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TACKLING SURGICAL TAKE SHIFTS TESS STEWART ANDObjectives ◦ To understand the structure of take shifts ◦ To review the basic principles of effective clerking and documentation ◦ To learn a systematic approach to diagnosing and managing common acute surgical presentations ◦ To practise applying this learning to tackling common clinical scenariosSTRUCTURE OF TAKE SHIFTSOVERVIEW OF SHIFT F1 shifts include: 1) Day, 2) On-call, 3) Night, 4) Take/Post-take 0800 Day Team 1700 On-call Team 0000 Night Team 0800 Take shifts are for completing the initial assessment and management of new patients Clerk new patients and Collect bleep complete tasks Return bleep Receive handover Handover to On- from Day Team call TeamPRINCIPLES OF CLERKING AND DOCUMENTATION CLERKING 1. History ◦ PC ◦ HPC Bedside Laboratory Imaging ◦ PMH • Capillary blood • Bloods • USS ◦ DHx glucose • Blood cultures • XR ◦ SHx • Ketones • Urine cultures • CT • Urinalysis • Swab cultures • MRI ◦ ROS 2. Examination • Urinary hCG • Stool samples • ECG 3. Investigations • VBG or ABG 4. Impression 5. PlanDOCUMENTATIONCOMMON SURGICAL PRESENTATIONSTYPES ABDOMINAL PAIN Three main types of abdo pain: ◦ VISCERAL ◦ PARIETAL ◦ REFERRED Visceral pain occurs when nerves running through the walls of the organ get stretched ◦ Poorly localised pain: dull ache ◦ Hollow organs cause intermittent pain: colicky ◦ Solid organs more likely to cause constant pain Pariental pain (peritoneal irritation) is sharp and can be localised to a specific point Referred pain: brain mistakenly thinks pain is coming from one area, when actually coming from a different organ ◦ Shoulder tip pain can be referred pain from diaphragm (this can indicate free fluid/blood in abdomen or pelvis, irritating the underside of the diaphragm) ABDOMINAL PAIN: GI TRACT ◦ GI tract dysfunction will initially present in one of three areas (VISCERAL PAIN) ◦ When/if the segment of GI tract causes local inflammation of the peritoneum at the site, then you get localised pain (PARIETAL PAIN) ◦ If pain is sudden onset in a specific localised area e.g. LIF, then it is less likely =Foregut to be associated with the GI tract, and =Midgut more likely to be urinary tract or gynae =HindgutSCENARIO 1 32 year old male patient, admitted with right sided abdominal pain. History: ◦ HPC – Initially started around the umbilicus, now focused in the right iliac fossa. Feeling nauseous but no vomiting. Feels feverish and sweaty. One episode of loose bowels. . ◦ PMH – Normally fit and well. ◦ DHx – Nil. ◦ SHx – Lives with partner. Drinks 10-14 units per week, never smoked. Examination: ◦ NEWS 1: RR 12, SpO2 98% on air, BP 114/82, HR 98, Alert, Temp 38.1 ◦ Looks slightly flushed. Mobilised with pain into examination room. ◦ WWP. Pulse reg, good volume. HS I+II+0, ◦ Chest clear. Good AE throughout. ◦ Abdo tender ++ RIF, rebound tenderness. Rovsing’s positive. ◦ Calves SNT. No oedema/erythema. Investigations: ◦ Bloods – WCC 13.4, Hb 156, CRP 78, U&Es NAD, eGFR >90.APPENDICITIS Investigations ◦ Bedside: VBG, Urine Dip, ECG. ◦ Bloods: FBC, CRP, U&Es ◦ Imaging: USS/CTAPMANAGEMENT OF APPENDICITIS Appendicectomy Fluids, Antibiotics No follow up and Analgesia requiredSCENARIO 2 43 year old female patient, admitted with right upper quadrant pain. History: ◦ HPC – Pain started after her Full English breakfast. Described as colicky and radiating around to her back. She’s had similar episodes of pain before that normally resolve after a few hours. ◦ PMH – Hypertension, T2DM ◦ DHx – Metformin 1g BD, Ramipril 10mg OD. ◦ FHx – Mother and sister suffer from gallstones. ◦ SHx – Morbidly obese, lives with husband. Occasional smoker. No alcohol. Examination: ◦ NEWS 0: RR 18, SpO2 98% on air, BP 154/102, HR 102, Alert, Temp 37.7 ◦ Uncomfortable at rest. ◦ WWP. Pulse regular. HS I+II+0.. ◦ Chest clear. Good AE throughout. ◦ Large body habitus. Abdo soft, tender +++ RUQ. Murphy’s positive. BS present. ◦ Calves SNT. No oedema/erythema. Investigations: ◦ Bloods – WCC 10.5, Hb 134, CRP 102, Bili 54, ALT 103, ALP 201, eGFR >90.CHOLECYSTITIS Investigations ◦ Bedside: VBG, Urine Dip, ECG. ◦ Bloods: FBC, CRP, LFTs, U&Es, Amylase ◦ Imaging: USS/CTAP/MRCPMANAGEMENT OF CHOLECYSTITIS IV Fluids, Analgesia ERCP Cholecystectomy AntibioticsSCENARIO 3 71 year old man who was admitted to ED with severe abdominal pain. History: ◦ Improves when he leans