Ebook The mont reid surgical handbook (6th edition): Part 1

sixth
EDITION

THE MONT REID
SURGICAL HANDBOOK

The University of Cincinnati Residents
From the Department of Surgery
University of Cincinnati College of Medicine
Cincinnati, Ohio
EDITOR-IN-CHIEF
Wolfgang Stehr, MD


1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

THE MONT REID SURGICAL HANDBOOK, SIXTH EDITION

ISBN: 978-1-4160-4895-4

Copyright © 2008, 2005, 1997, 1994, 1990, 1987 by Saunders, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
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Notice

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary
or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is
the responsibility of the practitioner, relying on their own experience and knowledge of the patient,
to make diagnoses, to determine dosages and the best treatment for each individual patient, and
to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor
the Editor assumes any liability for any injury and/or damage to persons or property arising out of
or related to any use of the material contained in this book.
The Publisher

Library of Congress Cataloging-in-Publication Data
The Mont Reid surgical handbook / the University of Cincinnati residents from the Department of
Surgery, University of Cincinnati College of Medicine ; editor-in-chief, Wolfgang Stehr. -- 6th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4160-4895-4
1. Therapeutics, Surgical--Handbooks, manuals, etc. I. Reid, Mont. II. Stehr, Wolfgang. III. University
of Cincinnati. Dept. of Surgery. IV. Title: Surgical handbook.
[DNLM: 1. Surgical Procedures, Operative--Handbooks. WO 39 M7575 2008]
RD49.M67 2008
617.9--dc22
2008012874
Acquisitions Editor: Jim Merritt
Developmental Editor: Greg Halbreich
Senior Production Manager: David Saltzberg
Design Director: Louis Forgione
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors
Steven R. Allen, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
Alexander J. Bondoc, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
Bryon J. Boulton, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
Eric M. Campion, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
Ondrej Choutka, MD
Resident
Department of Neurosurgery
UC College of Medicine
Cincinnati, Ohio
Callisia N. Clarke, MD
Resident
Department of Surgery

UC College of Medicine
Cincinnati, Ohio
T. Kevin Cook, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
Bradford A. Curt, MD
Resident
Department of Neurosurgery
UC College of Medicine
Cincinnati, Ohio

Benjamin L. Dehner, MD
Resident
Department of Surgery
Division of Urology
UC College of Medicine
Cincinnati, Ohio
Gerald R. Fortuna, Jr., MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
Michael D. Goodman, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
R. Michael Greiwe, MD

Resident
Department of Orthopaedic
Surgery
UC College of Medicine
Cincinnati, Ohio
Julian Guitron, MD
Resident
Department of Surgery
Section of Cardiothoracic
Surgery
UC College of Medicine
Cincinnati, Ohio
Nathan L. Huber, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
Karen Lissette Huezo, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
v


vi

Contributors
Lynn C. Huffman, MD
Resident

Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Renee Nierman Kreeger, MD
Resident
Department of Anesthesia
UC College of Medicine
Cincinnati, Ohio

Thomas L. Husted, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Ryan A. LeVasseur, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Angela M. Ingraham, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Jaime D. Lewis, MD
Resident

Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Sha-Ron Jackson, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Jocelyn M. Logan-Collins, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Mubeen A. Jafri, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Christopher A. Lundquist, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Marcus D. Jarboe, MD
Resident

Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Jefferson M. Lyons, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Andreas Karachristos, MD, PhD
Transplant Fellow
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Rian A. Maercks, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Dong-Sik Kim, MD
Transplant Fellow
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Grace Z. Mak, MD
Resident

Department of Surgery
UC College of Medicine
Cincinnati, Ohio


Contributors
Amy T. Makley, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Shannon P. O’Brien, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Joshua M. V. Mammen, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Brian S. Pan, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Colin A. Martin, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Prakash K. Pandalai, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Rebecca J. McClaine, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Charles Park, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Benjamin C. McIntyre, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Parit A. Patel, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Kelly M. McLean, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Jonathan E. Schoeff, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Stacey A. Milan, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

John D. Scott, MD
MIS Fellow
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Rajalakshmi R. Nair, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Thomas W. Shin, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

vii


viii

Contributors
Wolfgang Stehr, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Konstantin Umanskiy, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Janice A. Taylor, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio

Paul J. Wojciechowski, MD
Resident
Department of Anesthesiology
UC College of Medicine
Cincinnati, Ohio

Ryan M. Thomas, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio
Jonathan R. Thompson, MD
Resident
Department of Surgery
UC College of Medicine
Cincinnati, Ohio


