Medical patient review

Clerking and reviewing patients > Reviewing inpatients

Summarise the patient’s case

Demographics: name, age
Patient background: comorbidities, medical history
Admission details: date of admission, presenting complaint
Diagnosis/diagnoses/differentials so far
Management so far
- Investigations: results of important investigations the patient has had during this admission
- Treatments
Planned management
- Management plan
- Stage reached
- Why they are still in hospital

Note: whenever you see a patient you have not previously reviewed yourself, you should go through everything in detail – don’t just accept other people’s diagnoses/plans. If you have reviewed a patient before and been through the case in detail, a basic diagnosis/problem list every few days will usually suffice.

Investigation results review

Latest bloods and trends, e.g. haemoglobin, inflammatory markers (WCC/CRP), other relevant blood results
Other new investigation results

Patient assessment

Questioning

Current symptoms: determine current symptoms, explore as usual

Changes since last review/coming into hospital

Concerns

Functional assessment: eating/drinking, bowel habit, mobilisation

Nursing charts

Observations: review current condition and trends on observation chart/temperature spikes

If being recorded and relevant
- Stool chart: check when last opened bowels and stool type
- Capillary glucose chart (if diabetic): check the range of glucose levels
- Fluid chart: check input, output and balance
- Food intake chart

Examination

Focussed system examinations as relevant

Plan and medications review

Make plan (including further tests/management)
Review current medications (don’t forget about VTE prophylaxis!)

Tips!

Reviews must be patient-centred (treat the patient, not the disease). Consider:
- Disease
- Comorbidities
- Social factors: home, family, carers (involve nurses and occupational therapists)
- Occupation (e.g. type of work if epileptic)
- Mobilisation status (involve physiotherapists)
- Polypharmacy (involve pharmacist)
- Strength/habitus and diet (involve dietitian)
Consider making a problem list
Ensure you always think about why a patient is still in hospital and think about their case with a view to discharge
It can be difficult to build and maintain good patient relationships when you are busy and have a long list of jobs to do. Some tips
- Introduce yourself properly
- Check what they like to be called and use that name throughout the consultation
- Ensure you check for their concerns/questions at the end

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