Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Yeah. Okay. So I think, I think we'll make a start and see if anyone's anyone else will join us in a few moments time. Um, can I just check that everyone can hear me? Okay. First of all, give me a thing. Perfect. Ok. So my name is Angus. I'm one of the junior doctors working at Royal Albert Edward Infirmary in Wigan. I'm a F one, I'm halfway through my first year. Um Just so I've got a good idea of who is in the audience today. Can you just let me know sort of at what stage and your training or what, what you work as because that will help me to pitch it correctly for everybody here? Excellent. So we've got some third year, third year medical student. Whereabouts is everyone else? Okay. Well, if we, if, if I pitch it at roughly sort of medical student slash amp level, that's kind of what I was aiming for. So we've got, yes, we've got enough. So we've got a foundation year too. So probably maybe even though it's a bit more than me. But, you know, uh, it's never, you can always pick up new tips and tricks. So maybe there's something in here that will, um, help you as well. Um, so I decided to give you, give you some teaching about clerking because it's something that you're going to be doing as a mps junior doctors. Um, and no one really throughout medical school will give you some formal teaching on it and, and you're just sort of expected to have picked it up at some point. But if no one's ever really told you how to do it and what the common pitfalls and some tips and tricks for clerk and then you know how you're supposed to, how you're supposed to be expected to do it to a good standard. If no one's ever really shown you how. So that's kind of what I wanted to address this evening. So here's the broad aims of the session. So to be more confident or familiar with clerking documents, when I say ticking all the boxes, I mean, that basically just means not to forget any of the important bits. I'm going to be talking a little bit about awareness of specialty specific requirements. So certain specialties will have different needs from their clerking documents. Different bits of information that are going to be important to consultants from different specialties and the management and investigations are also going to be a bit different depending on what specialty you're going to be clerking in. Um, and then we're going to round things off with avoidance of common pitfalls. What I've done is I've spoken to some of my colleagues and picked up some of the tips and tricks from them and some of the things that they've noticed sometimes forgotten that are actually quite important not to forget. So before we move on, what, what does everybody understand by the term clerk? And what do we think that clerking means? What, what does it mean to Clark's clerk, a patient into hospital? Just pop the answers in the chat? Sorry. When I ask a question, I should, I should highlight when I asked a question, it'd be really great. Um If you could just pop your answers in the chat, um they're not hypotheticals for the most part. So Anthony's got a really, really good suggestion there. So you get all the information necessary before admitting the patient. So yeah, that's, that's the one really important component of a good clerking document is information gathering because you're admitting someone. So you need all the information about sort of presenting complaint, what's going on, what's brought them to hospital. That's definitely one part of it. Yeah. And there's, there's a few other components as well, which will, we'll talk about in a little bit unless, unless someone in the chat thinks they might know some other, some other aims of clerking, the purpose of clerking. So we can come onto it a bit later if, if people are drawing a blank. So obviously these are the components of clerking and we've spoken a little bit about, uh, information gathering. So that will be in the history and the examination. But then once you've got all the information, so once you've gathered that information necessary to admit the patient, you want to come up with a sort of plan, so you want to come up with a bit of a plan in terms of investigations. So how are we going to find out exactly what's gonna going on? How can we confirm or disprove are differentials at this stage? We're also going to want to think about management. So how are we going to manage the clinical situation of the patient that's in front of us and we need to think about some additional components as well. So this is things like medications that they're usually on, this is things like social background, uh baseline in terms of mobility ADLs, what clerking is, it's so this is where I'm getting onto with the purpose. So these are all the components of clerking, but it's actual purpose is to ensure that there's a good transition of care from the community into hospital that there's no gaps in medical treatment that's ongoing in the community for when they get into the hospital. And also that there's nothing missed from the presentation that could be managed better. So it's just a it's a holistic way of looking at an admission is how I like to think of it. So the first component or the first thing that you're going to be addressing as a junior doctor, clerking a patient in is the history. So you're going to go. No, maybe not. So you're not going to start with the history. Can anyone think what we might start with instead of the history? So instead of, so we've been told by the coordinator that there's gentleman and a and e that we need to go and clerk in for medicine. What we're going to do before we go and take the history. Does anyone know? So, yeah, we want to confirm that we're gonna go and see the right