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Start Your NHS Journey Workshop: Medical History, Physical Examination and Clerking Patients Date: 31st August and 1st September 2024 Clerking Patients ● As the FY1 on-call, you might have to ‘clerk’ patients (Initial review of patient in ED with history, examination, initial investigations and management plan) → Usually then presenting this to a senior/ consultant on ‘post take’. Top Tips ● Don’t be afraid to ask for help - you will always have support! ● Be organised ● Keep a handover with patient details ● Prioritise - you don’t need to do everything! ● Keep calm and make sure you take breaks, look after yourself in order to look after others! Clerking Patients - where do I begin? ● You are the FY1 on call, asked to see a new patient in ED: ○ Have a read of the handover note from ED to Top Tips medicine/speciality ● Be slow and thorough rather than rush and make mistakes. ○ Have a look at the initial ED notes/ambulance ● Make sure you check where your sheet (ED will usually have done the initial patient is. history/examination and investigations to ● The more you clerk the easier it will guide you) get! ● Don’t focus on the obvious ○ You might have access to the patient’s GP diagnosis, try to come up with records (SCR) and could have a look through differentials. their past medical history. ● You don’t need a diagnosis to treat! ○ Also have a look at previous hospital - gather as much info as you can, admissions/investigations to help guide you do the simple things based on ● Grab yourself a clerking booklet…. findings! ● Again escalate if you are unsure!The history taking:History taking and worked examples: Structured Patient Consultation Framework Step Key Points 1. Introduction & Consent - Introduce yourself - Confirm patient identity - Obtain consent - For phone calls, confirm identity and preferred form of address 2. Presenting Complaint (PC) - Ask the patient about their main issue (e.g., "What seems to be the problem?") 3. History of Presenting Complaint - Use SOCRATES for pain: (HPC) - Site: Where is the pain? - Onset: When did it start? - Character: What does it feel like? - Radiation: Does it move anywhere? - Associations: Any other symptoms? - Time course: Duration and pattern? - Exacerbating/relieving factors: What makes it better or worse? - Severity: Pain scale (1-10)? 4. Past Medical History (PMH) - Discuss any other medical conditions 5. Drug History (DH) - List current medications and dosages - Check for allergies 6. Family History (FH) - Ask about familial conditions (e.g., diabetes, heart disease) 7. Social History (SH) - Explore lifestyle factors (smoking, alcohol, drugs) - Discuss living situation and caregiving responsibilities 8. Review of Systems (ROS) - Briefly assess other body systems not covered in HPC Treatment Plan & Safety Netting - Outline the treatment plan - Advise on when to seek further help (e.g., worsening symptoms) ICE ICE (Ideas, Concerns, Expectations) is a crucial framework in patient-centered communication. It involves: ● Ideas: Understanding what the patient thinks is wrong with them, including their thoughts on the nature, cause, or progression of their condition. ● Concerns: Identifying the patient’s fears and anxieties, such as the seriousness of the issue or its impact on their life. ● Expectations: Clarifying what the patient hopes to achieve from the consultation, like specific treatments or diagnostic tests. Using ICE helps in building rapport, addressing patient concerns, aligning goals, and improving overall consultation outcomes. Introduction to ICE in Consultations ● ICE: Ideas, Concerns, Expectations ● Purpose: Understanding the patient’s perspective, enhancing communication, and improving consultation outcomes. ● Benefits: ○ Increased treatment adherence ○ Reduced unnecessary prescriptions ○ Improved shared decision-making ○ Greater patient satisfaction Exploring the Patient’s Ideas ● Goal: Understand the patient's thoughts about their condition. ● Questions to Ask: ○ "What do you think is causing this?" ○ "What thoughts have you had about this?" ○ "What ideas do you have about what’s going on?" ● Outcome: Clarifies misconceptions, builds rapport, and improves understanding.Addressing the Patient’s Concerns ● Goal: Identify fears and anxieties about the condition. ● Questions to Ask: ○ "What worries do you have about these symptoms?" ○ "Is there something specific worrying you?" ○ "What is your biggest worry at the moment?" ● Outcome: Addresses emotional impacts and the seriousness of the condition. Understanding the Patient’s Expectations ● Goal: Align the consultation with the patient’s expectations. ● Questions to Ask: ○ "What do you hope to get from the consultation?" ○ "What were you hoping I might do for you today?" ○ "How would you like to go forward with this?" ● Outcome: Ensures the patient’s needs are met, guides the consultation plan.https://www.britishjournalofnursing.com/content/clinical/using-the-sbar-handover-tool/Physical Examination Physical Examination ● Look from the end of the bed (general appearance - quiet/unwell/not engaging in eye contact/ incomprehensible sounds) ● Basic multi-system exam ○ 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 movement/sensation, mental status if elderly/confused. ● Focused exam on relevant system in more detail → documenting presence/absence of signs of differential diagnosesBased on our cases, how would you structure your examination? -Any areas to focus on? -Review any investigations that have already been performed. -Review your plan with seniors if you are unsure! -Keep it simple! Formulate a differential diagnosis/ impression/problem list → plan investigations/management. ● What treatment do I need to manage the immediate issue? ● What other investigations do i need to prove or rule out differentials ● What symptoms are bothering the patient? ● What needs to be done to enable a safe discharge? Based on our cases what would your differential diagnosis and management plan be?Post Take Ward Round:Ward Round Documentation ● Patient details, date and time ● Name and grade of who is leading the ward round + others present ● Problem list (include resolved ones and active ones) ● Observations, including bowels/eating and drinking/ fluid balance ● Bloods and investigations ● Examination ○ Appearance, mental status, physical examination and any discussion with patient. ● Impression ○ Working diagnosis ● Plan ● Sign (your signature, name, grade, bleep, GMC) Tips: -Try to prep the notes beforehand -Read the last entry -Make a jobs list as you go along -Handover to nurses. Medical Abbreviations History Time PC: presenting complaint HPC: History of presenting complaint 1/7 = 1 day PMHx: Past Medical History 1/52 = 1 week SR: systems review 1/12 = 1 month DHx: Drug History FHx: Family History SHx: Social History Medication Examination OD: Once a day BD: Twice a day O/E: on examination BM: blood glucose TDS: Three times a day QDS: Four times a day RR: respiratory rate HR: Heart rate PRN: as required SC: subcutaneous I+II+0 = no added heart sounds IM: Intramuscular IV: Intravenous RUL/LUL = right/left upper limb PO: orally Abx: antibiotics RLL/LLL: right/left lower limb IVF: IV fluids SNT: soft non-tender BS: bowel sounds Documentation R/v: review △= Diagnosis POC: package of care MFFD= medically fit for discharge PT/OT: physiotherapy/ occupational therapy MOFD = medically optimised for discharge ?something = suspected something NAD: no abnormality detected F/up or FU = follow up LOTS MORE and a LOT of ambiguityExamination Diagrams What would the chest diagram look like for our respiratory case? What would the abdominal look like for our gastro case?References https://www.ambulatoryemergencycare.org.uk/uploads/files/1/Resources/Medical%20Admissions%20Clerking%20Proforma%20-%20S windon.pdf https://oscestop.education/learning/ward-round-documentation/ https://oscestop.education/learning/admission-clerking/ https://geekymedics.com/clerking-101/ https://mindthebleep.com/clerking-patients-few-tips/ https://mindthebleep.com/surviving-ward-rounds/ https://app.medall.org/event-listings/zero-to-fy1-series-clerking-and-ward-round-documentationAny questions?