clerkship. The major textbooks, referred to by their leading editors Sabiston, Schwartz, or Greenfield, are the most comprehensive resources providing information on history, epidemiology, anatomy, pathophysiology, basic science, surgical procedures, complications, and clinical outcomes. The disadvantage of these texts is that they require much time to read. There are shorter versions of these major texts that ar OK for a clerkship but not sufficient as a reference text in the future. Another text, Cameron's, is more clinically oriented with shorter chapters. Cope's Acute Abdomen provides an overview of common general surgery topics through superb correlations between anatomy, pathophysiology, and historical and exam findings. The disadvantage of this book it is provides little information on basic science and surgical treatment. Surgical Recall and Advanced Surgical Recall provide a question/answer approach to teaching surgery. Given their brevity, they are a poor source to learn from. However, they provide an excellent way to review previously studied topics and to quickly assimilate some information on a topic when you are unexpectedly and completely unprepared.
Feedback and Evaluations
When receiving feedback, always listen, never react, and always say thank you. Decide later whether the feedback is valid by comparing feedback from various sources. Swiftly modify your behavior such that others can witness your growth. If given the opportunity to provide feedback to someone else, remember to be tactful and respectful because you may encounter that individual in the future.
Evaluations by residents and attendings on any service are subjective in large part. My recommendations are to 1) be early to everything, 2) dress professionally (clinic), 3) know everything about your patient's medical history, hospital course, and disease, 4) know a little about all patients on service (i.e.. their diagnosis, treatment, and complications), 5) volunteer to help with time-consuming tasks, 6) participate in all aspects of patient care (i.e. patient interaction, write notes, orders, and discharge paperwork, and participate in operations), 7) be honest, and 8) be excited about your learning experience on surgery. Never do the following: 1) lie, 2) be late, 3) fail to complete required tasks or those you agreed to accomplish, 4) make excuses, 5) blame others, or 6) complain.
Your Health, Hobbies and Loved Ones
The surgical service will affect many aspects of your life outside the hospital. Friends and family may feel as though you are neglecting them. Alternatively, they may feel "left out." It helps them to hear how you spend your day, but not in gory detail. When you are on call, and time permits, call your friends and family and talk to them briefly. Let them know you are thinking about them. Never make plans to meet someone in house when you are on call, because inevitably you will be called off to perform some task at the most inopportune time. When making plans on regular work days, be sure to schedule meetings later in the evening because check-out time from work can be unpredictable. As for your hobbies, try your best to engage in them to give yourself a break from medicine. Even though you may be tired, exercise can counter-intuitively give you a sense of added energy. Do not forget to feed yourself throughout the long day. On the other hand, do not over-eat because you are under a lot of stress.
Surgery as a Career
You may develop an interest in a career in surgery after having rotated on a surgical service. However, know that your experience as a student on service does not approximate your experience as a resident or an attending. The greatest chance of correctly choosing a career comes from the maturity of having exposure to and indulging in several different fields of medicine. One of my mentors told me that if there was any other field of medicine that I found as rewarding as surgery then I should choose that field. Her reasoning was that the sacrifices that one makes, as outlined above, are enormous. That being said, she also confirmed that the rewards greatly exceed the sacrifice.
If after reflecting on all possibilities you are convinced you must pursue a career in surgery, then you must accomplish several tasks. Identify a mentor and discuss your short term (residency) and long term (specialty, academics vs community, etc) goals. You should plan for at least one surgical sub-internship during the summer of your fourth year (confirms your decision and a great source of letters of recommendation). Enroll in at least one SICU rotation. If you are very strong academically, never do an away rotation. You can only make yourself look bad. If you are very weak academically, do away rotations. You have nothing to lose. If you are middle-of-the-road, then do an away rotation at the institution that you want to match. Research helps, but is not necessary. Perhaps the most important factors for obtaining an interview are your surgery clerkship, third year clerkship, and fourth year sub-internship grades, board score (step 1), letters of recommendation, and personal statement. Letters from well-known full professors go a long way. The interview is hugely important in determining how the program will rank you (because they have to work with you for at least 5 years). Then, the hardest part, you must choose a program that can help you achieve the goals you identified with your mentor.
So, GOOD LUCK and WELCOME to Surgery !!
APPENDIX A--History and Physical
The goal of the H & P is to provide the reader with a comprehensive review of the patient's current problem, complete medical history, work-up and results, and finally the assessment and plan. In addition to providing information relevant to clinical decision making, the H& P is also used for billing purposes (i.e. more reimbursement for more complete H & Ps). Thus, all H & Ps should include the following parts:
HPI
PMH
PSH
Meds
Allergies
SH (occupation, family members, tobacco, EtOH, and drugs)
Fam Hx
ROS (at least 9 systems)
PE
Labs
Imaging
Assessment
Plan
The above discussion only pertains to H & Ps used in patient care settings. Please refer to your course objectives for guidelines on academic H & Ps.
