Date
Time:
MS3 Progress Note (surgery)
S:
Interval history?
Pain?
Bowel movement?
Nausea/vomiting?
Flatus?
Appetite?
NOW THINK: what is happening with my patient? Anything special I need to think about? Anything I don’t understand
about what is happening with them?
O: VS: Tm
I/O:
Tc
P
R
BP
Drains?
Sat
on
Gen: Sick vs well appearing?
Lungs:
C/V:
Abd: Distention? BS? Soft? Tenderness? Guarding? Rebound?
Wound: where? Clean? Dry? Intact? Erythema? Drainage?
Extremities: Tenderness? Swelling? Warm?
Antibiotics?
Pain meds?
DVT prophylaxis?
Diet:
Labs:
Cultures
Imaging
A/P
Day
of
GI prophylaxis?
Fluids
Rate?
Etiologies of Postop Fever
The 5 W’s
Wind (atelectasis, pneumonia)
Water: UTI
Wound: infection
Walking: DVT/PE
Wonder drugs: drug fever
Causes of Panceatitis
I GET SMASHED
Idiopathic
Fistulas: conditions preventing closure
HIS FRIEND:
High output (>500mL/day)
Intestinal destruction
Short segment (<2.5cm)
Scorpion bites
Mumps (viruses)
Infection
Autoimmune
Steroids
Hyperliidemia
ERCP
Drugs
Foreign body
Radiation
Infection
Epithelialization
Neoplasm
Distal obstruction
Gallstones
Ethanol
Trauma
Causes of GI bleeding
ABCDEFGHI
Angiodysplasia
Bowel cancer
Colitis
Diverticulosis/ Duodenal ulcer
Epistaxis/ Esophageal (cancer, esophagitis, varices)
Fistula (anal, aortoenteric)
Gastric (cancer, ulcer, gastritis)
Hemorrhoids
Infectious diarrhea/ IBD/ Ischemic bowel
Causes of a unilateral swollen leg
TV BAIL:
Trauma
Venous (varicose veins, DVT, venous insufficiency)
Baker's cyst
Allergy
Inflammation (cellulitis)
Lymphedema
Treatment of acute pancreatitis
MACHINES:
Monitor vital signs
Analgesia/ Antibiotics
Calcium gluconate (if deemed necessary)
H2 receptor antagonist
IV access/ IV fluids
NPO
Empty gastric contents (NG tube)
Surgery if required/ Senior review