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Admission Clerking

History & examination
 See OSCEstop notes histories and examinations

Document admission and plan
 Date, time, location
 Patient age, sex, ± relevant background conditions
 History
o PC
o HPC (e.g. symptoms as separate major bullet points, with sub-bullet points exploding each symptom, and then relevant
system reviews as further major bullet points – include relevant positives and negatives)
 Symptom A
 Explode
 Explode
 Symptom B
 Explode
 Explode
 Relevant system review A
 Relevant system review B
o PMHx (supplement with information from patient’s previous eDocuments on the hospital system)
o DHx (including allergies)
o FHx
o SHx (must be very thorough in elderly patients – get collateral)
 Examination (you should do very basic multi-system exam like below for all new admissions regardless, but you should examine
the relevant systems in much more detail and specifically document the presence/absence of signs of differential diagnoses)
o OBS
o RS cyanosis, percussion, lung sounds, calf swelling/tenderness
o CVS JVP, heart sounds, peripheral oedema, peripheral pulses
o Abdo tenderness, masses/organomegaly, bowel sounds
o NS GCS, limb movements
 Differential diagnosis/diagnosis/impression
 Other issues
 Plan
o Investigations (with fill-in boxes – half fill when taken/requested, fully fill when result back and checked)
o Management
o Other aspects to plan
 Sign with name, role, bleep

Investigations
 Perform
o Site cannula and take bloods from cannula (consider doing before history and mark as urgent so results are back
quicker)
o Other indicated investigations e.g. ABG, LP, blood cultures
 Ask nurse
o Bedside tests e.g. ECG, urine dip (±MC&S), swabs
 Order
o Relevant imaging
o Any other tests required BOXES approach to investigations

•Bloods: venous (e.g. FBC, CRP, U&Es,
LFTs ± amylase, G&S, INR), blood cultures
Management (if pyrexial), ABG, cap glucose
 Implement ABCDE-type management as necessary i.e. oxygen, fluids •Orifice tests: urine dip,
 Fill in drug chart urine/sputum/faeces cultures
•X-rays/imaging: CXR, AXR, US, CT
o Disease-specific treatments
•ECG
o PRN analgesia ± anti-emetics ± anti-pyretic •Special tests: depending on likely cause
o Regular medications
o DVT prophylaxis (enoxiparin ± anti-embolism stockings)
 Order/perform any other disease-specific interventions
 Fill in a VTE assessment
 Keep patient NBM if surgery may be required
© 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

with a view to confirming/excluding the differential diagnosis (e. you should know exactly why you are doing them. abdominal X-ray to exclude small bowel obstruction)  Write quickly during the consultation to save time.Review  Note down the patients details and which investigations need to be chased  Follow up the results and document them in the notes  Change/initiate treatments if needed  Present to seniors (when initial investigation results are back) and implement any additional management plans Tips!  The difference between a medical student clerking and a senior doctor clerking is asking questions. rather than the whole of SCORATES. shake their hand.g. ask diagnosis-specific questions e. examining and investigating with a view to diagnosis rather than to including everything o Questions are asked to include or exclude differentials (e. start with open questions and find out their ideas. focussed questions. don’t worry about the notes not being neat. But.  Never forget your communication skills – introduce yourself properly. © 2013 Dr Christopher Mansbridge at www. what happened and to get more information about past/drug/ social history  Ensure you are leading the consultation – learn how to politely interrupt patients. ensure the patient is the main focus. still.g. use the patients name. use closed. “does the abdominal pain radiate to your back?” can suggest pancreatitis) o A basic ‘baseline’ multi-system clinical examination should still be done in everyone on admission but you should focus on looking for particular signs to include/exclude potential differential diagnoses (e.g.e.OSCEstop.com. a source of free OSCE exam notes for medical students’ finals OSCE revision . for investigations. If the patient is very talkative. letters. investigation results) for the patient on your hospital system to supplement PMHx/DHx and ensure you know accurately about their history  In some elderly patients. you may need to call next of kin or nursing/residential home for collateral history r. there’s no time to listen to patient’s chat.g. raised JVP and RV heave for PE) o Likewise. concerns and expectations.g. “Is the chest pain worse when you exercise?” can exclude angina. discharges.  Look through all the previous hospital eDocuments (e.

