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Medical patient review

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
    • NB: 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; shake the patient’s hand at the start and end; 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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