patient. We're gonna maybe have a look on the system and see where they are, who they are, make sure we're going to go and see the right patient. So we're going to check the notes on the system. Yeah. So this is arguably the most important part for me, at least as an f one of the clerking process is a bit of research, doing a bit of research, getting a bit of background. Um because this is ultimately going to help us to clark in a bit more efficiently. So what kind of things are we going to do before we get to the patient? So we've, we've had a look, we've had a mention of looking at notes. So what are we going to be looking for specifically and what we're going to be doing before we even get to the patient. Give it a few more seconds. See if anyone's got any suggestions. I'm sure we can be a bit more talkative tonight. So, previous admission's. Yeah. So that's especially important if this is someone who's been in hospital for a bit and they've been discharged and they've been bounced back. Yeah. Exactly. So, so if you think you've got it perfectly. So we want to know if this is a recurrent admission. Exactly, looking at the past medical history and actually, so even more simple than that. So I'll bring up what I've got. So exactly like Sophie's mentioned, we want to know about the past medical history. We also want to know about the drug history because we need to know if they're on any medications that might be contributing to their acute admission. And similarly, we want to know if they've got any medications that might be time critical that we need to prescribe for their new admission. A really good source of information is the A N D documents. So they've already been clocked in by A and E. So this is, I mean, this is if you're talking about a medical surgical obscene, Gynie, pediatric clerking, um you may, you may, you may be working in A AND E and you may be the first, you know, you may be the first person going to go and see this patient. So it may be that it's your clerking that, that everybody else relies on. But you can, if you're further down the line, if you're in medicine or surgery, you can look at that A and E document and get a really good idea of the presentation. So you can start formulating your clinical reasoning in the background. So you can be absorbing all this information coming up with a few differentials, a few different impressions and a bit of an idea about what you're going to do. You can also have a look at bloods. So you can check if their renal functions off if they're CRPS raised, if they've got high white cells and neutrophils, you know, these are things that might be pointing towards an infection, uh kidney injury, depending on, you know, whatever might be going on as well. Um So you can have a look at the bloods that have been taken in a and a and get a fairly good idea again of the clinical picture. And also sometimes there might have been some scans. So someone might have presented with an acute confusion. Um and A and E would have most likely very kindly organized a CT head. So that's already one of the big important factors that may be contributing, contributing to confusion ruled out for you already. So you can kind of take that off your differential or impression list before you go. So sitting down, prepping the notes and going in with a bit of a plan is definitely going to help you I've just noticed that did he has changed the setting. So thank you very much. Hopefully that will mean some more people can get involved in the chat. So this is just what I was talking about. Really before you've even seen the patient, you've got rules in. So things that you can rule in, things that you can rule out or things that you want to rule I/O based on what more evidence you get from the history and the examination, you can already come up with a bit of an impression. I this is effective. This is the body system that it's affecting if there. Um if a and they have found a new murmur, for example, you can be a bit more focused on a cardiac history and examination whilst also, you know, doing all the holistic, you know, full systems review that you can focus a bit more on the cardiac history there and you can come up with some differentials and like I say some plans for investigations and management. So you've now gone to see the patient and we're going to get a bit of a history. I like to use the grid system. I used to jot it down and I've managed to migrate that from written notes into my head, but this is just how I approach any clerking situation. Uh Does anyone know the grid system? Has anyone come across the grid system before? Something that I was taught in medical school. I'm not sure if other people have come across it as well. If they have, would they be willing to share the grid system once you see it? You'll recognize it. I'm sure. So if I start us off, right. So it's as simple as this, it's all the components of a history laid out into a grid great system. That's what it says on the 10. So you got the presenting complaint and the history of the presenting complaint past medical and surgical history, drug history, analogies, family history, social history, ideas, concerns and expectations not necessarily always relevant in eight clerking document because it's a bit more relevant to GP where, you know, people are a bit more. Uh you know, they've got some ideas about what they want from the interaction. They've made the appointment themselves in A and A when you ask them if they've got any ideas as to what's going on more than likely they're going to say no. And when you ask them what their concerns is, they just, you know, they just want to get better and they want you to fix them. So not always relevant, but can be a useful tool from time to