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Table of Contents
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The ability to assess a post-operative surgical patient is an important skill to develop during medical school and your foundation years. It is commonly tested in OSCEs and almost all foundation doctors will have at least one surgical rotation. Furthermore, assessing the post-operative surgical patient is also assessed at postgraduate surgical interviews.
This article will provide you with:
- A structured format for carrying out a thorough review of the surgical patient – with a worked example for use in an OSCE setting.
- A structure for categorising post-operative complications.
OSCE stations vary in their focus:
- A-E assessment of an acutely unwell surgical patient [ABCDE approach]
- A broader assessment of a post-operative surgical patient [SHE BOXED approach]
A-E assessment of an acutely unwell surgical patient
As with all OSCE stations, you should first introduce yourself, confirm the patient’s details and gain consent to proceed. The examiner of the station may then ask you to describe how you would approach an acutely unwell surgical patient.
An example of a response could be:
“I would approach the patient using a structured A-E approach according to Advanced Life Support guidelines, initiating immediate management as required and escalating appropriately.”
The A-E assessment is not in the scope of this article, however, it is an essential skill that all doctors should possess. See our A-E assessment guide for more details.
Once the A-E assessment has been completed and the patient has been stabilised, it is important to think more broadly about a thorough surgical assessment.
In an OSCE, after performing an A-E assessment, it is often sensible to suggest escalating to a senior member of the team.
The examiner will then often state: “Your senior is on the way”
Having been through the A-E assessment, you may have decided the patient needs to return to theatre urgently. You may be asked at this point: “What would you do whilst you wait for your senior?”
A good answer in this situation would be:
- Consent utilising the correct consent form (if you are trained to do so)
- Book the patient onto the emergency theatre list
- Inform the theatre coordinator and on-call anaesthetist
A broader assessment of a post-operative surgical patient [SHE BOXED approach] 2,4
It may be that in an OSCE scenario you complete your A-E assessment and the examiner then asks you “Now what would you do?”. If there is no clear indication to take the patient to theatre for an emergency operation, a further, more detailed assessment is required. In this situation, the SHE BOXED approach can be utilised.
SHE = Summary of History and Examination findings
“I would take a focused history from the patient and ask specifically about…”
A useful structure for quickly covering the salient features of a surgical history is the acronym AMPLE:
- A – allergies
- M – medications
- P – past medical history
- L – last eaten/had something to drink (patients should not have had something to eat in the 6 hours prior to an operation and should not have had water in the 2 hours before an operation)
- E – events leading up to admission/current situation/current positive examination findings (e.g tender at McBurney’s point)
Tip for surgical patients
Review the operation note and anaesthetic chart. Was the operation straightforward? Were there any complications? What were the post-operative instructions? What drugs were used during the operation? How has the patient been in recovery?
You then need to complete a focused examination of the relevant system. For example, if the patient is post-thyroidectomy then it would be worth stating that you would want to carry out a complete neck examination, inspecting for any visible swelling/airway compromise (e.g. in the event of a haematoma).
B = Bedside tests & bloods
- Basic observations
- Laboratory tests (e.g. FBC,U&Es,LFTs,Clotting, Group & Save)
- Blood cultures
- Gases (e.g. arterial blood gas or venous blood gas)
Isolated figures often are difficult to interpret. Therefore the TREND in blood test values and observations is important to pay attention to.
O = Orifices
Are there any results for:
- Sputum culture
- Swab results (e.g. from surgical site/MRSA status/previous operations)
- Urine culture
- Urine output
- Stool output
- Drain output
Work from the head downwards to help remember these! Also, don’t forget the TREND in the drain or catheter output.
X = Xray, imaging and special tests
E = Escalation plan
Is there a documented escalation plan? Would this patient be appropriate to receive HDU or ITU level care?
Who should you escalate to within your team? What other specialities should you escalate to (for example critical care team, medical registrar, anaesthetics etc)?
What organ support may be required from HDU/ITU (e.g. non-invasive ventilation/inotropic support/intubation)?
