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Take history and examine patient

  • Take a full history (see section on histories )
  • Examine patient (see section on examinations)
    • Look at the observations chart
    • You should do a basic multi-system exam for all new admissions 
      • Respiratory: cyanosis, percussion note, lung sounds, calf swelling/tenderness
      • Cardiovascular: capillary refill, pulse (rate/rhythm), JVP, heart sounds, peripheral oedema
      • Abdominal: tenderness, masses/organomegaly, bowel sounds
      • Nervous system: GCS, limb movements, abbreviated mental test score if elderly/confused
    • Examine the relevant system in more detail and specifically document the presence/absence of signs of differential diagnoses
  • Review any investigations that have already been performed (e.g. bloods, X-rays etc.)
  • Formulate a differential diagnosis/impression/problem list and plan investigations/management based on the above

Document 

  • Date and time
  • Patient age and sex
  • History
    • Presenting complaint
    • History of presenting complaint (e.g. main symptoms as separate major bullet points, with sub-bullet points exploring each symptom, and then relevant system reviews as further major bullet points – include relevant positives and negatives)
      • Symptom A
        • Explore
        • Explore
      • Symptom B
        • Explore
        • Explore
      • Relevant system review A
      • Relevant system review B
    • PMHx (supplement with information from computerised records)
    • DHx (including allergies)
    • FHx (relevant conditions)
    • SHx (must be very thorough in elderly patients – get collateral)
  • Examination
  • Investigation results so far
  • Differential diagnosis/impression/problem list
  • Plan
    • Investigations 
    • Management
    • Other considerations
  • Sign with name, role, bleep

Arrange investigations

  • Perform 
    • Site cannula and take bloods from cannula (consider doing this before taking a history so results are back quicker)
    • Undertake other relevant investigations, e.g. ABG, lumbar puncture, blood cultures 
  • Ask nursing staff
    • Bedside tests, e.g. ECG, urine dip (± MC&S), swabs
  • Order
    • Relevant imaging
    • Any other tests required

Implement management

  • Implement ABCDE management as necessary, e.g. oxygen, fluids
  • Fill in drug chart
    • Disease-specific treatments
    • PRN analgesia ± antiemetics ± antipyretic if required
    • Regular medications
    • DVT prophylaxis (e.g. LMWH/fondaparinux ± anti-embolism stockings)
  • Order/perform any other disease-specific interventions
  • Fill in a VTE assessment
  • Keep patient NBM if surgery may be required

Review 

  • Note down the patient’s details and which investigations need to be chased (use fill-in boxes – half fill when taken/requested, fully fill when result back and checked)
  • Follow-up the results and document them in the notes
  • Change/initiate treatments if needed
  • Present to seniors (when initial investigation results are back) and implement any additional management plans required 

Tips!

General tips

  • You will need to write quickly during the consultation but try to ensure the patient is still the main focus
  • Look through all the computerised records (e.g. GP record, discharges, letters, investigation results) for the patient to supplement the past medical/drug history
  • In some elderly patients, you may need to call the next of kin or nursing/residential home for collateral history (find out what happened and get more information about past/drug/social history and their baseline)
  • Ensure you are leading the consultation – learn how to interrupt patients politely. If the patient is very talkative, use closed, focussed questions.
  • Never forget your communication skills – introduce yourself properly, use the patient’s name, shake their hand, build rapport, start with open questions and find out their ideas, concerns and expectations

Advancing your clinical practice

  • As a medical student, you need to ask about everything and your clerking should be comprehensive. But as your experience grows, your goal is to become more efficient. A senior doctor will ask questions, examine and investigate in a way that stays focussed on the diagnosis and differentials. 
  • History
    • You should ask questions to include/exclude differentials (e.g. rather than going through the whole of SOCRATES for chest pain, listen to the patient’s description and then ask ‘Does the pain radiate to the back?’ if you need to exclude dissection; or ‘Does the pain get worse on exertion?’ if angina is a differential)
    • In addition to an open question about past medical history, you should also ask specifically about relevant comorbidities and risk factors (e.g. in suspected MI, ask about diabetes, hypertension, high cholesterol, smoking)
    • Ask about relevant family history and include travel/sexual histories when relevant
    • Social history is always important for older patients, and checking people’s occupation can provide key information
  • Examination
    • Quickly determine if the patient is well or unwell
      • General: confusion/cognitive change, skin colour, respiratory distress/oxygen requirements 
      • Circulation: peripheral pulse rate/volume, capillary refill, peripheral temperature 
    • A simple baseline multi-system clinical examination should still be done for everyone on admission but you should focus on specific signs related to the history – i.e. signs of the diagnosis/differential, the cause and complications of the condition – you should think about exactly what you are looking for and why
    • Note the presence or absence of relevant signs
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