Foreword
To the sixth edition
The Surgical Residency Training Program at the University of Cincinnati
has a long history of transforming medical students into capable, competent,
and compassionate surgical leaders. Paramount to effective surgical leadership is a continuous commitment to the renewal and refinement of the scientific basis of clinical practice. Concrete evidence of our exceptional collective
commitment is The Mont Reid Surgical Handbook. This sixth edition, composed on behalf of our residency and with faculty leadership and supervision,

provides a comprehensive, user-friendly document to facilitate the state-ofthe-art practice of surgery. The commitment and work ethic of these most
exceptional resident authors are evident in the quality of every chapter.
Having assumed the Christian R. Holmes Professor and Chair of the
Department of Surgery at the University of Cincinnati College of Medicine in
November 2007, I consider it a privilege to chair a department with such a
great legacy. The Mont Reid Surgical Handbook, as much as any other
achievement, is tangible evidence of our historical and ongoing commitment
to excellence in the comprehensive missions of clinical service, education,
and scholarship.

Michael J. Edwards, MD, FACS
Christian R. Holmes Professor of Surgery
and Chairman of the Department of Surgery
University of Cincinnati Medical Center
Cincinnati, Ohio
2008

ix


Foreword
To the first edition
Dr. Mont Reid was the second Christian R. Holmes Professor of Surgery
at the University of Cincinnati College of Medicine. Trained at Johns Hopkins, he came to Cincinnati as the associate of Dr. George J. Heuer, the
initial Christian R. Holmes Professor, in 1922, and became responsible for
the teaching in the residency. He assumed the Chair in 1931 and died in
1943, a great tragedy for both the city and the University of Cincinnati College of Medicine. He was beloved by the residents and townspeople. A very
learned, patient man, he was serious about surgery, surgical education, and
surgical research. His papers on wound healing are still classics and can, to
this day, be read with profit.

It was under Mont Reid that the surgical residency first matured. In his
memory, the new surgical suite built in 1948 was named the Mont Reid
Pavillion. Part of the surgical suite is still operational in that building, as are
the residents’ living quarters. The Mont Reid Handbook is written by the
surgical residents at the University of Cincinnati hospitals for residents and
medical students and thus is appropriately named. It represents a compilation
of the approach taken in our residency program, of which we are justifiably
proud. The residency program as well as the Department reflect a basic science physiological approach to the science of surgery. Metabolism, infection,
nutrition, and physiological responses to the above as well as the physiological basis for surgical and pre-surgical interventions form the basis of our
residency program and presumably will form the basis of surgical practice into
the twenty-first century. We hope that you will read it with profit and that you
will use it as a basis for further study in the science of surgery.

Josef E. Fischer, MD
Christian R. Holmes Professor of Surgery
and Chairman of the Department of Surgery
University of Cincinnati Medical Center
Cincinnati, Ohio
1987

xi


Preface
To the first edition
We can only instill principles, put the student in the right path, give him
methods, teach him how to study, and early to discern between essentials
and non-essentials.
Sir William Osler
The surgical residency training program at the University of Cincinnati

Medical Center dates back to 1922 when it was organized by Drs. George
J. Heuer and Mont R. Reid, both students of Dr. William Halsted and graduates of the Johns Hopkins surgical training program. The training program
was thus established in a strong Hopkins mode. When Dr. Heuer left to assume the chair at Cornell University, Mont Reid succeeded him as chairman.
During Reid’s tenure (1931–1943), the training program at what was then
the Cincinnati General Hospital was brought to maturity. Since then, the
training program has continued to grow and has maintained the tradition of
excellence in academic and clinical surgery which was so strongly advocated
by Dr. Reid and his successors.
The principal goal of the surgical residency training program at the
University of Cincinnati today remains the development of exemplary academic and clinical surgeons. There also is a strong tradition of teaching by
the senior residents of their junior colleagues as well as the medical students at the College of Medicine. Thus, the surgical house staff became
very enthused when Year Book Medical Publishers asked us to consider
writing a surgical handbook which would be analogous to the very successful pediatrics handbook, The Harriet Lane Handbook (now in its 11th
edition). We readily accepted the challenge of writing a pocket “pearl book”
which would provide pertinent, practical information to the students and
residents in surgery. The six chief residents for 1985–1986 served as
editors of this handbook and the contributors included the majority of the
surgical house staff in consultation with other specialists who are involved
in the direct care of surgical patients and the education of residents and
medical students.
The information collected in this handbook is by no means exhaustive.
We have attempted simply to provide a guide for the more efficient management of prevalent surgical problems, especially by those with limited experience. Therefore, this is not a substitute for a comprehensive textbook of surgery, but is rather a supplement which concentrates on those things that are
important to medical students and junior residents on the wards, namely the
initial management of common surgical conditions. Much of the information
is influenced by the philosophies advocated by the residents and faculty at
the University of Cincinnati and thus reflects a certain bias. In areas of controversy, however, we have also provided other views and useful references.
xiii