D = Do not attempt CPR (DNACPR) status
Does the patient have a valid DNACPR form in place? Is this something worthwhile highlighting with seniors to discuss?
You are the on-call doctor and are asked to see a 61-year-old male who is day 3 post laparoscopic cholecystectomy. He has spiked a temperature of 38 degrees celsius and is tachycardic at 120bpm.
How would you approach this situation?
In an OSCE you may initially state…
“I would approach the situation using a structured A-E approach, initiating immediate management to stabilise the patient. If required, I would also escalate appropriately.”
After a provisional A-E assessment, the patient is deemed stable. How would you now approach performing a comprehensive post-operative assessment?
Summary of history and examination findings (SHE)
“I would take a history, focusing on the patient’s allergies, medications, past medical history and when they had last eaten or had something to drink. In addition, I would clarify the recent events of the hospital stay, including admission date, the current diagnosis and any operation that has taken place. With regard to the surgery, I would want to review the operation note for post-operative instructions and evidence of complications. In addition, I would want to read over the most recent ward review. Given that this patient has undergone gastrointestinal surgery, I would focus my examination on their gastrointestinal system.”
“I would review the patient’s recent bedside observations, input/output charts, imaging and laboratory results (including blood tests and microbiology results). I would also ensure the patient had a valid group and save, should they need to return to theatre.”
“If the patient was potentially in need of HDU/ITU input, I would clarify the escalation plan with senior team members and ensure it was discussed with the patient and family as appropriate. I would also check if a DNA CPR form was present and if not, consider if this needed further discussion with senior team members and the patient/family.:
“Based on the findings of my assessment, I would then formulate a differential diagnosis and management plan accordingly.”
Title: General Surgery Review
Doctor name and role: Rakesh Mistry FY2
Asked to see patient regarding temperature (38 °C) and tachycardia (120bpm).
- Able to complete sentences
- No added breath sounds
- RR 23
- SpO2 96% on 15L O2
- Reduced breath sounds at both lung bases
- Portable chest x-ray ordered
- Peripheral capillary refill time approx 3 seconds
- Pulse 120 bpm regular
- BP 97/63 mmHg
- Temperature 38 ºC
- 2 large IV bore cannula inserted – 500mls Hartmann’s bolus administered
- FBC/U&E/CRP/LFT/Clotting/Group and Save
- Heart sounds normal on auscultation
- ECG – sinus tachycardia 120bpm
- AVPU: Alert
- Blood sugar 6
- Pupils equal and reactive
- Abdomen tender around surgical site with associated guarding
- Surgical site looks healthy with no evidence of breakdown
Summary of history and examination
Allergies – NKDA
Past medical history:
- Type 2 diabetes mellitus
Last intake of food/fluid:
- Last ate 7 hours ago
- Last had water 3 hours ago
- Admitted with epigastric discomfort and vomiting, Murphy’s positive
- CT abdomen: likely cholecystitis secondary to gallstones
- Started on IV Abx, analgesia and IV fluids
- Underwent laparoscopic cholecystectomy on emergency list under Mr Wan
- Operation note: Difficult procedure – extended operative time however no complications. No drain in situ.
- Post-operative instructions: Abx for 1/52, analgesia, can eat and drink, home when mobilising
- Day 3 post laparoscopic cholecystectomy for gallstone cholecystitis
- Seen on ward round – some mild abdominal tenderness
- FY1 review (evening): patient vomiting, bloated and becoming tachycardic 110bpm. Patient yet to mobilise.
Bedside (previous results in brackets):
- SpO2 96% 15L O2 (SpO2 86% 2L O2)
- RR 23 (16)
- BP 97/63 mmHg (105/70 mmHg)
- HR 120 sinus tachycardia (95 bpm)
- 06/01: Hb 130, WCC 15, U&Es and clotting awaited from this afternoon
- Blood cultures – taken earlier this afternoon. No previous results.
