General Surgery

Case Author: Mitchell Mammel, Class of 2021

Content Reviewer: Dr. Manpreet Sidhu, R2 Family Practice

Case Objectives

Review the elements of a general surgery consult.
Review the initial steps of a general surgery consult.
Understand how to find pertinent patient history on electronic medical records.
Practice creating a differential diagnosis to guide and organize a general surgery consult.
Practice delivering a structured presentation to a surgical preceptor.
Practice writing admission orders for general surgery.
Practice writing a rounding note for surgical patients.

Objective 1: Review the elements of a general surgery consult

Consults on Surgery

When you do a consult, in general, you are trying to figure out:

Why are they here? (CC)
Why are we seeing them?
And then completing the usual elements of a consult: CC, HPI, PmHx, Surg Hx Allergies, Social Hx, Medications, Physical, Investigations, Impression and Plan (Issues list)

In surgery, you are thinking about the following questions:

- Does this patient need surgery?
- If they do, how urgently?
- Do they need anything to be prepared for surgery? Ex. are they healthy enough? Are they on blood thinners?

Consults in surgery can happen throughout the day and/or night, if you are on call. Each morning, get the number of the surgeon on call and text them your name/number so they know you're on call. To get the surgeon's number, ask someone on your team, call switchboard, or check the call schedule posted in the OR on the wall across from the NUC's desk.

Start of Case: Receiving a Consult

You are on your first call shift of your Surgical rotation.You have texted the preceptor you’ll be working with so they have your number, and you receive a text from them: “Hey, we have a patient in the ER to see; they’re in Bay 6. Let me know when you’re ready to discuss the patient”.

Objective 2: The "initial steps" of a surgical consult

Finding your patients in the ER

Surgical Patients are generally found in the numbered bays in the diagram below, however they can also be in the other rooms shown. Charts are generally found in the following locations:

In the wall-mounted slots behind triage: these are typically patients in the Acute Emergency Room Waiting Area. In surgery, you will not see these patients as they need to be assessed by the ER team before you are consulted.
In the rack above the Nursing Unit Clerk (NUC) station.
In the rack between the two NUC desks: these are charts with pending lab work and imaging orders.
In the slots at each of the nursing stations surrounding the ER core: the slot numbers correspond to bed numbers in the ER. This is where you will most commonly find your patient's chart.

2. Introducing yourself to the patient's nurse

You see the patient's nurse sitting at the staff table near Bay 6 and introduce yourself as the Gen Surg student who will be reviewing the patient. They say "Oh yeah, that guy came in with blood per rectum over the last two weeks. He's been pretty stable while he's been here."

Nursing staff are very important in giving important information about a patient's condition and course in the ER, but it is your job to assess the patient and come up with your own opinion of their condition and diagnosis.

3. Checking the Patient's ER Chart

You quickly scan the patient's ER chart for the Chief Complaint, vitals, and other information.

The ER chart is usually fairly brief, and is useful to scan to see if there is any extra information in the chief complaint or anything unusual in the vitals. You can do this, but must confirm the chief complaint and the patient's stability yourself.

4. Gathering the Chief Complaint

You introduce yourself to the patient, and they confirm their chief complaint with you. They also look stable (AKA they don’t look like they’re rapidly deteriorating/imminently dying). You explain you’ll then be reviewing some of their information on their electronic record and you’ll be back to do an examination.

Chief Complaint:

The patient says “I’ve been noticing some blood in the toilet over the last couple of weeks. It’s been getting worse”. When you ask about abdominal pain and weight loss, they point to their LLQ and say “it’s kind of a dull pain, and it’s been getting worse these last 2 weeks too. I’ve lost some weight over the last couple months as well, like 15 pounds.”

When you check their vitals, you see the following:

-HR: 99 RR: 14 BP: 135/75 SaO2: 98% on RA T: 37.4

The patient looks uncomfortable, but of decent colour and does not appear in acute distress.

You decide they look fairly stable and after a couple of more questions, you learn that the blood in the toilet comes from blood with bowel movements, and not urination. You take this information and go to review their information on Powerchart and form your DDx.

The chief complaint you've gathered is lower GI bleed w/abd pain & weight loss. You can now review the patient's past medical history and create your differential diagnosis, which will guide your consult.

