should be <1.5 for most operations and lower if spinal or epidural anesthetic techniques ar e to be used; warn the anesthetist. Patients with prosthetic heart valves may need IV or SC heparin whilst warfarin is omitted (b p406) Clopidogrel must be stopped 7 \200\22310d prior to surgery, aspirin is usually continued un less otherwise instructed by senior surgeon (if in doubt check with the operating surgeon/n amed consultant) Oestrogens and progestogens HRT can be continued as long as DVT/ PE prophylaxis is undertak en. Progestogen-only contraceptives can be continued, but combined oral contraceptives shou ld be stopped 4wk prior to surgery and alternative means of contraception used Bowel preparation see table 2.15 b p109. Writing the drug chart Try and do this at pre-admi ssion clinic to save yourself time later. Document any allergies. Things to check include: \200 Prophylactic anticoagulation (b p406) \200 Antibiotics Consider pre-op antibiotics (check local guidelines) \200 Bowel preparation and IV \202 uid (b p109) \200 Regula r drugs Review these and write up those which should be continued in hospital (stop COCP, c lopidogrel as above, etc) \200 TED stockings Prescribe these under regular medications fo r all patients Analgesia and anti-emetics (b p86 and b p304) The anesthetist will usually write these up during the operation. Instructions for the patient \200 Where and when to go for admission (write this down for them) \200 If they are to have bowel prep, they should usually be on clear fl uids at least 24h before the operation (see b p111) Tell the patient about any drains, NG tubes or catheters which may be inserted during the operation Tell them if they are being admitted to ICU post-op. OHFP.indb 108 OHFP.indb 108 30/05/2014 16:17 30/05/2014 16:17 109 BOWEL PREPARATION Bowel preparation Before endoscopy and some GI surgery procedures patients are given laxati ves to clear the bowel (Table 2.15). For surgery the aim is to reduce the risk of post-op a nastomotic leak and infections. Accumulating evi- dence suggests that it does not improve c omplication rates and may even be harmful,1 hence use of bowel preparation prior to surgery is declining. Check your local policy for guidance. Where bowel prepara- tion is required, it is vital that patients are instructed properly and the importance of good compliance is stressed. For example, during colon- oscopy inadequate bowel preparation can lead to patho logy being missed or the procedure being aborted. Table 2.15 Procedures and the potential need for bowel preparation Bowel preparation Procedure None Phosphate enema (on day of surgery) OGD, ERCP, closure (reversal) ileostomy Anal fi ssure, haemorrhoidectomy, examination under anesthetic (sigmoid colon/rectum/perianal area), fl exible sigmoidoscopy Colonoscopy, rect opexy, right hemi-/left hemi-/ sigmoid/pancolectomy, anterior resection, abdominoperineal r esection, Hartmann \200\231s reversal Full bowel prep (see below) Full bowel preparation A variety of oral bowel cleansing products are available in the UK. In 2009 the National Patient Safety Agency issued an alert in response to safety incidents including a reported death following bowel prepara- tion. In particular, patients at risk o f renal impairment and electrolyte imbalance need careful identifi cation and prescribing. \200 Sodium picosulfate/Magnesium citrate combinations (eg Picolax ) give excellent bowe l preparation and are relatively acceptable to patients; they are relatively contraindicate d in those with stage 4 or 5 CKD or those at risk of electrolyte imbalance, cardiac or live r failure \200 Polyethylene glycols/macrogols (eg Klean-Prep , MoviPrep ) require large volumes of liquid to be drunk, but are safer in at-risk groups. Consider admitting elderly patients and those with comorbidities for IV fl uids and monitor ing during bowel preparation. Oral medica- tions should not be taken 1 h before or after ad ministration of bowel cleansing preparations; where reduced absorption could prove cata- st rophic (eg immunosuppressives post-transplant) consider admission for IV administration. Ad vise patients taking the OCP to take alternative precautions during the week following taki ng the bowel preparation. Off er patients written dietary advice on low-residue foods for t he 2d prior to their procedure (local documents should be available); those taking insulin will require specifi c advice and guidance for management. 1 Guenaga, K. et al. