Who the patient is:
28-year-old, Rosemary Parker. She had a caesarean section done 8 hours ago. She has delivered twins. Children are with the father. She has some complaints.Other information you have:
Surgery was successful. Post surgical notes is in side the cubicle.What you must do:
Talk to the patient, assess her and discuss management with the patient.
Post surgical notes – She was given diamorhine during surgery.
Dr: Hello Rosemary Parker, I am Dr … one of the junior doctors in the obstetrics department. Can you confirm your age for me please?
Pt: I am 28 years old
Dr: What would you like me to call you?
Pt: Rose Dr: How can I help you Rose?
Pt: Doctor I’m in pain
Dr: It might be really bothersome for you. I’m going to try my best to help you out with it. But before I give you any medication for that I need to ask you few quick questions, is that okay with you?
Pt: Yes
Dr: Meanwhile if the pain gets worse and it’s hard for you to continue with the consultation, please do let me know.
Pt: Yes Dr. Thank you.
Dr: Rose from my notes I can see that you’ve had a surgery earlier today, is that correct?
Pt: Yes Dr.
Dr: Can you please tell me a bit more about the surgery you had and how did it go?
Pt: Dr I had a C-section today, about 8hrs back, I delivered twins.
Dr: Congratulations Rose. I hope the babies are doing fine. Were there any complications that you are aware of with the surgery?
Pt: Not that I know of
Dr: And as you told me, you’re in pain right now, can you tell me a bit more about that?
Pt: Like what Dr ?
DO SOCRATES FOR PAIN *
Dr: You said it started 8 hr back . Where do you feel this pain?
Pt: Around my operation site
Dr: And how would you describe your pain? Pt: It’s a sharp pain doctor
Dr: Can you grade this pain on a scale of 1 to 10, 1 being the least and 10 being the highest for me please?
Pt: It’s about 7-8
Dr: Does it go anywhere else?
Pt: No Dr
Dr: Is there anything that makes it better or worse?
Pt: No Dr
Dr: Is it the first bout of pain you’ve felt since surgery?
Pt: Yes Dr.
Dr: Is your pain increasing or decreasing with time?
Pt: Increasing Dr
Dr: Any other symptoms other than pain?
Pt: No
Dr: Chest pain, Fever, SOB?
Pt: No
USE YOUR JUDGEMENT FOR A POST CS PATIENT under anaesthesia-
Dr: Do you feel sick or have you vomited?
Pt: I do feel sick Dr, but I have not vomited yet.
Dr: Do you feel like you want to pee, but are unable to?
Pt: Yes/No
Dr: Do you think you want to poo, but are unable to?
Pt: Yes/No
WHATEVER DATA YOU GATHER, LIKE NOT PASSED URINE, BRING IT AND MANAGE IT LATER IN CONSULTATION
Dr: Did you have anything to eat till now? Pt: No
Dr: Did you have anything sips of water? Pt: No.
Dr: Do you have any known medical conditions that you’re aware of or take medication for? Pt: No
Dr: Do you have any known allergies? Pt: No
Dr: Do you feel any pain elsewhere? Pt: No
Dr: Before the surgery did they talk about any pain medication with you? Pt: No
Dr: Were you given any pain medication during or right after the surgery? Pt: I don’t know during surgery but nothing was given after the surgery.
Dr: Rose, please give me a minute to take a look at your observations (doctor looks at monitor). Pt: Yes
OBSERVATIONS: SPO2 98% BP 110/70 PR 96bpm T 37.2
Dr: Your vitals seem fine but your heart seems to be beating a little too fast, but I suspect that might be because you are in pain right now.
Dr: Since you had a surgery earlier, I would like to examine your chest, tummy including the operation site and your front passage to ensure that everything is alright there. This will involve some level of exposure, and I will have a chaperone here with me. I’ll try and be as gentle as possible but if you feel any discomfort at any point, please let me know and I’ll stop. May I go ahead?
Pt: Yes doctor
Do Chest and abdominal examination IPPA – normal/tenderness in pre-op site.
Picture kept on the operation site. – wound site looks normal
Vaginal examination - Pad present in the genital area slightly soaked with blood otherwise normal. Check urinary catheter – catheter has normal coloured urine. Urine bag is full.
Dr: I would also like to check if you have IV cannula and if you do not have one then I would like to set an IV cannula so that I can send some basic investigations such as a complete blood profile, LFT, KFT and also later you can receive your medications and get fluids if needed. Is that alright with you?
Dr: Well, Rose I can see the area of your operation seems sore which is normal after a surgery and everything else seems to be fine as well.
Dr: Right now, I would like to check your post op notes to see the surgeon’s instructions. Give me a minute Pt: Okay doctor
Dr: I can see that you were given diamorphine which is a pain killer medicine during the surgery but no pain medication was given after the surgery. I’m very sorry about that you’re going through so much pain. I’ll start you on some painkillers right now.
Pt: I want morphine Dr.
Dr Rose is there any reason Why you need morphine? Pt : I am in pain doctor
Dr: Rose, when treating any pain, we follow pain-ladder i.e we start from simple pain killers and move on to stronger ones if the simple ones don’t work as well as we want them to.
Dr: I’ll start you on Paracetamol ( 1 gram IV) right now. We’ll check up on you after 30min-1hr, and if they don’t seem to be working that good for you, we’ll switch to something stronger.
Pt: But Dr why can’t I just have morphine
Dr: Rose, unfortunately we can’t use morphine right now. Not only are there lot many side-effects with it, it depresses your breathing a serious and common side-effect and also that it can cause constipation. So, let us start with Paracetamol as I suggested and we’ll see how it goes. We will consider giving Morphine if this pain killers don’t work Is that alright with you? Pt: Yes Dr.
[ If patient has not passed urine after the surgery –
Dr: Also you told me that you did not pee yet and I can see that you’re not catheterized. That can also be a cause of your pain. Therefore, I’ll pass a catheter right now for you. Is that alright with you? (IF patient said in History she hasn’t peed then manage it ) pass
Pt : yes okay Dr.]
Dr: I’ll immediately order for you pain medications. Dr: And Rose have you seen your baby yet? Pt: Not yet
Dr: I will talk to the nurses about that so that your baby is brought to you and you can start bonding with your baby. Is that something you would like? (IPS and rapport)
Pt: Yes doctor, very much
Dr: Is there anything I can help you out with? Pt: No Dr. Thank you.
Dr: Meanwhile if you think that the pain is getting worse, you start feeling dizzy or sick, please press the bell and someone will be with you here shortly to help.
Pt: Okay doctor. Dr: Have a good day.