Objective 3: Understand how to find pertinent patient history on electronic medical records.

Gathering Past Medical/Surgical History/Using Powerchart

Find a computer that looks free. They are all around the staff area. Log onto Powerchart (hospital’s EMR) where you can look at previous consults they may have had. From that, you can pull the most recent PmHx list for that patient, and the basic additional info on the most-current status for each medical issue (see Clerkship Guide, IMU section for that information).
- Jot down the patients PmHx and surgeries.
- Medications
  - Check to see if there’s a pharmanet (list of patient’s meds) printed out. If not, put in an order to get a pharmanet while you’re checking the PmHx. Patients often don’t know what meds they’re on, but if you can list them off and confirm they’re taking them (you can do this or if you’re lucky, a nurse already has).
- Quickly review labs (if they are done) to see if anything is abnormal
- Imaging
  - Imaging can tell you a lot for Gen Surg (and especially ortho).
  - If you want, you can interview the patient and try to come up with a differential, then look at imaging to test your Hx/Px skills. Or you can look before seeing the patient.

Either way, look at the imaging before you call/speak to your preceptor. Surgeons expect you to have reviewed imaging for every patient.

Objective 4: Practice creating a differential diagnosis to guide and organize a general surgery consult.

You’ve now reviewed the Past Medical History, and are preparing your Differential/History/physical for your patient

When preparing yourself to collect the history and physical on the patient, it is important to have a differential prepared so that this guides the questions and physical exams that you do. If you don't have a differential in mind, your history and physical, and later your patient presentation will be unorganized.
A useful trick is to have a spare piece of paper with your differential written out on it, with space below each for history, physical, and associated findings. You can use this to keep your questions to the patient organized and make sure you don't forget anything.
Below is an example of a partial differential for Lower GI Bleed w/weight loss and Abd pain, with associated notes.

Practice: Create your own Ddx.

Take 10 minutes to come up with a Differential for the CC, have one history question for each, and something you’d look for on Physical. Don’t really know a differential for this presentation? PERFECT: look one up (UptoDate/Dynamed/DxSaurus app).

Creating A Consult Note

From looking on Powerchart, you see the patient was diagnosed with colon cancer in 2012, and received a right hemicolectomy in that year. He was subsequently lost to follow-up, and has not seen a doctor for any follow up since. He has a PMHs of hypertension and diabetes. With your prepared differential list, you enter the bay and interview the patient. Upon completion, you place your notes into the official patient notes that will go into the patient’s binder.

If you decide to write your notes from the interview directly onto the physicians note sheet, or have a “scrap sheet” that you then copy onto the physician’s notes sheet is your choice. The DDx sheet above will organize you, and will allow you to put more succinct notes into the official Physician Notes sheet in a more specific order. The below image shows what a Surgery Consult note looks like on the Physicians Notes sheets.

Objective 5: Practice delivering a structured presentation to a surgical preceptor.

Tips for Presenting to a Preceptor

You’ve prepared your notes and think you’re ready to present to your attending. So, you call/text them saying “I’ve seen the patient and am ready to present”. They respond “Great, I’ll be there in 20”.

Presenting to a Preceptor is fairly similar throughout the various areas of medicine. What you are doing is telling a story by going through the main sections of the chart and giving pertinent positives and negatives that point towards what you think is going on.

Tips

Before you start your presentation, think about your DDx and commit to what you think is going on. Also, think about what you will say and keep the DDx in mind- this will keep things organized.
When you give the CC, the preceptor is already starting to think of what it could be (they have a differential forming in their mind): what you are doing through your presentation is guiding them to why you think it’s X vs. Y and Z.
For a consult on surgery, you are essentially just going step-by-step through ID/CC→ HPI→ PmHx → Surg hx→ other histories (social/family) → physical →investigations → Plan.
When reporting, report pertinent history findings, then move on to physical and report pertinents. DON’T jump between history and physical.

The below figures will show a "Presentation Script", which will give an example of how to present the above Consult Note to a preceptor.

