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General Clerkship Tips

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Commonly Used Clerk Abbreviations

POD # = post-op day #
PAD # = post-admission day #
AVSS = all vital signs are stable
SL IV WDW = saline lock IV when drinking well
Incision C/D/I = Incision clean, dry and intact
DNVI = distally neurovascular intact
LUTS = lower urinary tract symptoms (eg., dysuria, increased frequency, urgency)

OR Note

Please include the following information when writting OR notes:
Surgeons and assistants
Pre-op and post-op diagnosis
Intraoperative findings and speciments
Estimated blood loss
Count (complete/incomplete)

Post-op Orders

Similar to the admission orders, post-op orders follow "AD DAVID" format.

Admit to Dr. _ under Ortho
Diagnosis (eg., Left TKA for OA)
In/Outs (eg., intermittent catherization q6h prn, and call MD if U/O less than 120cc/4hrs)
Investigations (eg., post-op AP/Lat Xray of left knee in PACU, CBC, BUN, lytes, Cr on POD 1 and 3)
Drugs (pain control, antiemetics, prophylactic anticoagulation, bowel regimen, antibiotics, incentive spirometry, home meds etc.)
Consult OT, PT, arrange home physio, dressing changes etc.

Common Ward Problems

While rounding on inpatients, clerk should be able to identify some of the common problems seen in the post-operative patients.

Due to disruptions of vascular systems and patient immobility, orthopaedic population is at a higher risk of developing DVTs and less frequently, pulmonary emboli (PE). The use of prophylactic anticoagulation, early mobilization, incentive spirometry and compression stockings are aimed at reducing the number of such complications. Unfortunately, despite our best efforts some patients develop these problems. DVTs usually develop around POD 3-5, however they can present at any time. Patients may complain of unilateral edema, redness, direct calf tenderness and pain on passive dorsiflexion. Doppler ultrasound should be ordered in such cases, and patient management should be reviewed to prevent further complications.

Unfortunately, some patients develop PE and other cardiorespiratory complications. These patients may present with retrosternal discomfort, dyspnea and increased oxygen requirements; or be completely asymptomatic. Due to the use of high-dose analgesia, patients may not perceive chest pain, and may instead complain of nausea. MI tends to develop fairly early post-operatively; and could sometimes be prevented with aggressive fluid resuscitation. PE usually presents with acute onset of dyspenia and high oxygen requirements, and can be diagnosed with Pulmonary CT Angiogram.

Fever is another problem commonly seen on the surgical floor. The 5 "W's" of post-op fever include: Wind (atelectasis, pneumonia), Water (UTI), Wound (anastamotic leak, infection, hematoma), Walking (DVT, PE), and Wonder drugs (drug reactions, anaesthetics).

Fever secondary to medications is fairly rare, and difficult to diagnose. Atelectasis tends to develop within 1 to 2 days following surgery. Pneumonia presents a bit later on POD 3 to 5. Streptococcal or clostridial necrotizing wound infection develops early on POD 1-2. UTI's and non-necrotizing wound infections tend to develop after POD 5. Other wound complications (hematoma, anastamotic leak) occur around POD 3-5.

Sutures or staples can sometimes cause local skin reaction and even infection if left for too long. Sutures on extremities and around the joints are generally taken out on POD 10-14, scalp and trunk around day 7-10, and face around day 4.

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