xiv

Perioperative Care

The index has been liberally cross-referenced in order to provide a rapid and
efficient means of locating information.
This handbook would not have been possible without the enthusiastic
support and advice of our chairman, Dr. Josef E. Fischer, whose commitment to excellence in surgical training serves as an inspiration to all of his
residents.
We would also like to acknowledge the invaluable advice provided by
several of the faculty members of the Department of Surgery: Dr. Robert H.
Bower, Dr. James M. Hurst, and Dr. Richard F. Kempczinski. The authors
gratefully acknowledge the helpful input of Dr. Donald G. McQuarrie, Professor of Surgery at the University of Minnesota, for his review of each chapter
in the handbook. Also we would like to thank Mr. Daniel J. Doody, Vice
President, Editorial, Year Book Medical Publishers, for his patience and guidance in the conception and writing of this first edition of The Mont Reid
Handbook.
None of this would have been possible were it not for the word processing expertise and herculean efforts of Mr. Steven E. Wiesner. His assistance
in the typing and editing of the manuscript was invaluable.
Finally, this handbook is the result of the cumulative efforts of the surgical house staff at the University of Cincinnati as well as those residents who
preceded us and taught us many of the principles that are so advocated in
this book. We wish to thank all those who worked so diligently on this
manuscript in order to make the first edition of The Mont Reid Handbook a
reality.

Michael S. Nussbaum, MD
Editor-in-Chief
Cincinnati, Ohio
1987


Special Comment

To the sixth edition
It is hard to believe that it has been 20 years since the first edition of the
Mont Reid Surgical Handbook was published. In 1987, I was beginning my
career as an academic surgeon, starting a clinical practice, performing experiments in the laboratory, studying for the American Board of Surgery
Qualifying and Certifying Examinations, and completing the editing of the
book that my five fellow chief residents and I had initiated in 1985. The
inspiration for that first edition was our chairman at the time, Dr. Josef E.
Fischer, whose dedication to excellence in surgical training was the motivation for our efforts. His successor, Dr. Jeffrey B. Matthews, continued the
tradition through the last edition. Today I am the interim chair of the department, reviewing the most recent product of such efforts and hoping to carry
on the commitment to surgical excellence of my predecessors. We at the
University of Cincinnati remain very proud of this book and the legacy of
surgical tradition that it represents.
Beginning with that first edition and continuing on through this sixth edition, the goal has been to produce an up-to-date handbook that can serve as
a guide for efficient and effective management of common surgical problems.
This remains a book that is written by residents for students and residents,
and thus it continues to provide a fresh and practical approach to the care of
the surgical patient. Dr. Wolfgang Stehr, the current editor-in-chief, and his
fellow residents have provided a novel approach while relying on the traditional formula of delivering a comprehensive cross-section of relevant surgical problems as they are encountered in a surgical residency. The Mont Reid
Surgical Handbook remains a tribute to all of the University of Cincinnati
residents and faculty surgeons who have preceded us and inspired us to do
our best for our patients.

Michael S. Nussbaum, MD, FACS
Professor of Surgery and Interim Chairman
of the Department of Surgery
University of Cincinnati Medical Center
Cincinnati, Ohio
2007

xv

Preface
To the sixth edition
We are proud to present the sixth edition of The Mont Reid Surgical
Handbook. It has been 20 years since the book made its first appearance,
and it continues to be a day-to-day companion to residents and medical
students. During the past 20 years, the book has undergone multiple updates and improvements, and it continues to be a valuable and portable
textbook for medical students and residents.
We are aware that in today’s world of multimedia and the Internet, the
role of a book may be less important, but we are convinced that there is no
better way to foster an understanding of surgical pathologies, treatments and
care for the patient, and understanding of the “big picture” than by reading
a complete chapter in a textbook.
Once again this book is the work and product of the current residents at
the University of Cincinnati Surgery Residency program. We have been given
the opportunity to publish a new version of the Handbook every 3 to 4 years,
which allows us to remain up-to-date and relevant, which for many other
textbooks is impossible. As in years past, we did not attempt to create an
exhaustive textbook of surgery; rather, we published a cross-section of relevant surgical problems as they are encountered in a surgical residency. To
keep the book portable we have limited details on surgical procedures while
expanding the section on bedside procedures.
We restructured the book by surgical subspecialties. The new structure
allows the readers to find their questions answered under the surgical specialty that best fits the patient’s problem. The book is designed to help students and residents understand surgical thinking, decision making, and
surgical pathophysiology, and to allow them to find answers for questions on
rounds, in the OR, and in standardized tests.

