A Comprehensive Guide to Surgical Clerking

This guide is designed to help you identify the key areas you need to focus on when clerking a surgical patient. There are several differences when compared to clerking a medical patient, namely getting a more extensive surgical past medical history, examination and assessing frailty. Your clerking needs to be succint, pertinent and clear.

Presenting Complaint

This needs to be clear and brief– a headline to tell any reader why that patient has presented:

Good example: “1/7 colicky RUQ following meal out”

Bad example: “Patient went out for meal with family yesterday to celerbate passing their driving test on the 9th attempt. They ate a large portion of chips and a pulled pork burger. They had a warm chocolate fudge brownie with vanilla ice cream for dessert. About an hour after this, they started experiencing pain, on and off, under their ribs on the right side and felt like vomiting. They decided to come to A&E after speaking with someone via 111.”

Yes, I have seen clerking look like this and I can confirm, it does not go down well. Unless you’re documenting something hilarious, please keep it brief and to the point.

History of Presenting Complaint

  1. In this section use SOCRATES to document the pain. Absolutely feel free to write it out as a list, the reader will be able to see you did a thorough job.
  2. Include positive and negative findings (yes or no to nausea, vomiting, dizziness, bleeding, diarrhoea, weight loss, change in bowel or urinary habits, anorexia etc)
  3. If this patient has had previous episodes like this

Past Medical (Surgical) History

This section is best presented in bullet points. Have two columns (one medical and one surgical) so the reader can clearly see what and when previous surgical procedures were. Patients often forget if they have diabetes or hypertension so make sure you ask them specficially about common co-morbidities.

Specifically ask about ischeamic heart disease and clarify with the patient how it is managed. For example, if the patient has a stent then the type will guide the surgical team on the risks of stopping antiplatelets and may warrant discussion with Cardiology.

Always ask about last menstrual period and likelihood of pregnancy in those with a uterus.

Drugs/Allergies

When documenting drugs– try to get the dose and frequency (this can be found on Summary Care Records from the GP if you have access). Ensure you document any anticoagulation the patient is taking.
With allergies, document the effect it has on the patient and whether it is an allergy or an intolerance. Unlike a true pencillin allergy, patients can sometimes say they are allergic because it made them vomit when they were 5 years old. This is not a true allergy and they could either be tolerant to the drug now or we can provide antiemetic cover, for example. Some patients might be allergic to certain types of plasters and dressings- this is important to document here.

Social History

In social history you want to know the following things and why:

  1. Smoking– duration, amount, when they quit- because smoking impairs wound healing and can lead to less favourable outcomes surgically, anaethetists will also need to know as they may have COPD as a result
  2. Alcohol– amount- the patient may need to be assessed using the CIWA score for alcohol withdrawal. Your trust will have guidelines on the treatment regimen using chlordiazepoxide/lorazepam and pabrinex.
  3. Home situation– cohabitants, house with stairs or bathroom downstairs, how patient mobilises, how much they can independently carry out activities of daily living- these will help you assess this patient’s Clinical Frailty Score. This will help identify patients who will need tailored treatment escalation plans, DNACPRs, palliation and/or care in the community.

Family History

Family histories that are pertinent to surgical clerking include:

  1. Cancer- document relation and age they were diagnosed/died
  2. Appendicectomies (general surgery) and tonsillectomies (ENT) tend to run in families and may indicate a family history- worth documenting
  3. Strokes and history of VTE events
  4. Gynae histories: early menopause, fibroids, recurrent miscarriages, endometriosis
  5. IBD: Crohn’s and UC are likely to run in families
  6. Cardiac: IHD, MI, Valve diseases and replacements

Examinations

Your examination is extremely important and documenting what you did and didn’t do are both necessary. The examination will depend on what the presentation is and following your OSCE clinical examinations will help maintain a clear structure.

Keep your examination relevant to the presentation and ensure you examine lymph nodes!

Examples of examination findings you might find helpful to keep in mind (list not exhaustive):

  1. GCS 15/15- alert, orientated, looks comfortable, warm and well perfused, in obvious pain, looks pale and clammy etc.
  2. Hands and fingers: CRT, rheumatoid nodules, nicotine staining, clubbing, pulses (radio-radial dely/collapsing pulse)
  3. Eyes: pallor in conjunctiva, jaundice in sclera, photophobia, xanthelasma, ptosis, proptosis
  4. Face: symmetrical, dropping, rash, nerve palsies, flushed cheeks, rhinorrhoea, epistaxis, drooling
  5. Ears: abnormalities of the outer ear, otorrhoea, bleeding, visualisation of the tympanic membrane, Weber’s and Rinne’s tests
  6. Neck: tracheal tug, central trachea, thyroidectomy scar, lymph nodes, stiffness, pain
  7. Mouth and throat: dentician, hydration, cyanosis, appearance of tongue, tongue deviation, uvular deviation, tonsillar enlargement, peritonsillar mass, exutate, inflammation, stones
  8. Chest: symmetrical expansion, shallow/deep breathing (intercostal recession in babies and young children), rash, breath sounds, heart sounds, wheeze/stridor/crepitations/crackles, pain ± palpation, examination of breasts if relevant (inc. appearance, lumps and nipple discharge), excessive carinatum/excavatum
  9. Abdomen and pelvis: pain (use the 9 regions of the abdoment to document location) and nature of pain (whether on deep or superficial palpation), rashes, guarding, peritonism, distention, resonance, ascites, shifting dullness, masses, bowel sounds, hernial orifices, inguinal lymph nodes, hernias, abdominal aorta
    • Rovsing’s sign: palpation of the LIF will elicit RIF pain in a patient with appendicitis. The theory is that palpating the LIF will cause gas within the left colon to move back towards the right colon; this will distend the caecum and stretch the appendiceal orifice causing pain.
    • Psoas sign – the patient lies on their left side, whilst the right thigh is passively extended. RIF pain on this test indicates a possible retrocaecal appendix.
  10. MSK: always examine the joints above and below the target joint. Looks, feel, moves- comment on appearance, swelling, redness, warmth, obvious wounds overlying, deformities, pain on palaption, pain on movement (active and passive). Most joints have associated special tests- remind yourself of these, for example an examination for cauda equina will require a PR exam (usually expected by the radiologist before approving an MRI).
  11. Legs and feet: pallor, asymmetry in appearance, ulcers, signs of vascular insufficiency, ABPI, swelling (ankles, feet), calves (soft/firm/tender), toenails (long/unkempt may suggest self or carer neglect of elderly patient), pulses (very important), sensation and power
  12. PR exam: DOCUMENT YOUR CHAPERONE, blood, mucous, stool on glove, painful, difficult, haemrrhoids, firm stool in rectum, masses, peri-anal discharge, fissures, fistulae
  13. PV exam: DOCUMENT YOUR CHAPERONE, painful, difficult, masses, location and nature of pain, visualisation of cervix (appearance, os), fistulae, odour, discharge, bleeding