time in the history percent and complaint. You can also include a systems review in that. So you've done your kind of fairly focused cardiac history, for example, like we were talking about, but then you can dig into the systems review and just make sure that you're not missing anything. I tend to go top to toe. So start with neuro check their respiratory system, cardiac system, gastroenterological system and just work my way down the tree that way. So that's the grid system. Um And again, like I said, when I started clerking, I used to sort of draw it out and make notes. But um now that I'm a bit more used to it, I do it all in my head. So let's move on to a few cases. Just to demonstrate, you know, the kind of information that you'd want to gather in that presenting complaint, history, presenting complaints. You've got a 26 year old female, she's presented to any and she's got some shortness of breath. So what other questions do you want to ask her? What more do you want to know about this? What some of the details that you can try and pick up from the history? So, yeah, normal functional status compared with current. So how things have changed? When did it start? So, yep. So how is it episodically? So is it there all the time? Is it intermittent? Is there a pattern to it anything else? So, yeah, are there any precipitating factors? So activities time of day triggers as well. So I'm guessing you're thinking more of a along the kind of asthma kind of clinical picture with those kind of questions? Yeah. So these are, these are just kind of, I did a bit of a brain dump of all the things that I could think of connected to the shortness of breath and these are all things that you can ask for and we'll help you too discern more closely about what's going on. So we've, you know, we've spoken about triggers. Um We've spoken about onset and duration, exacerbations, relieving factors as well. So whether they're short of breath and they've used their inhalers if they are asthmatic um occupation. So again, that's thinking of uh different exposures. Um And we just want to get a characterization of the shortness of breath as well. So, you know, are there any of these associated symptoms? You know, if someone's short of breath and they've got cough and they've got fevers, chances are, you know, it could be a bit more effective if they've got some chest pain discipline, ear hemoptysis iss, then, you know, we might be thinking down a different route maybe p for example. So the history of presenting complaint presenting, you know, you guys got third year medical students and F two S I feel like I don't really need to be teach, but it's just getting, you know, thinking about making sure you're getting the full history so that you can come up with a really concrete solid management plan from the history that you've taken because it is because this is basically going to be evidence for your management plan. You know, if you, if you don't mention that they've got a coffin fevers. If you, if you don't ask about coughing fevers, why you starting them on antibiotics? For example, why are you ordering them a chest X ray? So this just helps give justification to all the actions that you take. You know, when you start thinking about investigations and management. So a little bit different this time, a 38 year old gentleman referred to medicine, he's recently started drinking again and he's gone cold turkey. So he's completely cut it out around two or three days ago and he says that he's now withdrawing. What do you want to know? Let's see, this is very different. You know, before we had a bit more of an idea about what's going or a bit less of an idea, I should say really about what's going on. Um, sounds from this situation that we've got a patient who there's maybe experienced this before, perhaps. So, what more would you want to know in this situation? How would your approach be different? So, this is, so, has he tried with drawn before? So how does it differ? What's it yet? Background is drinking? Exactly. Yeah. So those, so Anthony and Sophie, those, those are excellent. So, um, we focused on, you know, whether this is something that he has experienced before because it kind of sounds like he might have what symptoms he's noticed that makes him think that he's withdrawing. Um, So we're, you know, we're treating the pain, you know, the patient's going to know themselves, you know, what is it? Uh, William Osler, listen to, listen to the patient, they're telling you the diagnosis or whatever the quotas. Um, Sophie. Yeah. So find out about the background of his drinking. So, exactly. So we can get a really good idea of the symptoms that he's experiencing, whether these differ to anything that he's experienced before. And we can use this as an opportunity to get a really good alcohol history from him because that's gonna, you know, that's also gonna feed into how we investigate and manage. Um And it will give us some really good information as well when we want to refer to teams that might help with alcohol intake. So it's just a really good opportunity, know, you know what's going on and roughly from, from the presenting complaint and, you know, you've probably already formulated your management plan, thinking about Benzodiazepines and that kind of thing. But we can also use this as a really good moment to be able to gather some more information about the causes of him wanting to stop causes of him drinking, how much he's drinking, that kind of thing. So sometimes clerking can be really straight forward and sometimes it can be a bit less straightforward. Uh And there can, there can be some real curveballs thrown in there as well, which makes it quite interesting, quite engaging. Um it's always a bit