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001544. _OHFP.indb 109 _OHFP.indb 109 30/05/2014 16:17 30/05/2014 16:17 110 CHAPTER 2 Life on the wards Surgical terminology Pre \201 x/suffi x Meaning and example Angio- Relating to a vessel Angioplasty \200\223 reconstruction of a blood vessel Relating to the biliary system Cholecystitis \200\223 infl ammation of the gallbladder Meaning half of so mething Hemicolectomy \200\223 excising half the colon Relating to the uterus Hysterectomy \200\223 removal of the uterus Relating to the abdomen Laparotomy \200\223 opening the a bdomen Relating to the kidney Nephrotoxic \200\223 damaging to the kidney Total/every Panc olectomy \200\223 complete removal of the colon Going through a structure Percutaneous \200\223 going through the skin Near or around a structure Perianal \200\223 near the anus /around the anus Relating to the rectum Proctoscopy \200\223 examination of the rectum Rel ating to the renal pelvis Pyelonephritis \200\223 infl ammation of the renal pelvis Relati ng to the thorax Thoracotomy \200\223 opening the thorax Going across a structure Transoes ophageal \200\223 across the esophagus Surgical excision Nephrectomy \200\223 removal of a kidney A radiological image often using contrast medium Angiogram \200\223 contrast stud y of arteries Infl ammation of an organ Pyelonephritis \200\223 infl ammation of the renal pelvis Stone-like Faecolith \200\223 solid, stone-like stool A device for looking inside the body Sigmoidoscope \200\223 device for looking into the distal colon An artifi cial op ening between two cavities or to the outside Colostomy \200\223 opening of the colon to th e skin Cutting something open Craniotomy \200\223 opening the cranium (skull) Reconstructi on of a structure Myringoplasty \200\223 repair of the tympanic membrane Chol- Hemi- Hystero- Lapar- Nephr- Pan- Per- Peri- Proct- Pyelo- Thoraco- Trans- ectomy gram itis olith oscope ostomy otomy plasty OHFP.indb 110 OHFP.indb 110 30/05/2014 16:17 30/05/2014 16:17 111 PREPARING IN-PATIENTS FOR SURGERY Preparing in-patients for surgery Checklist Before your patient goes to theater, you have a responsibility to check the follo wing have been done: \200 The consent form has been signed by the patient and surgeon \200 The patient has been seen by the anesthetist \200 The operation site has been marke d by the surgeon (imperative if the operation could be bilateral, eg inguinal hernia repair) The pre-operative blood results are in the notes \200 The pre-operative ECG and/or CXR ar e available \200 Prophylactic LMWH, TED stockings and antibiotics have been prescribed where relevant (do not give heparin <12h pre-op if having spinal/epidural) The patient has received bowel preparation if necessary \200 The patient has been adequat ely fasted (see next section) \200 Blood has been crossmatched and is available if requir ed (b p398) \200 Check if the patient has any last minute questions or concerns and is still happy to proceed with the operation. Oral \202 uids pre- and post-op In general, patients should not eat for at least 6h befor e going to theater but can have clear fl uids until 2h. In emergencies this rule may be ove r- ruled, but the risk of aspiration of gastric contents will be increased. If patients are having an operation which requires bowel preparation, check local guideline s as to what oral intake the patient is allowed whilst taking the laxatives, usually it is either clear fl uids only or a low-residue diet (see b p109). Nil by mouth (NBM) Patients c annot have any oral food or signifi cant fl uid intake; hydration must be maintained with I V fl uids. However, oral medi- cation (eg anti-arrhythmics) may be taken with a sip of wate r, if not taking them would put the patient at more risk. Non-essential medication such as vitamin supplements may be omitted; check with your seniors. Clear \202 uids Include non-carbonated drinks such as black tea, black coff ee, water, sq uash drinks (not milk or fruit juice). Sips 30ml water/hour orally, usually given for the fi rst day after major abdominal surgery involving bowel anastomoses. Soft diet This includes food such as soup and jelly. Once patients have been tolerating cle ar fl uids post-operatively for at least 24h, they may be allowed to start a soft diet. Most patients can safely drink clear fl uids up to 2h before surgery. The following increas e the risk of aspiration: \200 Pregnancy \200 Being elderly \200 Obesity \200 Stoma ch disorders, eg hiatus hernia, refl ux \200 Pain (+opioids). _OHFP.indb 111 _OHFP.indb 111 30/05/2014 16:17 30/05/2014 16:17 112 CHAPTER 2 Life on the wards Booking theater lists Elective lists In some centers this is done by the surgeon or their secretary, however in m any places this task may fall to the surgical house offi cer. If you are required to book e lective lists this will likely be electronically using a local system which you should rece ive training for (very occasionally paper systems are still in place). You should fi nd out about your local procedures for booking elective lists. Discuss the order of the list with your consultant/registrar (you may need to obtain the op erating list from your consultant \200\231s secretary or direct from