Wolfgang Stehr, MD
Editor-in-Chief
Cincinnati, Ohio

2008

xvii


Acknowledgments
We want to thank the following faculty members of the University of Cincinnati
for their time and help in reviewing the chapters for the sixth edition of The
Mont Reid Surgical Handbook.
Syed A. Ahmad, MD
Richard G. Azizkhan, MD, PhD
J. Kevin Bailey, MD
David A. Billmire, MD
Karyn L. Butler, MD
Bradley R. Davis, MD
James F. Donovan, Jr., MD
Richard A. Falcone, Jr., MD, MPH
David R. Fischer, MD
Andrew D. Friedrich, MD
Michelle M. Gearhart, PharmD
Joseph S. Giglia, MD
John A. Howington, MD
Jay A. Johannigman, MD
W. John Kitzmiller, MD
Andrew M. Lowy, MD
Jeffrey B. Matthews, MD
Walter H. Merrill, MD
Mark Molloy, MD
xix

xx

Acknowledgments
Peter C. Muskat, MD
Raj K. Narayan, MD
Lindsey A. Nelson, MD
Michael S. Nussbaum, MD
Timothy A. Pritts, MD, PhD
Amy B. Reed, MD
Michael F. Reed, MD
Steven M. Rudich, MD, PhD
Elizabeth A. Shaughnessy, MD, PhD
Joseph S. Solomkin, MD
Sandra L. Starnes, MD
Jeffrey J. Sussman, MD
Amit D. Tevar, MD
Paul N. Uhlig, MD
John D. Wyrick, MD
Mario Zuccarello, MD
Special thanks go to April Dostie for her hard work and tremendous help
in putting this book together. Steve Wiesner gets special acknowledgment for
proofreading, as does Dr. Benjamin McIntyre for providing a significant number of the illustrations.


Surgical Education and Core
Competencies
Wolfgang Stehr, MD

Surgeons are trained, not born.

I.
A.
1.
2.

SURGICAL EDUCATION
PAST 100 YEARS
Apprenticeship-style training (Halsted)
Key points: learning of medical knowledge and surgical skills through 1
exposure, observation, and volume

B. 21ST CENTURY
1. Challenges:
a. Need to acquire medical knowledge and surgical skills
b. New generation of residents: baby boomers making room for Generation
X and Y
c. Work hour restrictions
d. Liability
2. Opportunities:
a. Increased knowledge about adult education
b. Computer-based simulators (minimally invasive surgery,
endoscopy)
c. Video and Internet as teaching adjuncts
3. New paradigms:
a. Training focused on specialty (plastics, cardiothoracic, vascular, early
specialization, 3yϩ3y programs)
b. Disease-focused training (breast, endocrine, oncology)
c. Trained surgeon educators
d. Continuous personal development
(1) Personal log-keeping of procedures, behaviors, experiences, and

their outcomes
(2) Critical assessment and development of an improvement plan
e. Improvement of quality of life for residents
4. Current recommendations and goals:
a. Medical students:
(1) Structured curriculum on surgical rotations; dedication of department, faculty, and residents to education
(2) Minimization of scutwork and integration in the care team
(3) Development of insight into surgical pathologies and surgical decision making
(4) Participation in surgical procedures, learning of basic surgical
skills (suturing, knot tying, assisting in surgical
procedures)
3


4

Surgical Education
b. Residents:
(1) Structured curriculum to provide knowledge in the principles of surgical diseases and patient care
(2) Optimization of teaching conferences with didactic materials by
trained surgeon educators
(3) Optimal use of training aids and simulators to teach technical surgical skills
(4) Minimization of scutwork and integration of physician extenders
into the care teams (nurse practitioners, physician assistants)
(5) Redesign of call schedules to comply with the 80-hour workweek
requirements
(6) Limiting fatigue to improve safety and promote better lifestyles for
residents and their families
c. These recommendations have been developed and are backed by
several surgical and medical associations including the American