different when, until it's not. So this is the final case in terms of history of presenting complaint. So this is a 54 year old female. It's been referred to the G P. The presenting complaint is hypochelemia. So the G P has done some routine blood tests and he's, they found that this uh this lady's got a low potassium and so they've sent them into the hospital. So here you kind of already know roughly what's going on. You've more or less got a diagnosis. Um, so what do you want to pick out from the history in this situation? And it kind of falls into two camps, the kind of information that you might want to gather. Yeah. Why did they do a blood test? So, really good question in this situation. They've gone for a well woman check and it just so happens that using these have shown a low potassium. Yeah. So Ben and auntie, you've, yeah, you've addressed one of the kind of boxes that I was going for. Um, so we need to know about why the potassium is low. So we need to ask about factors that might cause the potassium to be low. But also some ones presented with a known low potassium. We of course, want to know if they're symptomatic. So on the left here, we've got some symptoms that might be associated with low potassium. And then on the right, we've got exactly like you both pointed out some factors that might have led to the potassium being low because if we don't treat the underlying cause, then treating the low potassium, it's going to be a little bit redundant. So as you can see from those three cases, that information gathering part of the clerking can be a completely different and you can have a different agenda, a different approach, different aims, depending on what the presenting complaint is and what you're planning on doing next. So I got a really good history. We've already, we've taken a really good family history as well. I'm not going to patronize you. I know you can all take a wonderful history. This is more about the, you know, the different approaches to a clerking. So after history comes the examination, so what examination are you going to do? And people who might have been in my teaching before should know exactly what's coming. Any, any takers, any guesses, it's an a to a, it's an A to eat. Exactly. Bennett's an a to a, always an A TUI when in doubt doing a, to a, obviously, if someone's presented with fevers and a new murmur, you might do a bit more of an in depth cardio vascular examination. But ultimately, you're going to go top to tail because if someone's had an acute presentation, you're going to want to do a sort of relevant examination to that acute setting. So you're going to want to make sure that their airways okay. And then you can move down the tree from there. So, you know, be for breathing, see for circulation, D for disability, which is kind of your G C S uh pupils, that kind of thing. And then e for everything else, which essentially means an ABDO exam, but really everything else. Um and that just ensures that you're not missing anything because yes, they might have come in with a really clear sort of all. I've got a, I'm feeling and, well, I've got a calf, got a wheeze infective exacerbation of COPD, fairly typical history, but you want to make sure that you're not missing anything else in any of the other systems. So that's why you do an A to A and like I say, if something happens to crop up, then you can do a bit more of a focused in depth examination at that point of that system. So I'm not going to linger too much on investigations and management because obviously the kind of investigations and management that you are going to be doing is going to vary depending on what presents. So the investigations that you're going to do for a, uh, suspected stroke is going to be very different from your investigations for a DVT, for example. So I'm not going to go too deep into that. But what I've always tried to point out is that having a good system for these kind of things is going to see you right in your practice. So as per usual bedside, blood's imaging and specialist tests, that's the approach I always take when ordering investigations and coming up with the management plan. Um, so bedside, those are things like E C G S urine dips, bladder scans, anything that can be done as at the bedside and that includes blood glucose. If it wasn't already done as part of your eight, we blood's obviously you'll have some bloods already, but you might want to add on some additional bloods. So whether that's uh coagulation screens, ps assess all the weird wild wonderful stuff that can crop up um, tumor markers, for example. Yeah, you can add, you can basically add and subtract anything that's relevant to the presentation that's in front of you and that goes with the same for imaging as well and for specialist tests. So that's kind of investigations in a nutshell. Again, with management, I'm not going to linger too much on management because, you know, we could, we could go through every single body system, every single presentation, but that's going to take slightly longer than the amount of time that we've got allocated. And I think you'll probably be quite sort of tired and uncomfortable and unhappy with me if we, if we took that approach. So again, the management is just gonna be relevant to whatever you're aiming to treat. So if there's a pneumonia, obviously, you're going to you know, think about antibiotic therapy and pain relief. Uh, if it's a stemi, so if it's a myocardial infarction, you're going to follow your local protocol for, however you treat that usually dual anti platelet therapy, bisoprolol statins, you know, the works. So now I wanted to come onto some specialties and how, so there are, you know, a sort of handful of specialties that where they're