theater). The list usually must be submitted by the afternoon before the oper- ating day. You should include: \200 Theater number \200 Name of the consultant surgeon \200 Name, sex, age, hospital number, and location of each patient \200 Special patient requirements (eg DM, blood requested, ICU bed booked) Operation and side in full (eg open repair left inguinal hernia) \200 Sign and leave your bleep number \200 If the order of the list needs to be changed, contact theaters and inform them as soon as possible. Booking the order of operations In general, surgeons tend to prefer a specifi c order of pa tients: \200 Older patients before younger (except children) \200 Patients with comorbi dities (eg DM) before healthy \200 Clean operations before dirty (eg bowel resection) \200 Longer, more complex operations before shorter. 3Booking emergency operations \200 Ensure you discuss the case with the ST1/2 and registrar on-call and that they have agreed to put the patient on the list Enter the patient \200\231s details as outlined above, noting the time at which the patient last ate Inform the anesthetist covering the emergency theater about the patient (usually the on-call anesthetic registrar) Check the patient has been consented and make sure the results of any relevant investigatio ns are available (including a G+S sample and a pregnancy test in women of child-bearing age ) \200 You also need to inform the theater coordinator. OHFP.indb 112 OHFP.indb 112 30/05/2014 16:17 30/05/2014 16:17 113 SURGICAL INSTRUMENTS Surgical instruments (a) (b) (c) (d) (e) (f) (g) (h) (a) Mayo (b) Halsey (c) curved (d) McIndoe (e) non-toothed (f) toothed (g) Allis (h) Little woods Needle-holders Scissors Dissecting forceps Tissue forceps (j) (i) (k) (l) (m) (n) (o) (i) Mosquito Halstead (j) Spencer Wells (k) Kocher \200\231s artery forceps (l) Langenbeck (m) Morris (n) Doyen (o) Deaver Haemostatic forceps Retractors Fig. 2.10 Surgical instruments. _OHFP.indb 113 _OHFP.indb 113 30/05/2014 16:17 30/05/2014 16:17 114 CHAPTER 2 Life on the wards The operating theater Theater design Operating theaters include an operating area, a scrubbing-up area, a prepara tion room, a sluice (area for dirty equipment and dirty laundry), and an anesthetic room. T here will also be a whiteboard (to document date, operation and number of swabs/blades/sutu res used), a display system for viewing radiology and an area to write up the operation not es and histopathology forms. Above the operating table, there are usually main sets of ligh ts, as well as smaller, more mobile units (satellites). Theater staff Each operating theater has a team of assistants who clean and maintain the th eater. The \200\230scrub nurse \200\231 scrubs for each operation to select instru- ments as requested by the surgical team. One other trained nurse and an auxiliary nurse act as \200\230runners \200\231 to fetch equipment for the scrub nurse and to monitor the number o f swabs and sutures used (displayed on the whiteboard). An operating departmental assistant (ODA) maintains the anesthetic equipment and assists the anesthetist. Each operation is lo gged, with details of the patient, name of the operating surgeon, patient \200\231s consult ant, and anesthetist. Theater clothing Fresh scrubs should be worn for each operating list and should be changed between lists, or between cases if they become dirty or potentially infected with MRSA. The ater shoes are essential for safety purposes and you will not be allowed to enter without t hem. Theater scrubs and shoes should not be worn uncovered outside of theaters except in an emergency. Scrubbing up Scrubbing up is an art and a key part of minimizing infection risk to the pati ent. If in doubt, a theater nurse can show you how to do it. \200 Prior to scrubbing, rem ove jewelry and put your mask and a theater hat on Open a gown pack and drop a pair of sterile gloves on top \200 When scrubbing up for the fi rst patient, scrub under your nails using a brush with iodine or chlorhexidine. Wash han ds for a further 5min Unravel your gown; ensure that it does not touch the fl oor \200 Touching its inner aspec ts only, put it on with the end of the sleeves covering your hands Put on your gloves. Do not touch the outside of your gloves with your bare hands For high-risk operations (eg Cesarean, HIV +ve) double-glove and protect your eyes with a visor or safety spectacles Wait for an assistant to tie your scrub gown from behind \200 If your hand becomes non-st erile, change your glove. If your gown becomes non-sterile you need to rescrub; change your gown and gloves. OHFP.indb 114 OHFP.indb 114 30/05/2014 16:17 30/05/2014 16:17 115 THE OPERATING theater Theater etiquette \200 If you are scrubbed up: ask someone not scrubbed to adjust the lights for you \200 do not pick up instruments whi ch fall to the ground \200 if you