College of Surgeons (ACS), American Board of Surgery (ABS),
Association of American Medical Colleges (AAMC), Accreditation
Council for Graduate Medical Education (ACGME), and Residency
Review Committee (RRC).
II. CORE COMPETENCIES
A. THE OUTCOME PROJECT
1. In 2001, the ACGME (www.acgme.org) implemented a curriculum
and evaluation program covering six core competencies.
2. The goal was to provide evidence that residents are not only exposed
to training, but to show that residents develop “know-how” and eventually can “show how.”
3. The residency program must demonstrate that it has an effective plan
that assesses resident performance throughout the program, and that
it uses assessment results to improve resident performance.
4. Residents must be evaluated, and timely feedback must be provided
to achieve progressive improvements in residents’ competence and
performance.
B. THE SIX CORE COMPETENCIES
1. Patient care:
a. Patient management skills—collection of data, synthesis of data, clinical
judgment
b. Technical skills—manual dexterity, mastery of fundamental technical
skills, conduct of operations, bedside procedures
2. Medical knowledge:
a. Fund of fundamental surgical basic science and clinical knowledge
b. Application of knowledge to solution of clinical problems
3. Practice-based learning:
a. Notes, summaries, and operative reports are complete, concise, and
completed on time.

b. Presentations at morbidity and mortality conference demonstrate
mechanism of complication and ways to prevent complications in
the future.
4. Communication and interpersonal skills:
a. Rapport with patients and families, effective communication with
nurses, colleagues, consultants, and other members of the care team
b. Organized and succinct oral presentations
c. Effective teaching of junior residents and students
5. Professionalism:
a. Demonstration of initiative in caring for patients
b. Acceptance of appropriate level of responsibility
c. Honesty and reliability
d. Empathy and compassion
e. Team player
f. Professional appearance
6. System-based practice:
a. Familiarity with the medical care delivery system in which residents
practice
b. Appropriate and effective use of clinical pathways
c. Cost-effective care without compromising quality
RECOMMENDED REFERENCES
Accreditation Council for Graduate Medical Education—
American Board of Surgery—
American College of Surgeons—
Association for Surgical Education—

5

1

SURGICAL EDUCATION AND CORE COMPETENCIES

Surgical Education and Core Competencies


Medical Record
Christopher A. Lundquist, MD

I.
A.
1.
a.
2.

SURGICAL HISTORY AND PHYSICAL EXAMINATION
MEETING THE PATIENT
Initial contact
KISS mnemonic: Knock. Introduce yourself. Scrub your hands. Sit down
Put patient at ease: Take time to ask the patient a personal, nonmedical question before starting. Minimize all environmental
distractions. Ensure that you and the patient are as comfortable as
possible.
2
3. Listen to your patient. He or she is trying to tell you the diagnosis. As
a general rule: Listen more, talk less, and interrupt infrequently. Ask
the patient what his/her goals of treatment are so you can address
them adequately.
B. HISTORY
1. Chief complaint—in the patient’s own words and in quotations
2. History of present illness
a. Main symptom—helpful mnemonic: OPQRST

Onset: When did it (main symptom) start? Was the onset gradual or
acute? What was the patient doing when it started? Any previous similar episodes?
Position: Where is it located? Is it focal or diffuse? Does it radiate? Has
it migrated?
Quality: What is it like? Is it sharp and stabbing? Dull and cramping?
Has it changed?
Related symptoms: Are there any other symptoms that could be related?
Severity: How bad is it currently? How bad at onset? Has it worsened?
Timing/triggers: What makes it better or worse? Eating? Position? Movement? How long does it last? How frequent? Is it constant or intermittent?
Always conduct a comprehensive review of symptoms. The following
factors require extra attention in general surgery:
b. Fever/chills: Onset and severity help distinguish between inflammatory
and infectious diseases.
c. Emesis: Inspect vomitus when possible. What is its appearance? Is
it bilious, feculent, or bloody? What is the volume? How often does
this occur? Is it projectile? Is it associated with pain? With eating?
With nausea? The relation among onset of abdominal pain, onset
of vomiting, and quality of the emesis may indicate the level of
obstruction.
d. Bowel habits: Any change? Last bowel movement? Flatus? Stool consistency? Appearance? Intermittent constipation and diarrhea suggest colon
cancer or diverticular disease, whereas constipation coupled with pencilthin stools imply anal or rectal malignancies.
9


10

Perioperative Care
e. Bleeding
(1) A history of bleeding is the best predictor of perioperative bleeding.
(2) Abnormal bleeding from any orifice must be evaluated carefully.

