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An Introduction to Medical Clerking Dr Marcus Dawson IMT2 THE BULGARIA STUDENT SUPPORT NETWORKOutline: Learning Objectives: Topics for discussion 01 To become more aware of the 01 Clerking in the hospital process of medical clerking admission process 02 Build confidence in taking histories, what to look out for in 02 Before you see the patient – the electronic notes examination of patients and formulating management plans. 03 Key features of the presenting history and social history 03 Become more familiar with advanced directives, social circumstances such as 04 The A – E examination alcohol/tobacco and social 05 The drug chart care needs An example case 04 Discuss pearls and pitfalls of 06 common pathologies you will see on the medical takeWhat is clerking? Gathering information on patients that have been accepted for a new admission to hospital, taking the history examining the patient, interpreting any tests and formulating an initial management plan For each patient when starting a rough time frame is 1.5 – 2 hrs per patient but this can vary depending on complexity of the patient and issues within the hospital Often takes place in the A&E department or an emergency assessment unit Your initial medical plan needs to keep the patient safe until the post take (where the consultant reviews your patient) Consultant post take reviews can take place minutes later or many hours later or even the next day if working overnight (must be complete within 24 Hrs of admission)How to see a new TIP: patient - the process You are never starting from a blank slate Use the information of colleagues that have Dig in to the history: seen the patient before you! Use previous discharge summaries GP summary care records (latest medicines and most recent consultation) Previous scans/tests US CT MRI ECHO Previous microbiology reports Old blood tests (eGRF / trop) Any advanced directives (DNA CPR/ preferred place of care) Document new tests/scans/bloods and history or obs from the paramedics: Take a focused history from the patient, then a review of the symptoms history Take a social Hx, collateral Hx Focused examination and document findings: Basic heart lungs abdo legs in all patients any additional examination based on the presentation (CN exam, fluid status) Make an impression (Imp) or differential diagnosis (Ddx) Formulate a plan (there'll be more on this later)Example of a clerking bookletExample of a clerking booklet THE SOCIAL HISTORY TIP: Smoking – in pack year history One of my key questions… Alcohol – in estimated units Who does your food shopping Drugs – what, how often, and how Walking distance / walking aids Activities of daily living Carers – how many times per day Care home / nursing home Clinical frailty scoreCo-morbidity Common meds PAST MEDICAL HISTORY: AF Apixaban bisoprolol Brief summary of past diagnoses Note any relevant past test results COPD Salbutamol trimbow pt with heart failure – document previous ECHO and ejection fraction pt with UTI – any previous urine culture results CHF Bisoprolol, ramipril, furosemide pt with COPD – spirometry / sputum cultures Make sure the drug list corresponds with the BPH Finasteride, tamsulosin PMHxCASE 1: 85yr old male admitted after being found on the floor of his home by his carer in the morning No significant injuries, ambulance crew assisted pt to his feet able to walk Pt unclear how long he was on the floor for Fell whilst mobilising to the bathroom overnight with stick found by his side PMHx HTN – amlodipine ramipril BPH – tamsulosin T2DM – metformin and gliclazide Cognitive impairment – no formal diagnosis of dementia Before even seeing the patient, taking the drugs list into consideration, what could have caused the fall?CASE 1: 85yr old male admitted after being found on the floor of his home by his carer in the morning No significant injuries, ambulance crew assisted pt to his feet able to walk Pt unclear how long he was on the floor for Fell whilst mobilising to the bathroom overnight with stick found by his side PMHx HTN – amlodipine 5mg OD ramipril 5mg OD AF – bisoprolol 10mg OD Benign prostatic hyperplasia – tamsulosin 400mcg OD T2DM – metformin 1g BD and gliclazide 80mg OD Cognitive impairment – no formal diagnosis of dementia Obs RR18, Hr 59, BP 105/64 Sats, 95% OA, 36.5Oc Blood glucose 3.9 GCS 15 Now taking the obs into Bloods taken by A+E – results awaited consideration any further ideas what could have caused his fall? Question.... What do you think is the most likely cause of this patient's fall? Case 1: 85yr old male admitted after being found on the floor of his bungalow by his carer in the morning No significant injuries, ambulance crew assisted pt to his feet able to walk Pt unclear how long he was on the floor for Fell whilst mobilising to the bathroom overnight with walking stick found by his side PMHx HTN – amlodipine 5mg OD ramipril 5mg OD AF – bisoprolol 10mg OD BPH – tamsulosin 400mcg OD T2DM – metformin 1g BD and gliclazide 80mg OD The classic Cognitive impairment – no formal diagnosis of dementia multifactorial fall Obs RR18, Hr 59, BP 105/64 Sats, 95% OA, 36.5Oc Blood glucose 4.0 GCS 15 Bloods taken by A+E – results awaited The classic multifactorial fall Bloods taken by A+E – results awaited Case one – Key questions When going to see this patient what do you want to ask? At what time did you fall over? Is there a possibility of a long lie and rhabdomyolysis with acute kidney injury Have you had many falls in the past? Recurrent faller at high risk of more falls vs accident Do you drink alcohol? If he drinks half a bottle of wine per night how is the case different? Do you take your medication regularly? If he sometimes forgets his meds then double doses the next day how does that change things Do you live alone or with somebody else? Risk of adverse event from future falls, will he be safe at home Case one – Key clinical examinations When going to see this patient what do you want to ask? Fluid status General cognition / GCS Dehydrated leading to likely dementia hypotension Mobility Heart sounds Straight leg raise, sitting balance Systolic murmur limiting pulse pressureCase one – key tests Lying / standing BP – is the medication too much HbA1C – is the glycaemic control too tight Bloods FBCs – rule out anaemia Average Hr / ECG – rule out bradycardia or heart blocks Bloods U+Es – rule out AKI due to dehydration/rhabdo Additional tests Bloods – iron studies, Vitamin D and Calcium CXR – baseline chest X-ray Bladder scan – urinary retention Case one - Plan How to investigate Phase 1 Phase 3 Phase 5 How to prescribe his regular Catheterise? Occupational therapy input medication -how much retained urine in - falls alarm, increased care - Should he be on three too much visits, care home antihypertensives? Phase 2 Phase 4 Rehydration Physio input - IV vs oral fluids - use a frame rather than a stick Case one - Conclusion This 85 yrs old man went home three days later … His standing blood pressure was maintained with fluid rehydration His bradycardia resolved with reduction of bisoprolol His amlodipine was stopped – BP increase to 145/85 His gliclazide was stopped and his glucose target range was 5-15 mM Carers were arranged 4 times per day rather than twice Bladder scan proved his was not in retention of urine His renal function was shown to be normal and at his baseline Summary It is the clerking doctor's responsibility to take a history, examine the patient, make an initial management plan and prescribe new and regular medication Use previous sources of information to gain a preliminary history and idea of the issues Go to the patient with an agenda of that to ask and what to examine Get simple bed side tests to aid better management Prescribe regular medication with caution Involve Multidisciplinary  colleagues where appropriateThank you for your time!