are handed an instrument by someone who is not scrubbed , check that you can touch it before accepting it In operations involving the abdomen and the perineum, if you are asked to move from the perineum to the abdomen you must rescrub. This is not necessary when swapping from abdomen to perineum \200 If you sustain a needle-stick injury, leave the o peration and report to occupational health (b p106) Always eat/drink and go to the toilet before going to an operating list. Watching an operat ion Make sure you can see; get a stool or stand at the patient \200\231s head if the anesth etist allows. Although you are not actively participating in the operation, use the time to learn surgical techniques. If you can \200\231t follow what \200\231s going on, ask. As th e operation fi nishes, fi ll in any histology forms or TTOs if appropriate. Check histology samples are labeled accurately. WHO Surgical Safety Checklist In 2009 NHS Patient Safety Agency (NPSA) released guidance on the WHO Surgical Safety Checklist, a process by which all members of the theater team have a discussion about the operation and the patient in advance of undertaking the procedure. The aim of this is to improve patient safety and prevent errors such as wrong-site surgery, retained throat-packs, avoidable delays in obtaining blood products or senior help should an unexpected incident arise. Most Trusts have devised their own checklist so these vary be tween hospitals, but are all based on the NPSA guidance.1 The checklist is read out loud be fore the anesthetic is given, before the operation starts, and after the operation is compl eted. Before the opera- tion everyone in theater introduces themselves, the patient \200 \231s details, the procedure about to take place and the site are confi rmed, relevant equi pment is checked to be present, and VTE prophylaxis measures are declared. At the checkout after the operation swab counts, instrument and sharps counts are checked, the operation no te is confi rmed, and spec- imens labeled. Plans for post-operative management are also con fi rmed. 1 (cid:27)www.nrls.npsa.nhs.uk/resources/clinical-specialty/surgery/?entryid45=59860 _OHFP.indb 115 _OHFP.indb 115 30/05/2014 16:17 30/05/2014 16:17 116 CHAPTER 2 Life on the wards Post-op care As well as seeing patients pre-operatively, you should review them after the o peration. This means you can review and discharge day cases with your team, as well as maki ng sure the in-patients are stable after the operation. Discharging day cases (this may be done by nursing staff ). Before sending day surgery patients home, you should make sure they are alert, have eaten a nd had fl uids without vomiting, have passed urine, are mobilizing without fainting, and ha ve adequate pain relief. Inspect the operation site and check their observations. Go throug h the operation procedure, fi ndings, and follow-up with the patient. Organize appropriate follow-up care and clarify if they need dressing changes, suture remov al dates and where this can be done (GP surgery, the ED or ward). If the patient develops a ny post-operative temperatures, pain or bleeding, they should contact their GP or come to t he ED. Common questions about discharge \200 Patients can self-certify as unfi t for work for up to a total of 7d (including time spent as in-patient); if you anticipate required time off work will routine ly be longer than this, issue a Fitness to Work/Med 3 note (b p80) for the total expected t ime; this is the responsibility of the hospital team, not the patient s GP. Unanticipated e xtensions to the recovery period can be handled by the GP Patients requiring proof of hospital admission (for sick pay or social security payments) s hould be issued with a Form Med 10 (b p80) \200 Tell the patient if their sutures are dis solvable or if they need to return to have them removed (give dates; often GP practice nurs es will do this) \200 Patients can shower and commence driving again 48h after minor surgery (as long they can perform an emergency stop; see b p605) Advise patients not to fl y for 6wk following major surgery. In-patient post-op care Post-o p patients are at risk of complications associated with the opera- tion, either directly (e g hemorrhage) or indirectly (eg PE). When reviewing post-operative patients, document the n umber of days since the operation and the operation they underwent (eg 2d post left mastect omy). Ask about pain, ability to eat and drink, nausea/vomiting, urinary output and color, bowel movements/fl atus, mobilization. Examine wound site, chest, abdomen, legs, drains, st oma bags, IV can- nulae, catheter bag, drain entry site, amount drained, color of any fl ui d being drained. Look at the observations pyrexia, HR, BP, RR, 24h fl uid balance (total in put and output (including drains) and net balance); document all fi nd- ings. Review