How to Present a Surgery Patient

2 minute read

Introduction

Post-op surgery presentations are often an intimidating task for students. This is understandable considering they are quick, poignant, and variable between attendings and even between the days.

The following is a standard order of operations you should follow when giving a presentation about a post op patient. Like almost all inpatient presentations, it will follow the SOAP format. This will also help guide your history and physical exam you do on pre-rounds. No presentation will contain all aspects listed, but they should all follow this rough outline, and roughly in the order they appear on this page.

Subjective

Overnight events

  • What happened
  • What was done about it
  • If nothing happened then = no acute events overnight. (NAEO).
  • This information can be gathered from the chart, nurse or hand off from overnight resident.

Patient’s perspective

  • Pain level and what medications are being used
  • Bowel movement, flatus status and what medications
  • Nausea or vomiting
  • Voiding status on their own?
  • Are they walking? Working with PT?
  • Tolerating diet order without n/v?
  • Procedure specific questions i.e., oral numbness, tingling, cramps (thyroid or parathyroid surgery).
  • (no) chest pain, sob, fever, chills

Family perspective

  • It is a good idea to get these questions ahead of time so you can make conversations with the family and the team go faster.

Nursing concerns

  • The nurse taking care of the patient will often have a good idea of what needs to be addressed on rounds.

Objective

Vital signs

  • Temperature
  • Heart rate
  • Blood pressure. It is a good idea to provide a rough range of blood pressures overnight, especially in ICU patients and those with abnormal readings. If you do this there is no need to use exact numbers i.e. you can say 100s/70s to 160s/100s rather than 101/72 to 159/101.
  • Oxygen saturation and oxygen requirement

INs and outs

  • PO in
  • IV and NG in
  • Urine output (possibly separated by 3 shifts, use cc/kg/hr for pediatric patients)
  • NG output and fluid characteristics
  • Drain output (state last three shifts and total) and characteristics

Labs and imagining from last 24 hrs

  • Do not repeat labs or imaging from previous days
  • Include pertinent negatives, but otherwise it is likely okay to leave out normal values

Exam

  • Procedure specific exam ie MSK and neuro exam on spine surgery patient
  • CV
  • Lungs
  • Abdomen
  • Extremities LE equal in size without redness or swelling

Assessment

  • Quickly restate procedure and post op day
  • 1 sentence on status ie “..with signs of bacteremia” , “complicated by pulmonary embolism”, “recovering nicely”

Plan

  • Only new plan items
  • Plan on most urgent issue ie abx for possible bacteremia.
  • Procedure specific plans
  • Pain plan ie increase PRN meds or transition to PO meds
  • Bowel plan
  • Voiding plan
  • Almost everything else in the plan is not stated in presentation but is written in the plan section in note.

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