Stool blood, whether gross or occult, is due to gastrointestinal (GI)
malignancy until proved otherwise.
f. Hematemesis or hematochezia: Is it clotted? Is it bright or dark red
blood? Has it changed in any way? Its character helps discriminate between pathologic states. Coffee-ground vomitus is indicative of slow
gastric bleeding. Dark, tarry stool is characteristic of upper GI bleeding.
Acute-onset lightheadedness and diaphoresis are indicative of rapid GI
blood loss.
g. Jaundice: The rate of onset and the presence of clay-colored stools and
dark urine help differentiate surgical from medical causative factors.
h. Weight loss: Unintentional weight loss with normal appetite may indicate
a malignant cause, whereas weight loss secondary to pain with eating
suggests ulceration or intestinal ischemia.
i. Trauma: Details must be established precisely.
j. Medications: Inquire into which medications have been tried and their
efficacy. Query the use of over-the-counter drugs and herbals, as well as
opiates, nonsteroidal antiinflammatory drugs, diuretics, corticosteroids,
antiepileptics/sedatives, and cardiac/respiratory drugs. Indicate dose,
route, frequency, and duration of usage. Obtain a written record of current
medications if possible.
3. Medical history: Always obtain prior operative reports, imaging/
laboratory studies, and discharge summaries. A comprehensive
medical history is imperative in assessing patients for potential perioperative complications.
a. Chronic illnesses—diabetes mellitus, hypertension, coronary artery
disease, chronic obstructive pulmonary disease, renal/hepatic/adrenal
disease, hematologic disorders, malignancies, etc.
b. Acute illnesses/hospitalizations—pneumonia, asthma attacks, diabetic
ketoacidosis, biliary or renal colic
c. Injuries/accidents—prior trauma
d. Gynecological history—last menstrual period, history of sexually transmitted diseases, pregnancies
4. Surgical history

a. Type, date, hospital of surgery, and name of surgeon
b. Indications for surgery—emergent vs. elective
c. Prior difficulties with anesthesia; perioperative complications
5. Allergies—specific drug reaction (e.g., rash/hives, stridor,
anaphylaxis)
6. Social history—alcohol, tobacco, illegal drugs (Route? How much?
How long? History of withdrawal?), and sexual history/orientation
7. Family history—any surgical disorders are familial (e.g., colonic
polyposis, multiple endocrine neoplasia syndromes, breast
carcinoma)


Medical Record

11

C. REVIEW OF SYSTEMS
The system review must be formalized and methodical to ensure important
details are not overlooked. Nutritional deficiencies (particularly recent acute
fluid losses, weight loss, anorexia), chest pain, and dyspnea must be noted.
Record pertinent findings.

E. RECAP
Recapitulate to your patient your understanding of his or her problems and/or
findings in the context of the patient’s goals of therapy. Inquire further into
any new findings. Allow the patient to clarify or correct any misconceptions.
Have members of the patient’s health-care team available at this time to
ensure all constituents acknowledge these problems and goals.
F. ANCILLARY STUDIES
1. Laboratory examination. Objectives of the laboratory studies are as

follows:
a. Diagnose surgical disorders.
b. Confirm the suspected diagnosis and rule out alternative diagnoses.
c. Screen for diseases that may require preoperative treatment or may contraindicate elective surgery.
d. Screen for asymptomatic disease that may affect perioperative course
(diabetes mellitus, adrenal insufficiency).
2. Routine laboratory studies
Complete blood cell count ± differential
Electrolyte profile, blood urea nitrogen/creatinine
Coagulation profile (prothrombin time/international normalized ratio/
partial thromboplastin time)
Urinalysis
Electrocardiogram (Ͼ40 years of age or known history of cardiac disease)
Hepatic profile for evaluation of specific diseases, known liver problems,
or if hepatic surgery planned
3. Radiologic evaluation
A chest radiograph is indicated for most patients undergoing major surgery.
Order special radiographs and studies in specific clinical situations. Provide
radiologist with an adequate patient history, physical examination, and a
specific reason for ordering each study.

MEDICAL RECORD

D. PHYSICAL EXAMINATION
1. Ensure patient comfort.
2. Develop a system. Develop a comprehensive yet systematic method of
examination so that no detail is omitted. Ensure all tools are convenient and that lighting is optimal.
3. Assess the patient. Ensure that the patient is warm, pink, urinating, 2
and talking. Look at the patient before the “laying on of hands.”
4. Refer to Chapter 3 for a detailed description of pertinent physical

findings associated with multiple surgical diseases.