clerking is slightly different from medicine. So medicine is a bit more straightforward. Someone comes in acutely and well sort of formulate a diagnosis and management plan and it's, it's fairly typical in terms of body systems, in terms of pediatrics, ob gyn guinean surgery, there are some extra things to consider. So I might have given the game away a little bit there. So for pediatrics, obviously hadn't put an animation onto that slide. So for pediatrics, is there anything that differs from a adult medical presentation that you'd want to know in the presenting complaint in the history in the past medical history? So, can anyone think of any components of it? So, yeah. So Ben, you've actually highlighted something that I've forgotten off the next slide, which I'll have to remind myself to talk about. Yeah. So details of birth immunizations, nutrition, development, in depth, social stuff as well. So any complications and birth. Yeah. So we're thinking about sort of factors that might mean that they have uh on your other cover abilities. So it's a more detailed presenting complaint and history essentially. So pregnancy and scans such you're kind of antenatal screening. So whether there were any um anything picked up on the dating or anomaly scan and whether the pregnancy was on an eventful, whether they had gestational diabetes, for example, uh birth and post. So, was it a difficult birth? Was it c section? Was it normal vaginal delivery? Any post natal period of time spent in nicu so development. So you're going to want to know that they're developing along the right tracks and the vaccination history. And I've also completely neglected to include here, which I would get reprimanded for by the Pedes Clinical teaching fellow who taught me because she really drummed it into us. So I'm quite embarrassed that I've forgotten this, but diet and toilet eating as well. Really important. Are they off their food? Are they still passing stool and water? And that's particularly important for infants who can't communicate because those are signs that, um, you know, they can be really helpful in sort of pointing out whether kids on well, has anyone come across this heads? Pneumonic for social history with pediatrics or can anyone guess what heads might stand for any ideas? So one of the essays is not school but school is in there. So e is for education. So we've got the E crossed off. Can anyone think of any of the other letters? What they might stand for smoking? Yep. Perfect. One of the S is, is for smoking. So, yeah, so Ben got smoking. Anthony got h for home. So, yeah, home who's at home? Are there any, uh, you know, additional people outside the family, inside the family? Uh, any additional help at home? That kind of thing? So, we've got e for education. So, where are they in their education? Are they homeschooled? Are they at school? Are they having any difficulties at school? One of the S S is smoking. So for adolescents, do they smoke? Although you never know younger than adolescents, maybe smoking? Um, but you can also, you know, if this is an infant, for example, you can also talk about smoking at home. So a is for activities. So outside of school, what do they like to do? Are they active? Do they have hobbies? So D D is probably more relevant for the adolescent, um, section of pediatrics. Really? That might give it away. So, can anyone have a guess as to what d might be drugs? Yeah. Are they engaging in any recreational drug use? And then again, one of the s is probably a bit more relevant for the adolescent. So it's sexual history. So whether they are sexually active, um because that's obviously going to be, you know, important to consider if they've got an infection, particularly urinary tract infections, that kind of thing. So just things to consider in the social history there as well that you might not consider talking about in as much depth with, with adults. So I think next, we've got jobs and Gynie and I've given it away again, the animation is not there. Sadly. So can anyone think of features of an obscene guinea history uh that are important to take off, important to include? Okay. And these aren't necessarily uh features of a history that wouldn't come up in a medical presentation or a surgical presentation. But these are important parts of the history that an Abs and Gynie consultant is going to want to know about. Yeah, excellent. So we want to know about gravity and the gravity and parity five P S O. I haven't come across the five P S before. So partners protection, pregnancy. So two of those are covered by one of mine. I can't remember the other two. That's fair enough. So how I was taught to do it and how I quite like doing as well as having grabbed the im parity in the intro. So for example, we go back to our earlier patient, let's say this is an OB Gyn by any presentation we can say we've got a 26 year old female uh G two P one or G two P one plus plus one. And that frames that presenting complaint in the mind of the consultant that you've got in front of you. So that, you know, they've got a good idea of the kind of background um medical history, gynecological well, more obstetric history, sorry, before you even get into the presenting complaint. And then there are these five components that I always include in any obs angina history and presentation and you can kind of arrange them into or you know, rename them and arrange them into whatever anagram you find most helpful. But that's what helped me to make sure that I've ticked off all of these. So see, for cervical smears, whether they're up to date and obviously that's going to be relevant, have different relevance depending on how old the patient is. So whether they're up to date, whether they've ever had