O/E: OBS: Sats 99% RA. -No change in bowel habbit.requested 2) CXR ↘APACHE scoring (inc ABG) 3) If all normal. No PV discharge/bleeding. apyrexial excessively.5 Ur 6. reassure and discharge with analgesia ↘Add calcium to bloods and smoking advice -Management CTN ↘IV fluids C.N. No leg ↘Small volumes swelling ↘Not related to food -No Hx of recent long haul flights. PE Wells score = 0) ↘Urine dip + βHCG ↘USS abdomen mane . Using condoms for contraception. PMHx: -Mild asthma: Dx 2001. No alcohol consumption. Mansbridge Surgical SHO Oncall (bleep 1226) © 2013 Dr Christopher Mansbridge at www.26.55 Medical Admission Clerking Surgical Admission Clerking background of mild asthma Epigastric pain x 1/7 PC: Right sided chest pain x1/7 HPC: -Epigastric pain HPC: -Pleuritic chest pain ↘Gradual onset last night from 6pm ↘Across lateral wall of right chest ↘Sharp gripping pain ↘Since waking at 8am today ↘Radiates to back ↘Aching in character ↘Constant ↘Radiates to front of chest and back. no fever/rigors -Salbutamol inhaler PRN PMHx: -Type II Diabetes (diet controlled) -Ramipril 10mg OD -Appendicectomy 1988 FHx: No FHx of atopy. dry mucus membranes Resonant to percussion Chest: Chest clinically clear Normal air entry.0 Chest expansion normal Cap refill 4s. no wheeze or added sounds HS I + II + 0 PEFR: 400ml (normal for patient) No peripheral oedema CVS: No heaves/thrills Abdo: No bruising HS I + II + 0 Soft abdomen.moving all 4 limbs. BP Never smoked. ˚Urinary frequency -Mild hypertension: Dx 2000.2 Cr 143 Amylase ∆∆: 1) Musculoskeletal chest pain 608 2) Small pneumothorax IMPRESSION: Pancreatitis 3) Viral pleurisy OTHER ISSUES: Acute kidney injury 4) P. colour/consistency).com. pallor +. No masses/AAA/hernias No masses/organomegaly. No periods of ↘No blood/bile immobility.2013 23. no peritonitits No peripheral oedema Tenderness and guarding over epigastrium and LUQ Abdo: S. lives with husband and two children. + NG tube if continued vomiting ↘Clear fluids only ↘Heparin (impaired RF) + Anti-embolism stockings ↘Admit to acute surgical team CTN C. cap refill <2s O/E: OBS: Sats 97% RA. HR 90bpm. RS: No cyanosis. RR 19/min. Drinks 2 glasses of wine each weekend – never drank 140/85mmHg. DHx: -NKDA -Feels generally well. No fever. No focal neurology.T. Independent at home with wife. BLOODS FROM A&E: Hb 135 WCC 30.unlikley PLAN: -Investigations PLAN: 1) Bloods (inc D-Dimer.OSCEstop.E. ↘No exacerbating or relieving factors ↘Constant ↘Severity 8/10 ↘Exacerbated by inspiration and movement -Vomiting ↘Severity 4/10 ↘3 times today -No SOB.11. BS present NS: GCS 15/15. SHx: Solicitor. No sputum/haemoptysis. no jaundice. DHx: -NKDA SHx: Works on building site. BP 170/95mmHg.42 29. RR 18/min.04. Epigastric percussion pain Normal bowel sounds. well controlled. No cardiac history.. T 37. -LMP 1 week ago. well controlled.2013 15. Mansbridge ↘Analgesia Medical FY1 Oncall (bleep 5211) ↘Anti-emetics. No cough.2 CRP 67 Na+ 143 K+ 4. HR 92bpm. a source of free OSCE exam notes for medical students’ finals OSCE revision . warm peripheries. never -No weight loss required hospital admission -No urinary Sx → ˚Dysuria. -No regular medications Smokes 10/day 30 years. Last opened bowels this morning (normal -Generally well.