12

Perioperative Care
G. ASSESSMENT AND PLAN
Following a thorough history and physical examination, one should be able
to assess the patient’s problems and form a differential diagnosis, construct
a problem list, and develop a diagnostic and therapeutic plan.
1. Problem list: List, from most to least important, the problems identified.
2. Assessment: An assessment includes a concise summary of relevant
data that support the tentative conclusions and diagnosis. Delineate
the thought process, including major decision-making points, deviations from the norm, alternative diagnoses, and complicating factors.
3. Plan: List specific diagnostic and therapeutic plans.
H. EMERGENT HISTORY AND PHYSICAL EXAMINATION
Initial efforts should be directed toward resuscitating the patient. The routine
history and physical examination must often be truncated.
1. History: The mnemonic is AMPLE.
Allergies
Meds
Past medical history
Last meal
Events preceding injury or illness
2. Physical examination: The mnemonic is ABCDE.
Airway
Breathing
Circulation
Disability
Exposure

II. PHYSICIAN ORDERS
Personally communicate all written and computer-entry orders to nursing
staff to minimize ambiguity.
A.

ADMISSION: A HELPFUL MNEMONIC IS ADCA-VAN-DIMLS.
Admit—admittance to ward or intensive care unit, surgery service/team,
attending/resident/intern, contact pager number
Diagnosis—illness/disease
Condition—excellent; good; fair; serious; critical
Allergies—specific symptoms
Vital signs
Frequency and need for neurologic/vascular checks
Parameters to notify physician
• Systolic blood pressure [SBP] Ͻ90, Ͼ180 mm Hg
• Diastolic blood pressure Ͼ110 mm Hg
• Pulse Ͼ110 or Ͻ60 beats/min
• Temperature Ͼ101.5° F
• Urine output Ͻ30 ml/h (Ͻ1 ml/kg/h in children)
• Change in neurologic/vascular status


Medical Record

13

MEDICAL RECORD

• Increasing oxygen requirement
• Respiratory rate Ͻ10 or Ͼ30 breaths/min

Activity or position
Weight-bearing status
Elevation of head or foot of bed
Prevention of decubitus and thromboembolism (e.g., turn side to side
every 2 hours, out of bed/ambulate with assistance three times a day)
Nursing orders
Strict intake and outputs
Blood glucose checks/sliding scale insulin parameters
Tube maintenance—nasogastric, feeding, urinary catheter, chest tube,
2
drains
Wound care—dressing type and frequency
Monitors/arterial line/central venous pressure/intracranial pressure
Respiratory care—vent settings, supplemental oxygen parameters, ventilator settings, pulmonary toilet
Compression boots/sequential compression devices or thromboembolic
disease stockings
Diet—nothing by mouth (NPO), clear liquid, regular, diabetic, special
diets, tube feeds, total parenteral nutrition
IV fluids (e.g., D5 1/2 normal saline ϩ 20 mEq KCl/L at 100 ml/h)
Medications (drug, dose, route, frequency, ϩ/Ϫ as needed, hold
parameters)
Helpful mnemonic—ABCDEFGHI
• Antibiotics
• Bowel regimen—stool softeners/laxatives
• Crying—analgesics
• Deep vein thrombosis prophylaxis—heparin subcutaneously
• Emesis—antiemetics
• Fever—antipyretics
• GI prophylaxis—H2 blockers vs. proton pump inhibitor (PPI)
• Home medications

• Insulin/itching—insulin/antipruritics
Laboratory tests
Special studies (radiographs, consults)
B.
1.
2.
3.
4.
5.
6.
7.
8.

PREOPERATIVE
NPO after midnight (including tube feeds)
Adjust or hold insulin/hypoglycemics for NPO
IV hydration (D5 1/2 normal saline ϩ 20 mEq KCl/L at 100 ml/h)
Perioperative antibiotics/stress dose steroids on call to
operating room
Bowel prep
Labs
Type and screen/cross-match blood and blood products
Special studies


14

Perioperative Care
C. POSTOPERATIVE
1. Pain medications (epidural, patient-controlled analgesic, IV morphine,

IV ketorolac tromethamine [Toradol])
2. Deep venous thrombosis prophylaxis
3. Perioperative antibiotic prophylaxis
4. GI prophylaxis
5. IV fluids/diet
6. Incentive spirometer/pulmonary toilet
7. Bowel regimen
8. Antiemetic, sleep, antipyretic, delirium tremens (DT) prophylaxis (as
needed).
III. NOTES
Date and time all medical record entries. Sign with name, service, and contact information.
A.
1.
2.
3.
4.

