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Theatre etiquette
• If you are scrubbedup:
•
ask someone not scrubbed to adjust the lights foryou
•
do not pick up instruments which fall to theground
•
if you are handed an instrument by someone who is not scrubbed,
check that you can touch it before acceptingit
• 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
• If you sustain a needle- stick injury, leave the operation and report to
occupational health (Ep. 03)
• Always eat/ drink and go to the toilet before going to an operatinglist.
Watching anoperationMake sure you can see; get a stool or stand
at the patient’s head if the anaesthetist allows. Although you are not
actively participating in the operation, use the time to learn surgical techniques. If you can’t follow what’s going on, ask. As the operation nishes,
ll in any histology forms or TTOs if appropriate. Check histology samples are labelled accurately.
WHO Surgical Safety Checklist In 2009, the National Patient
Safety Agency (NSPA) released guidance on the WHO Surgical Safety
Checklist, a process by which all members of the theatre 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
between hospitals, but are all based on the WHO checklist.
4
The checklist is read out loud before the anaesthetic is given, before
the operation starts, and after the operation is completed. Before the
operation, everyone in theatre introduces themselves; the patient’s
details, the procedure about to take place, and the site are conrmed;
relevant equipment is checked to be present; and VTE prophylaxis measures are declared. At the checkout after the operation, swab counts, instrument counts, and sharps counts are checked, the operation note is
conrmed, and specimens labelled. Plans for postoperative management
are also conrmed.
113THE OPERATING THEATRE
4
Mwww.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery
114 CHAPTER2 Life onthewards
Post- opcare
As well as seeing patients preoperatively, you should review them after the
operation. This means you can review and discharge day cases with your
team, as well as making sure the in- patients are stable after the operation.
Discharging day cases(This may be done by nursing sta.)
Before sending day surgery patients home, you should make sure they
are alert, have eaten and had uids without vomiting, have passed urine,
are mobilizing without fainting, and have adequate pain relief. Inspect the
operation site and check their observations. Go through the operation
procedure, ndings, and follow- up with the patient.
Organize appropriate follow- up care and clarify if they need dressing
changes, suture removal dates, and where this can be done (GP surgery,
ED, or ward). If the patient develops any post- op temperatures, pain, or
bleeding, they should contact their GP or come to theED.
Common questions about discharge
• Patients can self- certify as unt for work for up to a total of 7d
(including time spent as in- patient); if you anticipate required time o
work will routinely be longer than this, issue a Fitness to Work/ Med
3 note (E p. 84) for the total expected time; this is the responsibility
of the hospital team, not the patient’s GP. Unanticipated extensions to
the recovery period can be handled bytheGP
• Patients requiring proof of hospital admission (for sick pay or social
security payments) should be issued with a Form Med 0 (Ep. 84)
• Tell the patient if their sutures are dissolvable or if they need to return to
have them removed (give dates; often GP practice nurses will dothis)
• Patients can shower and commence driving again 48h after minor
surgery (as long they can perform an emergency stop; Ep. 633)
• Advise patients not to y for 6wk following major surgery.
In- patient post- opcare
Post- op patients are at risk of complications associated with the oper-
ation, either directly (eg haemorrhage) or indirectly (egPE).
When reviewing post- op patients, document the number of days since
the operation and the operation they underwent (eg 2d post left mastectomy).
Ask aboutPain, ability to eat and drink, nausea/ vomiting, urinary output
and colour, bowel movements/ atus, mobilization.
Examine Wound site, chest, abdomen, legs, drains, stoma bags, IV
cannulae, catheter bag, drain entry site, amount drained, colour of any
uid being drained.
Look atthe observationsPyrexia, HR, BP, RR, 24h uid balance (total input
and output (including drains) and net balance); document all ndings.
Review thedrug chartFor analgesia, antibiotics, uids.
CheckPostoperative Hb; transfuse if necessary (Epp. 420–5).
Involve Other members of the MDT if necessary, eg stoma nurse, pain
team, physiotherapists, social worker, occupational therapist.
Post- op problems
Hypotension(Epp. 476–7.)
Ask aboutPre- op BP, uid input, epidural, drugs,pain.
Look for Repeat BP, HR, uid input/ urine output, temperature, GCS,
orientation, skin temp, cap- rell, signs of hypovolaemia/ sepsis, wounds,
drain, abdomen, any signs of active bleeding.
Management Hypotension is common post- op and does not always
require intervention. Tachycardia is a worrying feature suggesting shock.
If this or other adverse features are present do 5min obs and monitor
hourly urine output (catheterize bladder). Lie the patient at, and give
oxygen. Get IV access, consider uid challenge (eg 500mL crystalloid
STAT, E p. 480). Send bloods for FBC and crossmatch (blood cultures
if you suspect sepsis). Apply pressure to any obvious bleeding points.
Call for senior reviewearly.
Pyrexia Temp 37.5°C, investigate if this persists/ increases after the
rst 24h post- op (E pp. 486–95; see Box2.8).
Ask aboutCough/SOB, wound, dysuria/ frequency, abdo pain, diarrhoea.
Look forBP, 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.