Patient Presentation

Patient Presentation in Summary

You have a DDx. in mind, and in each major section of your presentation (History, Physical, Investigations), you are describing the pertinent positives and negatives for each of your options on the DDx to rule them as more or less likely.
You’re not going to do these perfectly. You’ll get interrupted by questions from your attending, and you’ll say “I don’t know” to a lot of them, most likely. That’s normal.

You complete your presentation to your attending with the decision to admit the patient for further investigation and treatment.

Objective 8: Practice writing admission orders for general surgery.

Admission Orders Template

You complete your presentation to your attending with the decision to admit the patient for further investigation and treatment. Given the patient’s history of Colon Cancer and presentation, you decide to prepare that patient for an urgent Colonoscopy to be done over the next 1-2 days. He will be admitted, and begin a bowel preparation protocol to prepare for the colonoscopy.

Practice: Writing Admission Orders

Admission orders for this patient are written below. Try writing out some yourself using the above template before referencing the admission orders below.

Admission Orders

Admit To: General Surgery under Dr. X.

Diagnosis: Lower GI bleeding, query Colon Ca.

Diet: DAT, move to NPO 24 hrs before Colonoscopy.

Activity: activity as tolerated (AAT)

Vitals: Routine

Investigations

CBC, E7 daily
Group and Screen
ECG X1
CXR (Chest X-ray to look for lung metastases: Attendings may also chose a lung CT)

Input (Fluids):

NS 125ml/hr IV continuous when patient moved NPO
Monitor Ins/Outs when IV starts
- Stool chart monitoring throughout (To assess amount of blood in BM’s)

Medications:

Bowel Prep Protocol. Begin at (Enter Time).

Ramipril 5mg PO daily
PRNs (pain, N/V, bowels, sleep)
- Tylenol 650 mg PO Q6hrs PRN
- Dilaudid 1-2 mg PO q4Hrs PRN
- Dilaudid 1-2 mg SC q3Hrs PRN
- Dilaudid 0.1-0.2mg IV Q1hrs PRN for breakthrough
- Ondansetron 4-8mg PO/IV Q8hrs PRN

Objective 7: Practice writing a rounding note for surgical patients.

Rounding on Surgery Patients

The patient is admitted with a colonoscopy to be arranged in the coming days. You complete the rest of your call shift, and wake up the next day to round on your patients.

“Rounding” is literally “going around” and checking in on how patients have done over the last day. Any changes in their clinical picture? Any tests returned that we ordered? By the look of them, do they need any additional tests?
Things to look at: vitals, ins/outs (if they’re being recorded), lab measurements, imaging. Ask nurses how the patient is doing (are they eating? Are they able to ambulate? If they’re on oxygen, have they been needing more or less?)
Surgical rounding notes are usually fairly brief, and focus on patient stability (vitals, bleeding risk) and progression of their particular disease (Do they look better? Worse? Do they need antibiotics?).
In general surgery, if is important to always comment on the GI exam: Are their bowels working? Are they passing gas? Any abd pain?

Rounding Note from this Patient

ID: 78 y.o.m., admitted for lower GI bleed, awaiting colonoscopy, query Colon CA.

(S) : Patient feeling similar to yesterday. 2 BM’s last eve, both diarrhea w/hematochezia, approx. 20mls blood each time. Passing flatus. Abd pain unchanged: 6/10, LLQ, constant, not radiating. Mobilizing well, eating & drinking well. Will be moving to NPO at noon for Bowel Prep. No additional fatigue, night sweats, fevers. No CP, SOB, Calf pain/swelling.

(O) Vitals: HR 76, BP 130/82, RR 12, T: 37.4.

O/E: Fatigued, mild pallor. Abdomen soft and nondistended, some LLQ tenderness. Non peritonitic Lung sounds clear, S1&S2 Normal. No redness/swelling at calves. No BM at time of inspection, unable to assess blood in BM.

Labs: CBC: Hgb 92 (from 96 yest). WBC, Plt Normal. E7: Values within reference range. CXR: No signs of masses noted. CT from ER did not show Liver or Colon masses

(A/P)

Assessment: 78 y.o.m., admitted for lower GI bleed, awaiting colonoscopy. Mild anemia but vitals stable throughout night and this AM.

Plan: Patient moving to NPO, IV today at 00:00hrs and to begin bowel prep. Continue to assess vital routine and CBC daily re: stability and anemia.

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