PREOPERATIVE NOTES
Preoperative diagnosis
Procedure planned
Surgeon/service
Anesthesia anticipated (general endotracheal, monitored anesthesia
care [MAC], local, etc.)
5. Laboratory data
a. Minor operations—complete blood cell count and urinalysis
b. Major operations
(1) Complete blood cell count, electrolytes, coagulation profile (partial
thromboplastin time, prothrombin time)
(2) Urinalysis
(3) Electrocardiogram if patient is older than 40 or with cardiac risk factors

(4) Chest radiograph if no recent radiograph or as indicated
(5) Pulmonary function testing as indicated
(6) Type and screen or cross-match as indicated (verify cross-match
with blood bank)
(7) Blood gases, hepatic profile, other laboratory studies, or specific radiographs as indicated by patient’s comorbidities
6. Identify specific risk factors related to patient’s cardiac, renal, pulmonary, hepatic, coagulation, and nutritional status.
7. Current medications or allergies
8. Preoperative order checklist
9. Blood/blood products to transfuse before surgery or on call to operating room
10. Antiseptic scrub
11. Prophylactic antibiotics/stress dose steroids on call to operating room
12. Special medications (e.g., steroids, insulin, antihypertensives, anticonvulsives)
13. NPO after midnight


Medical Record

15

14. IV fluids
15. Document that potential risks and benefits of intended operation
have been explained, questions have been adequately answered,
and patient (or guardian) has consented to the procedure. Ensure
that signed consent is on the chart.

C. PROGRESS NOTES
Use Weed’s problem-oriented approach to medical records (see Recommended Reading).
1. Daily notes: Document current, newly identified, and potential problems.
Include postoperative and hospital day number, antibiotic, or hyperalimentation day number.
2. SOAP notes.

Subjective data (events overnight, patient complaints, nurse observations)
Objective data (vital signs, physical examination, laboratory data)
Assessment of condition
Plan (Diagnostic studies, therapeutic changes, patient education/
disposition)
3. Flow sheets: Adjuncts evaluate complex data as a function of time (e.g.,
hyperalimentation data, diabetes control, hemodynamic parameters).
IV. DICTATIONS
Dictate immediately after an operation.
A.
1.
2.
3.
4.
5.
6.
7.

OPERATIVE REPORT
Patient name
Patient medical record/account number
Date of procedure
Dictating physician
Attending surgeon
Assistants
Copies—to attending surgeon, assistants, billing office, referring
physician
8. Preoperative diagnosis
9. Postoperative diagnosis—accuracy imperative for medical record and
billing purposes

10. Procedure performed—dictate in list format

MEDICAL RECORD

B. POSTOPERATIVE NOTES
1. Subjective—patient concerns/complaints, oral intake, activity, nausea/
emesis
2. Mental status—neurologic examination, pain control
3. Vital signs, urine, and drain output
2
4. Physical examination—inspection of surgical dressings and wounds
5. Postoperative laboratory data
6. Assessment of condition and plan


16

Perioperative Care

11. Complications
12. Specimens
13. Indications for surgery
a. Brief history: Document explanation of risks and benefits and acquisition of informed consent
14. Details of operation:
a. Patient position/anesthesia
b. Skin prep and draping
c. Type/location/technique of incision and course of dissection
d. Pathology/operative findings
e. Therapeutic approach/complications/blood transfusions.
f. Intraoperative consultations

g. Closure technique/dressings/drains
h. Sponge/needle/instrument count
i. Presence of attending surgeon (and if scrubbed)
j. Postoperative complications/disposition
k. Note: Provide a concise written note with visual aids immediately after
all procedures to allow time for dictated operative reports to appear in
the formal medical record.
B.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

13.
14.
15.
16.

DISCHARGE SUMMARY/DEATH SUMMARY
Patient name
Patient medical record number/account numbers
Date of admission/date of discharge

Dictating physician
Attending surgeon
Copies—to attending surgeon, dictator, billing office, referring
physician
Discharge diagnoses
Operations/procedures performed
Consultations
Allergies
Discharge medications—current and any new medications
Indication for admission—history of present illness with
pertinent preoperative physical findings, laboratory values,
and studies
Hospital course
Condition on discharge—pertinent postoperative physical examination findings, laboratory values
Discharge instructions—diet and activity restrictions, follow-up
appointments, and studies
Note: Dictated discharge summaries take time to appear in the
patient’s medical record. A simple written document with pertinent discharge information should be submitted with the medical
record.