forwards, worse on inspiration. Feeling nauseous, reduced appetite.ours ago. ◦ PMH – Asthma, Hypertension. Previous Appendectomy 25 years ago. ◦ DHx – Salbutamol, Ramipril 10mg OD, Aspirin 75mg OD. Allergic to penicillin. ◦ SHx – Lives with wife. Normally relatively fit and active. Drinks 20 units per week. Smokes 5 day. Examination: ◦ NEWS 4: RR 24, SpO2 96% on 2L, BP 92/58, HR 125, Alert, Temp 37.8. ◦ Appears clinically unwell. ◦ Dry mucous membranes. CRT 3 secs. Pulse reg. HS normal. ◦ Good air entry bilaterally. ◦ Abdo soft, tender epigastrically and RUQ. Voluntary guarding. Investigations: ◦ ECG – Sinus tachycardia ◦ Bloods – WCC 12.4, CRP 102, Amylase 1504, Bili 21, ALT 43, ALP 102, eGFR 64.PANCREATITIS ◦ Gallstones I GET SMASHED ◦ Alcohol ◦ Drugs (steroids) S Steroids ◦ Trauma I Idiopathic ◦ Post ERCP M Mumps/Malignancy A Autoimmune ◦ Autoimmune G Gallstones ◦ Sphincter of Oddi dysfunction E Ethanol S Scorpion Bite ◦ Malignancy H Hypercalcaemia T Trauma E ERCP D DrugsMANAGEMENT OF PANCREATITIS IV Fluids Analgesia Consider AntibioticsSCENARIO 4 65 year old female admitted with cramping abdominal pain, nausea and vomiting. History: ◦ HPC – Six hours ago: sudden onset, cramping abdominal pain., Generalised pain, but worse around her middle abdomen. Multiple episodes of bilious vomiting, No stool passed for 48 hours, no wind since yesterday morning. ◦ PMH – Hypertension, Ulcerative Colitis. Previous cholecystectomy, left hemicolectomy. ◦ DHx – Bisoprolol 2.5mg OD, Amlodipine 5mg OD. NKDA. ◦ SHx – Lives in student halls. Non-smoker. Minimal alcohol. Examination: ◦ NEWS 2: RR 22, HR 98, Afebrile, Sats 99% on air. ◦ Looks uncomfortable at rest. ◦ Moist mucous membranes, CRT 2-3s.. Pulse reg, good volume.. HS normal. ◦ Good air entry bilaterally. No obvious added sounds. ◦ Abdo distended. Tender generally. Reduced bowel sounds. ◦ PR done with consent. Chaperone present. Empty rectum. No stool. No masses. No blood. Investigations: ◦ Bloods – WCC 13.0, CRP 56, eGFR 36BOWEL OBSTRUCTION Investigations ◦ Bedside: VBG, Urine Dip, ECG. ◦ Bloods: FBC, CRP, LFTs, U&Es, Amylase, Group and Save ◦ Imaging: CTAP Causes ◦ Adhesions ◦ Incarcerated hernias ◦ Volvulus ◦ Crohn’s Disease ◦ MalignanciesMANAGEMENT OF BOWEL OBSTRUCTION IV Fluids, NG Tube Laparotomy if Antibiotics Conservative Measures FailSCENARIO 5 61 year old male, admitted with left sided colicky abdominal pain, requiring IV morphine in ED. History: ◦ waves over the top. Feels nauseous when pain comes on.s ago. Unable to get comfy. Constant but exacerbations in ◦ PMH – Gout, Hypertension, Diverticulitis, IHD ◦ DHx – Allopurinol 100mg OD, Atorvastatin 40mg OD, Aspirin 75mg OD. NKDA. ◦ SHx – Lives with wife. Manages to mobilise independently. Drinks 6 units a week, smokes 10 cigarettes a day. Examination: ◦ NEWS 2: RR 24, HR 112, BP 180/102. ◦ Writhing around in pain ◦ Moist mucous membranes. HS I + II + 0. ◦ Chest clear. Good air entry bilaterally. ◦ Abdo soft. Tender Left flank, tender left renal angle. ◦ Calves SNT. No oedema/erythema. Investigations: ◦ Bloods – WCC 14.1, CRP 17, Na 137, K 4.5, eGFR 65 ◦ Urinalysis:: Bld 2+, Nit negURETERIC COLIC Investigations ◦ Bedside: Urine dip, VBG ◦ Bloods: CRP, U+Es, LFTs, FBC ◦ Imaging: USS vs CTKUB (gold standard) vs CTAP An infected Management ◦ Analgesia (PR Diclofenac 100mg 18 hourly) obstructed kidney ◦ Encourage fluid intake. = UROLOGICAL ◦ <5mm: likely to pass on its own ◦ <10mm: consider Tamsulosin EMERGENCY ◦ Offer lithotripsy (ESWL) if no signs of infection and stone visible with Xray/SCOUT ◦ If signs of infection/febrile, may require urgent ureteric stent & IV Abx ◦ >10mm: ureteroscopy ◦ Consider PCNL for impacted renal stonesSummaryKey Learning Points ◦ ALWAYS stick to your system! ◦ Make sure to thoroughly explore SOCRATES of pain to distinguish GI (hollow vs solid) vs urological vs gynae ◦ Use all your information to formulate your diagnosis and management plan ◦ Remember there can be more than one diagnosis! ◦ Take the time to document clearly and logically, use a diagram to convey examination findings ◦ Use your final year to practise clerking as many patients as possible! ◦ Download the Smart Dr or Pocket Dr apps ◦ Make sure you can arrange basic investigations and prescribe common medications (once you know renal function) ◦ Always take time to eat and rehydrate ◦ If in doubt, talk to your seniors!Questionshttps:/forms.gle/KGeaohpjAx8nGVx89