APPENDIX B--SOAP Notes
The goal of a daily soap note is to provide the reader with the data influencing clinical decision making and a summary of the day's assessment and plan. The following example is a note on a patient with diverticulosis who underwent a sigmoidectomy and whose post-operative course was complicated by pneumonia. Following the example is a list of common abbreviations.
4/1/03 General Surgery Progress Note:
0800
no events overnight, is passing gas, ambulating
Tm 37.7/TC 36.0 P 80 BP 140/90
RR 25 SaO2 92% on 4L O2
I/O 2000/3000 UOP 3000/24 hours, 1000/8 hours
NAD
Decreased BS over L base, improved
RRR no M/G/R
less distended/ soft/NT/+BS
wound c/d/i
POD#5 sigmoidectomy, post-op pneumonia
Improving on current management
ADAT
HLIV
Transition from IV narcs to PO narcs
Wean off O2
Continue Abx, day # 3
IS/ambulate
In general, avoid acronyms in the chart - they are often mis-interpreted if everyone is not on the same page. The following, however, are often used.
Abx antibiotics
ADAT advance diet as tolerated
AT atraumatic
BM bowel movement
c/c/e clubbing, cyanosis, or edema
c/o complaints of
c/d/i clean, dry, and intact
CT chest tube
d/c discharge or discontinue
EBL estimated blood loss
f/u follow-up
HD hospital day
HLIV heparin-lock IV, ( i.e. stop IVFs, but leave the IV in place)
I/Os ins and outs
IS incentive spirometry
IVF intravenous fluid
JP Jackson-Pratt drain
NGT nasogastric tube
NPO none per os
NT non-tender
n/v nausea vomiting
OGT orogastric tube
ORIF open reduction internal fixation
OT occupational therapy
PO per os (by mouth)
POD post-operative day
PT physical therapy
PTX pneumothorax
SBO small bowel obstruction
TPN total parental nutrition
UO or UOP urine output
APPENDIX C--Presenting Patients on Daily Rounds
The goal of presenting patients on daily rounds is to convey the greatest amount of relevant information in the least amount of time.
Presenting a new patient on daily team rounds (i.e. no attending) does not require presenting the entire H & P. For the uncomplicated patient, present the sex, age, diagnosis, and treatment to date in one sentence.
"BS is a 57 year old man with a history of multiple abdominal operations who presented with a small bowel obstruction and underwent an exploratory laparotomy with lysis of adhesions."
For the complicated patient, repeat the above but follow-up with a sentence for each co-morbidity influencing surgical management being sure to include the co-morbidity, its usual treatment, how it alters surgical management (if at all), and how the co-morbidity will be managed in the peri-operative phase.
"BS is a 57 year old man with a history of multiple abdominal operations who presented with a small bowel obstruction and underwent an exploratory laparotomy with lysis of adhesions. He has a history of atrial fibrillation treated with beta-blockers and coumadin and is currently on peri-operative IV beta-blockers and a heparin drip."
For the uncomplicated trauma patient, present the sex, age, mechanism of injury, list of injuries, and treatment.
"BS is 25 year old restrained driver t-boned on the driver side sustaining multiple left-sided rib fractures, a left-sided pulmonary contusion, grade IV splenic rupture, and left femur fracture who is now POD # 3 after having undergone splenectomy and ORIF of the left femur."
Complicated trauma patients should be presented similar to other complicated surgical patients. Although you do not present the entire H & P, you should know the entire H & P in the event that a team member requires more details.
Presenting ward patients should provide the listener with the data influencing clinical decision making and a summary of the day's assessment and plan. The following example is based on the soap note in Appendix B.
"BS is POD#5, had no events overnight, is passing gas, ambulating. Tmax 37.7, Tcurr 36.0, P 80, BP 140/90, RR 25, SaO2 92% on 4L O2, Ins and Outs 2000/3000, UOP 3000 over 24 hours, 1000 over the last 8 hours. He still has decreased breath sounds over the left base that have improved. His belly is less distended, with bowel sounds, soft, non-tender, wound clean/dry/intact. Overall he is doing better. Advance diet as tolerated. Hep-lock the IV. Transition from IV narcotics to PO narcotics. Wean off O2. Continue antibiotics, currently antibiotic day 3. Incentive spirometry. Ambulate."
updated 11/15/07