Box 2.8 Possible causes ofpost- op pyrexia
• Day – 2 Atelectasis; treat with salbutamol/ saline nebs and
chestphysio
•
Day 3– 4 Pneumonia; treat with antibiotics and chestphysio
•
Day 5– 6 Anastomotic leak; need to take back to theatre
•
Day 7– 8 VTE; wound infection (treat by opening up wound,
antibiotics, may need to return to theatre).
115POST-OP PROBLEMS
Shortness ofbreath/ dO2 sats (E pp. 285–97.)
Ask about Chronic lung/CVS disease, previous PE, chest pain, ankle
swelling, new- onsetcough.
Look for BP, HR, temp, pallor, lungs (consolidation, crackles, air entry),
signs of uid overload, leg oedema/ calf swelling.
ManagementSit up and giveO
saline nebs, antibiotics, and regular chest physiotherapy. If you suspect a
; bldsFBC,ABG; CXR, ECG.Consider 0.9%
2
PE (E p. 292) call for senior help and specialist advice (medical registrar
on- call). See also Box2.9.
I Box 2.9 Post- op problems covered elsewhere
Pain
Nausea and vomiting
Low urine output
E pp. 92–5
E pp. 38–9
E pp. 400–1
116 CHAPTER2 Life onthewards
Wound management
Types ofwound healing
Primary closureThis is most common in surgery, where wound edges are
opposed soon after the time of injury and held in place by sutures, SteriStrips™, or staples. The aim is to minimize the risk of wound infection
with minimal scar tissue formation (Table2.0).
Delayed primary closure This is more commonly used in ‘dirty’ or trau-
matic wounds. The wound is cleaned, debrided, and then initially left
open for 2– 5d. 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 intention 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 signicant trauma, where closing the wound
would be impossible or would give rise to signicant complications.
Table2.0 Abdominal wound complications
Ask about Examine Management
Supercial
dehiscence
Deep
dehiscence
Infection Pyrexia, pain,
Pink serous
discharge, burst
sutures
Pink serous
discharge,
haematoma,
bowel
protrusion
erythema, white,
yellow, or bloody
exudate from
wound site
Skin and fat
cavity exposed
(rectus sheath
closed)
Separation of
wound edges
with bowel
exposed
Tenderness,
odorous
discharge,
swelling
Not an emergency but
ask for senior review—
wound may need packing
± antibiotics
Call for senior help
urgently. Cover the
bowel with a large sterile
swab soaked in 0.9%
saline. Check analgesia
and uid replacement,
give antibiotics
Wound swab, broadspectrum antibiotics
initially (E p. 77),
discuss with your senior
Common elective operations
Laparoscopic cholecystectomyOperation to remove the gallbladder.
IndicationsSymptomatic gallbladder stones, asymptomatic patients at risk
of complications (diabetics, history of pancreatitis, immunosuppressed).
Pre- opNo bowel prep required, 6h fasting pre- anaesthetic (Ep. 06).
ProcedureThis involves insuating the abdomen with CO
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 anaesthetic,
and can usually go home later in the day or the following morning. Not
all patients are followed up; some consultants like to review patients in
clinic after6– 8wk.
Complications Haemorrhage, wound infections, bile leakage, bile duct
stricture, retained stones; may require conversion to more major open
surgery.
ColectomyOperation to remove part or all of the colon (Fig.2.0).
IndicationsMalignancy, perforation, IBD which can no longer be managed
medically.
Pre- opFull bowel prep rarely required, 6h fasting pre- anaesthetic (Ep. 06).
ProcedureThis involves a midline longitudinal laparotomy incision and re-
section of the diseased bowel if done open, can be done laparoscopically. Astoma may or may not be formed.
Post- opSips of uid orally for 24h post- op, gradually built up to free uids
and then light diet. Hospital stay 3– 7d (‘enhanced recovery pathways’ used
to streamline post- op recovery). All patients followed up in clinic.
Complications Haemorrhage, wound infection, wound dehiscence, anas-
tomoticleak.
, inserting 3 or
2
117COMMON ELECTIVE OPERATIONS
Fig.2.0 Common large bowel resections (the shaded area represents the
section of colon removed during the operation).
118 CHAPTER2 Life onthewards
Anterior resection
Anterior resection Operation to resect the rectum with a sucient
margin (usually 5cm) and anastomose the left side of the colon with the
rectal stump. See Fig.2..
IndicationsRectal carcinoma.
Pre- opFull bowel prep rarely required, phosphate enema h pre- op, 6h
fasting pre- anaesthetic (Ep. 06).
ProcedureThis involves a midline longitudinal laparotomy incision and resec-
tion of the diseased rectum if done open. Can be done laparoscopically.
Post- opSips of uid orally for 24h post- op, gradually built up to free uids
and then light diet. Hospital stay 4– 0d. All patients followed up in clinic.
Complications Haemorrhage, wound infection, wound dehiscence, anas-
tomoticleak.
Fig.2. Anterior resection.
Abdominoperineal resection (AP resection) Operation to re-
sect the rectum/ anus and form a permanent colostomy. See Fig.2.2.