the dr ug chart for analgesia, antibiotics, fl uids. Check post-operative Hb; transfuse if necessa ry (b p398). Involve other members of the multidisciplinary team if necessary, eg stoma nur se, pain team, physiotherapists, social worker, occupational therapist. OHFP.indb 116 OHFP.indb 116 30/05/2014 16:17 30/05/2014 16:17 117 POST-OP PROBLEMS Post-op problems Hypotension (b p473) Ask about pre-op BP, fl uid input, epidural, drugs, p ain. Look for repeat BP, HR, fl uid input/urine output, temperature, GCS, ori- entation, skin te mp, cap-refi ll, signs of hypovolaemia/sepsis, wounds, drain, abdomen, any signs of active bleeding. Management Hypotension is common post-op and does not always require intervention. Tachycar dia is a worrying feature suggesting shock. If this or other adverse features are present d o 15min obs and monitor hourly urine output (catheterise bladder). Lie the patient fl at, a nd give oxygen. Get IV access, consider fl uid challenge (eg 500ml crystalloid STAT, b p476 ). Send bloods for FBC and crossmatch (blood cultures if you suspect sepsis). Apply pressur e to any obvious bleeding points. Call for senior review early. Pyrexia Temp 37.5 C, investigate if this persists/increases after the fi rst 24h post-op ( b p482). Ask about cough/SOB, wound, dysuria/frequency, abdo pain, diarrhea. Look for BP, HR, temp, wound, catheter, IV cannulae, chest, abdomen. Management Urine M,C+S; blds FBC, U+E, CRP, blood cultures; imaging CXR, consider abdominal USS or CT, echo if new onset murmur. Possible causes of post-op pyrexia by day post-surgery \200 Day 1 \200\2232 atelectasis; treat with salbutamol/saline nebs and chest physio \200 Day 3 \200\2234 pneumonia; treat with antibiotics and chest physio \200 Day 5 \200\2236 anastomotic leak; need to take bac k to theater \200 Day 7 \200\2238 wound infection; treat by opening up wound, antibiotics , may need to return to theater Day 9 \200\22310 DVT/PE; treat with heparin/LMWH then warfarin. Shortness of breath/dO2 sats (b p271) Ask about chronic lung/CVS disease, previous PE, ches t pain, ankle swelling, new onset cough. Look for BP, HR, temp, pallor, lungs (consolidation, crackles, air entry), signs of fl uid overload, leg oedema/calf swelling. Management Sit up and give O2; blds FBC, ABG; CXR, ECG. Consider 0.9% saline nebs, antibiot ics and regular chest physiotherapy. If you suspect a PE (b p278) call for senior help and specialist advice (medical registrar on-call). Post-op problems covered elsewhere b p86 b p304 b p378 Pain Nausea and vomiting Low urine output _OHFP.indb 117 _OHFP.indb 117 30/05/2014 16:17 30/05/2014 16:17 118 CHAPTER 2 Life on the wards Wound management Types of wound healing \200 Primary closure This is most common in surgery, where wound e dges are opposed soon after the time of injury and held in place by sutures, steristrips \204 or staples. The aim is to minimize the risk of wound infection with minimal scar tiss ue formation (Table 2.16) Delayed primary closure This is more commonly used in \200\230dirty \200\231 or traumatic wounds. The wound is cleaned, debrided and then initially left open for 2 \200 \2235d. Antibiotic cover may be given until the wound is reviewed for closure Secondary closure This is much less commonly encountered in surgery. Healing by secondary i ntention happens when the wound is left open and heals slowly by granulation. This is used in the presence of large areas of excised tissue, infection or signifi cant trauma, where c losing the wound would be impossible or would give rise to signifi cant complications. Table 2.16 Abdominal wound complications Ask about Examine Management Pink serous discharge, burst sutures Skin and fat cavity exposed (rectus sheath closed) Separation of wound edges with bowel exp osed Not an emergency but ask for senior review \200\223 wound may need packing antibiotics Call for senior help urgently. Cover the bowel with a large sterile swab soaked in 0.9% sal ine. Check analgesia and fl uid replacement, give antibiotics Wound swab, broad- spectrum a ntibiotics initially (see b p179), discuss with your senior Super \201 cial dehiscence Pink serous discharge, haematoma, bowel protrusion Deep dehiscence Pyrexia, pain, erythema, white, yellow or bloody exudate from wound site Tenderness, odorous discharge, swelling Infection OHFP.indb 118 OHFP.indb 118 30/05/2014 16:17 30/05/2014 16:17 119 COMMON ELECTIVE OPERATIONS Common elective operations Laparoscopic cholecystectomy Operation to remove the gallbladder . Indications Symptomatic gallbladder stones, asymptomatic patients at risk of complication s (diabetics, history of pancreatitis, immunosuppressed). Pre-op No bowel prep required, 6h fasting pre-anesthetic (see b p109). Procedure Involves insuffl ating the abdomen with CO2 , inserting 3 or 4 ports through the anterior abdominal wall to enable