any positive smears, whether they've had any colposcopy is that kind of thing, menstrual history. So again, I'm sure you're all very competent in taking menstrual history, but it's getting that full picture of how often, how long for how much blood, that kind of thing, obstetric history kind of covered in the gravity and parity. But you can go a bit further into detail about the obstetric history and about complications about any gestational diabetes, about any preeclampsia, that kind of thing, sexual history, a sensitive subject, but always important to broach because if you've got a pregnant female with a sexually transmitted infection that can obviously have problems further down the line with, uh, what's the word? You know, when, when does it, what is the word? Oh, this is gonna, this is going to annoy me. It's not natural, it's transferred disease from mom to baby. The word will come back to me in a few minutes. I'm sure it will. Oh, we'll come back to me and then urinary tract symptoms as well. So, those are the kind of five important parts of the additional parts of the presenting complaint and the history of presenting complaint that are good to include in any sort of obscene going presentation and then surgery. So I just kind of go through this with you. So surgery, it's just about the fact that it's a bit more time sensitive and you're going to want to know when they're, when they've last eaten because they might be going to theater soon. So it's going to be important for the anesthetics team to know when they last ate because that might change their management in terms of airway, you're gonna want more, you're gonna want, you know, blood's that you'd usually get so your full blood counts, you're using these, your LFTs, you CRPS, but you also might want to think about getting a group, a group and save sample if they're going to be going to theater scans. So scans is something that you might want to get a bit more timely as well with surgery and you want to get senior support soon. Because if you're an F one, you're not going to be the one that's going to be consenting the patient that's going to be having some of the high level conversations So you're going to want to get senior support soon. If you do think that this patient's going to be going to theater. So those are kind of some more specialty specific uh features of the clerking that you might want to address. So I'm going to move on to some pitfalls. So these are common things that can be missed or mistakes that can happen in a clerking document. We're all under time pressure, these things can happen. But if you're aware of these pitfalls and the potential for them, then you can do some work to try and avoid them. So the first one is the V T assessment. So why is the VT assessment important? And that might seem like a obvious question, but it's an important document. So I want to make sure that we're Raul aware with how important and why VT assessment is important. Any ideas just pop them in the chat? Yep. So if someone's coming into hospital, they're going to be a lot more, well, maybe a lot more immobile than they are at home. It's not often you see patient's walking around the ward, they're usually either side in bed or sat in the chair. So the T assessment is also important because if they have, if they have a VT, then so treatment may change depending on VT risk. Yeah, exactly. So we, we may not even give low molecular weight heparin depending on the V T assessment. But VTE assessment always needs to be done because this is a legally required document. It's something that at wigan is a part of the clerking document and you can't close the clerking document until you've done a VT assessment and prescribed vte prophylaxis. If it's indicated, it's something that needs to be done for every patient because DVTs pes, they can be avoided uh on admission's by, you know, and it's really straightforward and easy to avoid them. Um If you, if you prescribe low molecular weight heparin early enough in the admission, so you're going to avoid a lot of complications. So this is something that and again, is going to vary, trust to trust. But wigan, you can do the V T assessment as part of the clerking document, not everyone because of time pressures because they've got way too much on their plate. It happens, not everyone always prescribed to PT. So if you just make it part of your mental process, when you're clerking patient into do VT assessment and to prescribe it, if it's indicated, then that's going to potentially save the patient from having a serious DVT or PE and it's going to save someone else down the line having to pick up this, you know, pick up the job that had been missed. It's just better around for everyone. So, prescribing regular medications. So when is this especially important? Obviously, in an ideal world, we'd have as much time as we needed to make sure that all the regular medications were prescribed but there are certain ones that really cannot be missed. Does anyone know what medications, uh, time critical, important medications that will need to be prescribed more or less as soon as you've clocked them in? Okay. Any ideas? Just need some classes of medications don't need specific drug names. Give it a couple more seconds. See if anyone's willing enough, anyone's brave enough to step forward. Go on. Fair enough. So, these medications are ones that really, you know, if the four of them definitely cannot be missed, one of them should not be missed. Antiepileptics. Parkinson's drugs, insulin and steroids. If they're on those medications at home missing, these medications can have serious consequences. I don't really feel like I need to explain why it should be fairly self evident. But obviously if they're