Investigations

Document positive findings from bloods and urine (and also document if everything is normal)

Key investigations that will be expected:

  1. Vitals and ECG- epigastric pain can also be a presentation of MI. An ECG will also help with anaesthetic planning
  2. Bloods: CRP, U&E, FBC, LFTs, INR (if on warfarin), VBG (for lactate, pH and glucose), amylase
    • Group and save: not all surgical procedures need group and saves- these are expensive and in many cases, unnecessary- check first!
  3. Urine: urinanalysis ± MC&S, pregnancy test in all with a uterus and of child-bearing age
  4. Wounds: swabs MC&S
  5. Erect chest x-ray: especially important in patients who have presented with falls and the elderly
  6. Specialty specific: ABPI- vascular, compartment pressure- orthopaedics, ocular pressure- ophthalmology

Imaging

It is best to clarify what kind of imaging to request with a senior. For example, an x-ray of the affected area will be usually expected in Orthopaedics and CTs are not routinely requested unless there is doubt. For General Surgery, CTs may be the imaging of choice, however, there will be considerations regarding radiation exposure and pregnancy in biological females of child-bearing age.

Document main findings from any imaging including if normal

Differential Diagnoses

You can use the surgical sieve approach to identify appropriate differential diagnoses. Ensure you management plan includes how you plan to rule out any immediate concerns and what the outcome is likely to be if normal.

Management Plan

Your management plan should include instructions from seniors on what they want next, however, there are definitely a few things you can get started on:

  1. Analgesia
    • Paracetamol unless allergic (500mg-1g QDS IV or PO)
    • Codeine unless allergic (30-60mg QDS PO)
    • PO morphine (PRN 2.5-5mg 2hourly or 5-10mg 4hourly (be kind))
  2. Fluids (IV or oral)- careful if the patient is elderly/has heart failure
  3. NBM until senior review
  4. Antibiotics if spiking temps (after bloods and blood cultures)
  5. VTE prophylaxis: ensure your trust’s preferred VTE prophylaxis protocol is followed- stockings at the very least unless contraindicated. Depending on specialty, there will be different anticoagulation requirements. Usually prophylactic dalteparin/fragmin is preferred for patients not usually on any anticoagulation, who are going to be minimally mobilising whilst they are an in-patient. Clarify with a senior whether chemoprophylaxis or the patient’s usual antiocoagulation needs to be held or continued.
  6. Laxatives: cannot be understated. In the elderly, constipation can cause delirium. Preferences vary between specialties, General Surgery prefer more loose stools and go a little heavier on the laxatives. Orthopaedic patients may be reluctant to mobilise excessively so enough to prevent constipation but not enough to cause increased frequency is preferred. The minimum would be 1-2 sachets macrogol per day if the patient is on opiates, titrate up based on response. Remember, you have Senna, lactulose, docusate, suppositories and enemas in your arsenal as well (pun very much intended).
  7. Patient’s usual medications on their drug chart: they may not be admitted in the end but it will certainly save lots of time and confusion later if they are
  8. Your department will have a preferred way of working, it may differ between registrars/consultants- rather than go nuts and stick in an NG tube, catheter and list them for theatre- check with your senior first if this is something they’d like you to do. Certainly it can feel like you need to pre-empt every need but it would be best for the patient to ensure that they are only getting the necessary interventions.

You should also document what the likely action is if investigations/imaging come back negative. For example: “If ultrasound negative then reassure and discharge”, “If CRP normal then safety net and advise to see GP if symptoms recur”

Treatment Escalation Plan/ DNACPR

Clearly document if the patient has an existing DNACPR in place- they may come to hospital with a copy. Ensure that there is a Treatement Escalation Plan and/or a DNACPR in place if required. These should be kept at the front of the patient’s notes (if in paper form).

References

  1. Breakdown of how to use SOCRATES to assess pain
  2. How to use the CIWA score for alcohol withdrawal
  3. Calculating the patient’s Clinical Frailty Score
  4. Approaching differential diagnoses using the surgical sieve

Author: Dr Cyra Asher (FY2 & Surgical Lead for Mind the Bleep)

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