laparoscopy and the use of operating instruments to remove the gallbladder. Post-op Patients can eat as soon as they recover from the anesthetic, can usually go home later in the day or the following mo rning. Not all patients are followed up; some consultants like to review patients in clinic after 6 \200\2238wk. Complications Hemorrhage, wound infections, bile leakage, bile duct s tricture, retained stones; may require conversion to more major open surgery. Colectomy Ope ration to remove part or all of the colon (Fig. 2.11). Indications Malignancy, perforation, IBD which can no longer be managed medically. Pre-op Full bowel prep rarely required, 6h f asting pre-anesthetic (see b p109). Procedure Involves a midline longitudinal laparotomy in cision and resec- tion of the diseased bowel if done open, can be done laparoscopically. A stoma may or may not be formed. Post-op Sips of fl uid orally for 24h post-op, gradually bu ilt up to free fl uids and then light diet. Hospital stay 3 \200\2237d ( enhanced recovery pathways used to streamline post-operative recovery). All patients followed up in clinic. Complications Hemorrhage, wound infection, wound dehiscence, anastomotic leak. Right hemicolectomy Transverse colectomy Left hemicolectomy Sigmoid colectomy Fig. 2.11 Common large bowel resections (the shaded area represents the section of colon re moved during the operation). _OHFP.indb 119 _OHFP.indb 119 30/05/2014 16:17 30/05/2014 16:17 120 CHAPTER 2 Life on the wards Anterior resection Operation to resect the rectum with a suffi cient margin (usually 5cm) a nd anastomose the left side of the colon with the rectal stump. See Fig. 2.12. Indications Rectal carcinoma. Pre-op Full bowel prep rarely required, phosphate enema 1h pre-op, 6h fas ting pre-anesthetic (see b p109). Procedure Involves a midline longitudinal laparotomy inci sion and resec- tion of the diseased rectum if done open. Can be done laparoscopically. Pos t-op Sips of fl uid orally for 24h post-op, gradually built up to free fl uids and then lig ht diet. Hospital stay 4 \200\22310d. All patients followed up in clinic. Complications Hem orrhage, wound infection, wound dehiscence, anastomotic leak. Anterior resection Fig. 2.12 Anterior resection. Abdominoperineal resection (AP resection) Operation to resect the rectum/anus and form a pe rmanent colostomy. See Fig 2.13. Indications Low rectal carcinoma where it would be impossi ble to resect the tumor without removing the anus, can also be performed as part of a panpr octocolectomy for ulcerative colitis. Pre-op Full bowel prep rarely required, phosphate ene ma 1h pre-op, 6h fasting pre-anesthetic (see b p109), stoma nurses to be involved. Procedur e Involves a midline longitudinal laparotomy incision and resec- tion of the diseased rectu m and anus. Post-op Sips of fl uid orally for 24h post-op, gradually built up to free fl ui ds and then light diet. Hospital stay 4 \200\22310d. All patients followed up in clinic. Co mplications Hemorrhage, wound infection, wound dehiscence, stoma retraction. AP resection Fig. 2.13 AP resection. OHFP.indb 120 OHFP.indb 120 30/05/2014 16:17 30/05/2014 16:17 121 STOMAS Stomas Colostomy LIF or right hypochondrium Common locations Features May be permanent or planned for subsequent reversal; mucosa sutured directly to skin Soft/s olid stool; intermittently passed Colorectal cancer, diverticular disease, trauma, radiatio n enteritis, bowel ischaemia, obstruction, Crohn \200\231s disease Output Indications Ileostomy RIF Common locations Features May be permanent or planned for subsequent reversal; bowel mucosa sutured to form a \200 \230spout \200\231 to avoid skin contact with bowel contents which are irritating (not fl u sh with skin) Liquid stool (may be bile-stained); passed continuously Output Indications GI tract cancer, IBD, trauma, radiation enteritis, bowel ischaemia, obstruction Urostomy Sometimes referred to as a nephrostomy if originating in renal pelvis Left or right fl ank, lower anterior abdominal wall Common locations Features A ureteric catheter may be protruding from the skin into the stoma Clear urine passed conti nuously Renal tract cancer, urinary tract obstruction, spinal column disorders, hydronephro sis, urinary fi stulae Output Indications Common complications \200 Electrolyte/fl uid imbalance (see b p385 \200\223389) \200 Is chaemia/necrosis shortly after formation \200 Obstruction/prolapse/parastomal hernia \200 Skin erosion/infection \200 Psychosocial implications. It is important to refer pat ients who are likely to need stomas to the stoma care nurse prior to the operation. Patient s with stomas also need to alter their diet to avoid excess fl atulence or overly watery st ool, so should also be referred to the dietician. Troublesome high-output stomas leading to fl uid balance problems or excessive need for bag emp- tying