- Arterial blood gas on 15L O2:
- pH 7.28
- PO2 19.3 kPa
- pCO2 5.9 kPa
- HCO3– 27 mmol
- Lactate 4.0
- No sputum, wound or faeces samples
- Catheter in situ – urine output past 3 hours in ml/kg: 1/0.8/0.4
- No drain in situ
- Portable CXR ordered now – awaited
- CT abdomen 01/01: cholecystitis secondary to gallstones
- Previous endoscopy (2002): gastritis
Discussed on ward round this morning – would be for HDU care and potentially inotropic support if required
DNACPR status: No DNACPR status recorded
- Day 3 post laparoscopic cholecystitis – hypotensive, tachycardic, pyrexial and vomiting (guarding around surgical site).
- Elevated WCC
- Lactic acidosis
Impression: Likely anastomotic leak post laparoscopic cholecystectomy
- Ensure “Sepsis 6” has been completed in light of septic picture
- Assess response to 500mls IV Hartmans
- Inform surgical registrar – will need senior review ?return to theatre
- Inform anaesthetics and theatre co-ordinator if surgical registrar believes likely to return to theatre – may need HDU/ITU bed post-operatively for possible inotropic support
- Get consent form ready for registrar arrival
FY2 General Surgery
Surgical risk factors
When assessing any patient, it is important to have an awareness of possible surgical complications that may affect them. Each patient’s risk of surgical complications differs depending upon the presence or absence of various factors. Below are two different ways of applying a structured approach to considering surgical risk factors.
Risk factors can be broken down into the following categories:
For example: “You are called to see an obese diabetic 50-year-old patient following their open mesh inguinal hernia repair. The patient is 3 days post-op and is complaining of pain around his surgical site in his groin. The nurse reports some swelling at the site and a foul odour.”
- Pre-operative: diabetic and obese patients are more likely to develop surgical site infections and wound breakdown
- Peri-operative: the operation was completed open and with a mesh. An open wound is more likely to breakdown in an obese patient and the mesh is a foreign material which increases the possibility of infection.
- Post-operative: What were the post-operative instructions on the operation note? Did the patient receive antibiotics?
Another simple way of categorising these risk factors is:
- Patient factors (i.e. patient risk factors)
- Operation factors (e.g. surgical technique, post-operative care/instructions)
For example, risk factors for a post-operative infection may be categorised as shown below.
|Patient factors||Operation factors|
In an OSCE, you may be in a situation whereby you need to identify the most likely post-operative complication and manage the patient appropriately.
Complications may be classified by time or underlying cause.
Complications can be classified by time as follows:
- Immediate: <24 hours
- Early: within 30-days (usually within 1 week)
- Late/long term: after 30 days or after discharge
Complications can be classified by the underlying cause (i.e. aetiology) as shown in the table below.
|Reaction to anaesthesia||Adjacent structure damage|
|Haemorrhage||Gastrointestinal: anastomotic leak, visceral injury, strictures|
|Pyrexia||Vascular: ischaemic colitis, endoleaks, graft migration|
|Wound infection/surgical site infection||Plastic surgery: scarring, flap failure|
Both time and aetiology may also be combined to categorise complications as shown in the table below.
Adjacent structure damage
Pyrexia – chest/urine/line
VTE – PE/DVT
Inability to eat
Post-operative pyrexia is a common issue and the differential diagnosis is highly dependent on the timescale.
The trend of the pyrexia is also very important (i.e. new, persistent, swinging).
The 7 C’s of post-operative pyrexia is a helpful way to remember potential sources of post-operative pyrexia:
- CVP Line
- Cut (surgical wound)
Timeline of pyrexia
|1 – 3||
Metabolic response to trauma
Drug reaction – IV fluids/transfusion
Instrumentation of viscus – transient bacteraemia
|4 – 6||
Superficial wound infection
Suppurative wound infection
Deep abscess (swinging pyrexia)
Mr Mustafa Jaffar
St. Mary’s Hospital, Imperial College Healthcare Trust
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- Frost P, Wise M. Early management of acutely ill ward patients. BMJ online 2012; 345: e5677. Available from: [LINK].
- Goldberg A, Stansby G. Surgical Talk, 2nd Edition ed: ICP, 2005