Indications Low rectal carcinoma where it would be impossible to resect
the tumour without removing the anus, can also be performed as part of
a panproctocolectomy for ulcerative colitis.
Pre- opFull bowel prep rarely required, phosphate enema h pre- op, 6h
fasting pre- anaesthetic (E p. 06), stoma nurses to be involved.
Procedure This involves a midline longitudinal laparotomy incision and
resection of the diseased rectum andanus.
Post- opSips of uid orally for 24h post- op, gradually built up to free uids
and then light diet. Hospital stay 4– 0d. All patients followed up in clinic.
ComplicationsHaemorrhage, wound infection, wound dehiscence, stoma
retraction.
AP resection
Fig.2.2 AP resection.
Stomas
Colostomy
Common locations LIF or right hypochondrium.
FeaturesMay be permanent or planned for subsequent reversal; mucosa
sutured directly toskin.
OutputSoft/ solid stool; intermittently passed.
Indications Colorectal cancer, diverticular disease, trauma, radiation en-
teritis, bowel ischaemia, obstruction, Crohn’s disease.
Ileostomy
Common locationsRIF.
Features May be permanent or planned for subsequent reversal; bowel
mucosa sutured to form a ‘spout’ to avoid skin contact with bowel contents which are irritating (not ush withskin).
Output Liquid stool (may be bile- stained); passed continuously.
Indications GI tract cancer, IBD, trauma, radiation enteritis, bowel is-
chaemia, obstruction.
Urostomy
Sometimes referred to as a nephrostomy if originating in renal pelvis.
Common locations Left or right ank, lower anterior abdominalwall.
Features A ureteric catheter may be protruding from the skin into
thestoma.
OutputClear urine passed continuously.
IndicationsRenal tract cancer, urinary tract obstruction, spinal column dis-
orders, hydronephrosis, urinary stulae.
Common complications
• Electrolyte/ uid imbalance (E pp. 407–11)
• Ischaemia/ necrosis shortly after formation
• Obstruction/ prolapse/ parastomalhernia
• Skin erosion/ infection
• Psychosocial implications.
It is important to refer patients who are likely to need stomas to the
stoma care nurse prior to the operation. Patients with stomas also need
to alter their diet to avoid excess atulence or overly watery stool, so
should also be referred to the dietician. Troublesome ‘high- output ’
stomas leading to uid balance problems or excessive need for bag
emptying require specialist gastroenterologist advice.
119STOMAS
Chapter3
History and examination
Basic history 22
Basic examination 24
Recording your clerking 25
Medicine
Cardiovascular 26
Respiratory 28
Gastrointestinal 29
Neurological 30
Endocrine 35
Skin 36
Oncological/ haematological 38
Surgery
Breast (male and female) 39
Eyes 40
Head and neck 42
Musculoskeletal 44
Urological 52
Other specialties
Female reproductive system 54
Obstetric 56
Psychiatric 58
Neonatal examination 6
Paediatric 62
121
122 CHAPTER3 History and examination
Basic history
Taking a thorough history is an essential skill as a junior doctor and
something you will become extremely practised at. The basic features
of a history, with details of how to perform a basic examination are described in this chapter. How to rene these approaches is further described for specic situations you may encounter.
Taking a history(E OHCM1p. 26)
• Try to be in a setting that oers privacy and hasabed
• Establish the patient’s name and check their date ofbirth
• Introduce yourself and begin with open- ended questions.
Presenting complaintWhy has the patient come to hospital? Let them tell
their story. Write their main problem(s) in their own words along with
duration of symptoms and who referred them; if the referral letter has a
dierent presenting complaint then document thistoo.
History ofpresenting complaint(s) Ask questions aimed at dierentiating
the causes of the presenting complaint and assessing its severity. Try
to exclude potentially life- threatening causes rst. Ask specically about
previous episodes and investigations/ treatments. Use the SOCRATES
questions for pain (Site, Onset, Character, Radiation, Associations,
Timing, Exacerbating/ relieving factors, Severity). Ask about the eect
on their activities of daily living (ADLs). If there are multiple problems,
ask if they come on together or are related.
Risk factorsDocument recognized risk factors for important dierentials.
Past medical history Ask about previous medical problems/ operations and
attempt to gauge the severity of each (eg hospital/ICU admissions, exercise tolerance, treatment); use the drug history to prompt the patient’s
memory. Consider documenting specically about asthma, DM, angina,
iBP, MI, stroke, VTE, epilepsy, malignancy.
Drug history Document all drugs along with doses, times taken, and any
recent changes. Always document drug allergies along with the reaction
precipitated. Or no known drug allergies (NKDA). Remember to ask
about OTC medications. Ask about compliancetoo.
Family history Ask about relevant illness in the family (eg heart problems,
DM, cancer). What age were they at diagnosis? Are 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);
exercise tolerance (how far can they walk on level ground? Can they
climb stairs?);
ettes/ d and pack- years), recreationaldrugs:
• Alcohol: unit=⅓ pint of beer, ½ glass of wine, measure of spirits
• Smoking:20 cigarettes/ d for yr= pack- year.
Lifestyle Occupation, alcohol (units/ wk), smoking (cigar-
Mobility Walking aids (stick/ frame),