on anti epileptics and they haven't had them than the chance of them having a seizure increase, they haven't had their Parkinson's meds. They're going to become symptomatic with the Parkinson's and it's going to set them back, make them more and well, insulin as well. I mean, you know, if they don't take their insulin, what's going to happen if you haven't prescribed someone's insulin, what's the complication, what's going to happen? D K. Exactly. And then steroids as well. If they're regularly on steroids and they miss steroid doses, there's a chance that they could have an adrenal crisis. So, obviously we don't want any of that to happen. Because that's quite bad news, analgesia so important to manage pain relief. Because, you know, if, if you came to hospital you had a lot of pain, you'd want that to be managed. That's probably the first thing that you'd want doing is something to take that pain away. So, if they're on regular analgesia, you want to make sure that's prescribed and then that's what's so new medications. So, what kind of pitfalls do we think could crop up when prescribing new medications? What things could be missed, what things could go slightly wrong. So, not considering allergies. Exactly. Yeah. So if we haven't, if you haven't got any allergies listed on the system and, um, we haven't asked them about it as well, then, you know, we could, we could potentially miss something, then especially if this is the first time that they've come to hospital, you know, it might be that they're from Altuve area so that their allergy history might not be on the system. And we've just prescribed them an, an antibiotic that they're allergic to. That's a bit of an issue. So, allergies definitely, definitely one of them, anything else about new medications. So, these are just some of the new medications that can be, you know, can be prescribed incorrectly. So, and some of this is, some of this is a bit more relevant to people who will be working in a, in a system that has electronic prescribing. So if you have paper prescribing, it will be a bit different. But this is kind of more aimed at. Um some of them are kind of more aimed places that have electronic prescribing. So, Merriam's pointed out contraindications with other medications. So, yeah, if you're prescribing an anti, so let's say, for example, you're prescribing an antibiotic and you're prescribing Clarithromycin and they also happen to be on an anti epileptic that can lower the seizure threshold. So we need to think about contraindications with other medications. Um So antibiotics. So sometimes a Andy will prescribe single doses of antibiotics and you might see that the antibiotic is there on the system. However, they don't necessarily have a full course prescribed. So sometimes antibiotics can, you can miss doses there. So the steroids as well. So steroids are generally given in the morning. So if you are clerking someone in at seven at night and they are having an acute exacerbation of COPD and you want to prescribe them some steroids. If you aren't taking, you know, extra precaution. When prescribing the steroids, it might be that you prescribed them for the next morning. So again, they might miss out on that dose that could help their systems until the next day. So we're thinking about timing of prescribing with this one. We've already spoken about vte prophylaxis. But I'm just driving that point home, especially for surgical patient's um fluids and oxygen. There also two things that seem obvious but can be missed when you're in a rush, when you clark them in, you've gone back to the office, you're doing your electronic prescribing on the system and you forgot to prescribe the fluids while you were there at the bedside. Um So obviously, if you haven't prescribed their fluids and that's going to be essential in their care, then you know, that can be missed and then oxygen as well. Oxygen is something that we prescribe. Uh and this is going to be especially relevant. We've spoken about COPD quite a lot this evening, but this is gonna be especially relevant in COPD where they've lost that hypoxic drive because they're hypercapnic drive. Sorry. Wait. No, they've, oh gosh. No, they've lost, yeah, they lost the hypoxic drive because uh chronic retainers is that right? They forgot it great. Anyway, not creating a problems list. So this is something that, you know, might be a new concept for people who haven't caught patient's in before. So for me, a problems list isn't just the diagnosis and the acute medical problem that you're dealing with the problems list is a bit more holistic. So it doesn't just look at the pneumonia's you're treating. It's also, you know, considering poor mobility or is this a, a new onset of dementia that, you know, they come in with confusion, but this is um not necessarily um to do with an under guard underlying pathology that's, you know, an infectious cause, um, you know, it could be that there's a dementia that needs to be referred to, you know, specialist nurses. Although they've come in with this chest infection, their glycemic control might be off. So maybe you need to think about referring to the diabetes specialist team while they're in hospital. So this is just to make sure that yes, you're treating whatever's cause this acute presentation, but you're also addressing all those other problems that might be going on. So this is where problems list can be really handy. And it can just show that, you know, you thought more broadly about the patient and you're not just focused on the main pathology. So this is again something that can happen, not enacting plans before post take. So post take for those who aren't aware what post take is because it took me until I was an F one before I