MRCS PART A ESSENTIAL REVISION NOTES BOOK 1 - PasTest

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Assessment of fitness for surgeryObtaining consentThe General Medical Council gives the followingguidelines (GMC 2008).Ask patients whether they have understood theinformation and whether they would like morebefore making a decision. Sometimes asking thepatient to explain back to you, in his or her ownwords, what you have just said clarifies areasthat the patient does not really understand andmay need more explanation.The legal right to consentThe ability to give informed consent for differentpatient ages and groups is discussed fully inChapter 8, Ethics, Clinical Governance and theMedicolegal Aspects of Surgery.CHAPTER 1Obtaining consentProvide sufficient information: Details of diagnosis Prognosis if the condition is left untreated and if the condition is treated Options for further investigations if diagnosis is uncertain Options for treatment or management of the condition The option not to treat The purpose of the proposed investigation or treatment Details of the procedure, including subsidiary treatment such as pain relief How the patient should prepare for the procedure Common and serious side effects Likely benefits and probabilities of success Discussion of any serious or frequently occurring risks Lifestyle changes that may result from the treatment Advice on whether any part of the proposed treatment is experimental How and when the patient’s condition will be monitored and reassessed The name of the doctor who has overall responsibility for the treatment Whether doctors in training or students will be involved A reminder that patients can change their minds about a decision at any time A reminder that patients have a right to seek a second opinion Explain how decisions are made about whether to move from one stage of treatment toanother (eg chemotherapy) Explain that there may be different teams of doctors involved (eg anaesthetists) Seek consent to treat any problems that might arise and need to be dealt with while thepatient is unconscious or otherwise unable to make a decision Ascertain whether there are any procedures to which a patient would object (eg bloodtransfusions)13
Perioperative CareCHAPTER 11.4 Identification anddocumentationPatient identificationPatient identification is essential. All patientsshould be given an identity wristband onadmission to hospital, which should state clearlyand legibly the patient’s name, date of birth,ward and consultant. He or she should also begiven a separate red wristband documentingallergies. Patient identification is checked by thenursing team on admission to theatre.DocumentationMedical documents (medical notes, drug andfluid charts, consent forms and operation notes)are legal documents. All entries to the notesshould be written clearly and legibly. Alwayswrite the date and time and your name andposition at the beginning of each entry.1.5 Patient optimisationfor elective surgeryMorbidity and mortality increase in patientswith comorbidity.Optimising the patient’s condition gives themthe best possible chance of a good surgicaloutcome. Do not forget that this includesnutrition.In patients with severe comorbidity thenNCEPOD recommend the following: Discussion between surgeon andanaesthetist before theatre Adequate preoperative investigation Optimisation of surgery by ensuring: An appropriate grade of surgeon (tominimise operative time and blood loss) Adequate preoperative resuscitation Provision of on-table monitoring Critical-care facilities are availableDocumentation often starts with clerking. Recordas much information as possible in the formatdescribed above for history and examination.The source of information should also be stated(eg from patient, relative, old notes, clinic letter,GP).Accurate documentation should continue foreach episode of patient contact, includinginvestigations, procedures, ward rounds andconversations with the patient about diagnosisor treatment.File documents in the notes yourself; otherwisethey will get lost. This is important to protect boththe patient and yourself. From a medicolegalpoint of view, if it is not documented then itdidn’t happen.Optimisation of patients forelective surgeryControl underlying comorbidity: specialistadvice on the management of underlyingcomorbidities (cardiovascular, respiratory,renal, endocrinological) should be sought.Individual comorbidities are discussed later inthe chapter. Optimisation should be undertakenin a timely fashion as an outpatient for electivesurgery, although some may occasionallyrequire inpatient care and intervention beforescheduling an elective procedure.Nutrition: good nutrition is essential for goodwound healing. Malnourished patients dobadly and a period of preoperative dietaryimprovement (eg build-up drinks, enteralfeeding, total parenteral nutrition or TPN)improves outcome.14
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MRCS PART A ESSENTIAL REVISION NOTES BOOK 1 - PasTest

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