require specialist gastroen terologist advice. _OHFP.indb 121 _OHFP.indb 121 30/05/2014 16:17 30/05/2014 16:17 This page intentionally left blank Chapter 3 History and examination 123 Basic history 124 Basic examination 126 Recording your clerking 127 Medicine Cardiovascular 128 Respiratory 130 Gastrointestinal 131 Neurological 132 Endocrine 137 Skin 138 Oncological/hematological 140 Surgery Breast 141 Eyes 142 Head and neck 144 Musculoskeletal 146 Urological 154 Other specialties Female reproductive system 156 Obstetric 158 Psychiatric 160 Neonatal exa mination 163 Pediatric 164 _OHFP.indb 123 _OHFP.indb 123 30/05/2014 16:17 30/05/2014 16:17 124 CHAPTER 3 History and examination Basic history Taking a thorough history is an essential skill as a junior doctor and some- thing you will become extremely practiced at. These two pages show the basic features of a history, with details of how to perform a basic exami- nation following after. The rest of the chapter shows how to adapt these basic approaches for specifi c situations. Taking a hi story (OHCM9 b p20) \200 Try to be in a setting that off ers privacy and has a bed \200 Establish the patient \200\231s name and check their date of birth \200 Introduce yourse lf and begin with open-ended questions. Presenting complaint Why has the patient come to ho spital? Write their main problem(s) in their own words along with duration of symptoms and who referred them; if the referral letter has a diff erent presenting complaint then docume nt this too. History of presenting complaint(s) Ask questions aimed at diff erentiating the causes of th e presenting complaint and assessing its severity. Try to exclude potentially life-threaten ing causes fi rst. Ask specifi cally about previous episodes and investigations/treatments. Use the SOCRATES questions for pain (site, onset, character, radiation, associations, timi ng, exacerbating/relieving factors, severity). Ask about the eff ect on their activities of daily living (ADLs). If there are multiple problems ask if they come on together or are re lated. Risk factors Document recognized risk factors for important diff erentials. Past medical history Ask about previous medical problems/operations and attempt to gauge th e severity of each (eg hospital/ICU admissions, exercise tolerance (ET), treatment); use th e drug history to prompt the patient \200\231s memory. Consider documenting specifi cally a bout asthma, DM, angina,iBP, MI, stroke, PE/DVT, epilepsy. Drug history Document all drugs along with doses, times taken and any recent changes. Alway s document drug allergies along with the reaction precipitated. Alternatively if the patien t has never had a drug allergy then document this. Family history Ask about relevant illness in the family (eg heart problems, DM, cancer). Ar e other family members well at the moment? Social history This is essential: home ask about who they live with, the kind of house (eg bungalow, residential home), any home help, own ADLs (cooking, dressing, washing); mobility walking aids (stick/ frame), exercise tolerance (how far can they walk on level ground? ca n they climb stairs?); lifestyle occupation, alcohol (units/wk), smoking (cigarettes/d and pack years), recreational drugs: \200 Alcohol; 1 unit = pint of beer, glass of wine, m easure of spirits; bottle of wine = 9units, 1l of strong cider = 8.5units Smoking; 20 cigarettes/d for 1yr = 1 pack year. OHFP.indb 124 OHFP.indb 124 30/05/2014 16:17 30/05/2014 16:17 125 BASIC HISTORY Systems \200\231 review Relevant systems \200\231 review will often be part of the HPC; a t horough systems \200\231 review is only necessary if you are unsure what is rel- evant or a re struggling to explain the symptoms. See OHCM9 b p22. Chest pain, palpitations, SOB, ankle swelling, orthopnoea Cough (?blood), sputum, wheeze, S OB Abdo pain, nausea/vomiting, bowel habit (?blood), stool color and consistency, distensio n, dysuria, frequency, urgency, haematuria Headache, photophobia, neck stiff ness, weakness , change in sensation, balance, fi ts, falls, speech, changes in vision/hearing Systemic Ap petite, weight loss/gain, fever/night sweats, malaise, stiff / swollen joints, fatigue, ras hes/itch, sleep pattern CVS Resp Abdo Neuro Summarizing Ask if there are any other problems that have not been discussed and repeat bac k a summary of the history to the patient to check that they agree. It is a good idea to us e the ICE questions (Ideas, Concerns, Expectations) at this point \200\223 ask the patient if they have any idea or suspicion of what might be wrong with them, if there \200\231s an ything in particular that they \200\231re worried about (this may prompt them to admit spec ifi c concerns eg having cancer), and what they expect will happen to them whilst they are in hospital. Most patients have no idea about tests and investigations and