actually knew already understood what that meant. So you clark the patient in and then a consultant or reg will then come and see the patient with you and they do a bit of it. They listen to the history and examination that you've done, do a bit of history and examination themselves and come up with. Well, they either agree with your plan if it's a really stellar shining sparkly plan or they add some additional components and just provide that extra bit of insight that consultant has. So, but sometimes, and this has happened to me, you've, you've not even finished documenting for your, for the person that you've just clerked and the consultants come and they've either pulled you off to do a post take on a different patient or do a kind of more direct post take where they go and see the patient that you, you know, you, you haven't even clerked yet perhaps. And so sometimes it can happen, certain parts of the plan can get a bit missed, especially if you're on a very busy shift with a long patient list. So everybody is keen to see as many patient's as they can before handing over to the night team. And so sometimes bits of the plan can get, can get missed. So what I would advise in this situation is just to take yourself to one side almost or be quite firm when, when you're working with people in saying that okay. Yes, I will come and you know, do this post take, I will go and see that next patient. But first I need to do these things because otherwise things can get missed. So this is something that some of the other f ones that I worked with brought up. So not including the past medical and surgical history in the clerking document. Now, this sometimes happens because it's not as much of an acute issue if someone's come in with an acute abdomen. So they've got an appendicitis. It might not necessarily be relevant to the immediate immediate investigations and management that they've got a cardiac history, um, or that they are asthmatic diabetic, whatever. So you might be so focused on getting them to theater that, you know, you don't necessarily pop all the past medical and surgical history in. However, this can become a bit of an issue later on. Can any of you think of any specific health conditions when it comes to maybe prescribing new medications or initiating treatment where this might cause a few hiccups if the past medical history is not there. And there's one example that was brought up that, uh, is common and, you know, it can have some pretty nasty consequences if, if it's not documented clearly in the past medical history. So to give you a bit of a clue, it's to do with IV fluids. So, diabetes is important because, you know, if diabetes isn't included, that might not highlight to you that you need to prescribe some diabetes medications. So if they're on insulin, that might mean their insulin get, gets missed. But that should hopefully been picked up when you're prescribing those regular medications. So, yeah, exactly. Heart failure. So heart failure is the one. So if someone's come in, they've been acutely unwell and it hasn't been documented that they've got heart failure and you've been asked to go and see them because they've got a BP of 86/50 for and you think, okay, I'll give them a stat bolus of 500 mils of normal saline. What do you think is the risk there? You look on the documents they haven't got past medical history. Yeah, exactly. You're gonna fluid overload them, you might send them into a pulmonary edema and if they're already unwell and hypertensive, throwing a pulmonary edema in there as well, probably not the best of ideas. So, although it may not seem like the biggest priority when you're there, like writing out that long list of other past medical history because, you know, patient's rarely just have one of the condition. They've usually got hypertension hyperlipidemia I H D A F COPD, diabetes, thyroid, you know, sometimes they just have the lot and it might just seem like, well, is this really relevant to this moment in time? Not necessarily, but it could, it could cause issues further down the line. So I think I can't go forward anymore on the slides. So that has led us to the conclusion of tonight's teaching. I just want to say a massive thank you to everyone who's joined me, to everyone who's chipped in in the chat. I really appreciate it. Um If you have any further questions for me at the moment, then please ask away. Uh I'll hang around for a bit. Um Just to answer any questions, I really hope that, you know, this kind of giving you a bit of an introduction to clerking and just some things to consider my recommendation to you medical students specifically because obviously the F two is in the chat. Um There will be diving straight in and getting cracking with the clerking. But for medical students try and get as many opportunities clerking as you can because that's definitely the time where you learn most about how to really manage patients'. And that's something that all the other doctors that I've spoken to when preparing this have have echoed as well. Um, it just, it's, yeah, they're definitely like the most high yield learning opportunities and I know that high yield is exactly what medical students need. So, get cracking and hopefully this will give you a bit of confidence when you're clerking as a medical student. And like I say, any questions, pop them in the chat, really, really would value and appreciate your feedback. Will help me to fine tune this and other teachings for, um, for you guys at later dates as well. I hope you will have a wonderful evening and if you're in Wigan, I'll see you on the wards at some point. Yeah. Okay. Yeah, there are no questions. Then I'll leave you all to your Wednesday evenings. Have a good one. See you soon.