fi nd being admitted to hospi tal a frightening event; they often value the opportunity to talk about possible options an d ask questions. Always fi nish your history by asking specifi cally if the patient has any further question s or any other issues they would like to discuss, as frequently they will be too embarrasse d/shy/reticent to ask. Should you take notes whilst clerking? There is no simple answer to this. Taking notes whil e the patient talks may allow you to record important details accurately or even to write u p your clerking as you go. This can be extremely useful during busy on-calls. Alternatively not taking notes allows you to give the patient your undivided attention and the opportuni ty to record the clerking having considered the whole picture. In the end it comes down to individual preference and workload. After the history By the end of taking the history you should have a reasonable idea of the diff erential diagnosis. Try to think of specifi c signs that would be present on examinat ion to confi rm or refute these diff erentials. A basic examina- tion is described on the n ext page. _OHFP.indb 125 _OHFP.indb 125 30/05/2014 16:17 30/05/2014 16:17 126 CHAPTER 3 History and examination Basic examination It is good practice to perform a brief CVS, RS, abdo and neuro exam on al l patients but focus your examination according to their history. Check observations (temp, BP, HR, RR, O2 sats): \200 Ask a nurse to chaperone you if necessary \200 Get consent before touching the patient, ask where it hurts \200 First assess briefl y whether the pa tient looks well or ill. Hands (b p152) \200 Inspection at the hands for signs of disease \200 Palpation check the pulse for rate, rhythm and character (eg ?collapsing pulse). Mouth \200 Inspection central cyanosis, mucous membranes, stomatitis, beefy tongue (diron), candidiasis, ulcers, dental hygiene (risk factor for SBE). Cardiovascular system (b p128) \200 Inspection JVP (very useful if visible), swollen ankl es \200 Palpation temp of hands, capillary-refi ll, carotid pulse (volume and character), apex beat, heaves/thrills, hepatomegaly Auscultation heart sounds, added sounds/murmurs (timing, volume, radiation), carotid bruits, basal crackles. Respiratory system (b p130) \200 Inspection asterixis (fl ap), stridor, JVP, RR and eff o rt (accessory muscles, recession), chest wall movement, peripheral oedema Palpation trachea, cervical lymphadenopathy, expansion \200 Percussion does right equal l eft?, hyperresonant, dull, stony dull \200 Auscultation air entry, crackles, wheeze, bron chial BS, rub. Abdomen (b p131) \200 Inspection jaundice, scars, distension, hernias, oed ema \200 Palpation start away from pain and watch patient \200\231s face: tenderness, peritonism (guarding, rebound, rigidity, percussion tenderness), masses, liver, spleen, kid neys and AAA (expansile mass), hernias, genitalia, PR (masses, stool, tenderness, prostat e, blood/mucus/melaena) Percussion ascites (shifting dullness, fl uid thrill), liver, spleen \200 Auscultation bo wel sounds (absent, reduced, increased, tinkling). Peripheral nerves (b p134) \200 Inspec tion posture, movement of limbs \200 Palpation tone; power (5 normal, 4 weak, 3 against g ravity only, 2 not even against gravity, 1 twitch, 0 none); re \202 exes tendons, plantars ; sensation Coordination fi nger \200\223nose, slide heel down opposite leg. Cranial nerves (b p133) \200 Inspection GCS, mental state (b p161), facial symmetry, scars, obvious gaze palsies, speech, posture Eyes (II, III, IV, VI) acuity, pupil reactivity, fi elds, movements, fundi \200 Face (V, VII) sensation and power \200 Mouth (IX, X, XII) tongue movements, palate position, cough \200 Other (VIII) hearing, balance, gait (XI), shrug, head movements. OHFP.indb 126 OHFP.indb 126 30/05/2014 16:17 30/05/2014 16:17 127 RECORDING YOUR CLERKING Recording your clerking The initial clerking of a patient is one of the most important step s in their journey through the hospital. It will be reread by every team that looks after t he patient and used as a benchmark for measuring the progress of the patient \200\231s cond ition. A good clerking gives the patient the best opportunity to receive the correct invest igations and treatment. Heading Your name, position, location, date, time; state clearly why the patient is being c lerked (eg referred from ED with chest pain). Format Follow a logical order setting out each section under the head- ings shown over thes e four pages. If a piece of information from a dif- ferent section is really important then write it in the history of presenting complaint and/or under the social history. Sources State where you got important information from (eg patient, relative (with name and relationship), notes, computer records). This makes it easy to check if the information is of critical importance.