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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
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, examining and investigating
with a view to diagnosis rather than to including everything
o Questions are asked to include or exclude differentials (e.g. rather than the whole of SCORATES, ask diagnosis-specific
questions e.g. “Is the chest pain worse when you exercise?” can exclude angina, “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. raised JVP and RV heave for PE)
o Likewise, for investigations, you should know exactly why you are doing them, with a view to confirming/excluding the
differential diagnosis (e.g. abdominal X-ray to exclude small bowel obstruction)
 Write quickly during the consultation to save time. But, still, ensure the patient is the main focus; don’t worry about the notes
not being neat.
 Look through all the previous hospital eDocuments (e.g. discharges, 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.e. what happened
and to get more information about past/drug/ social history
 Ensure you are leading the consultation – learn how to politely interrupt patients, there’s no time to listen to patient’s chat. If the
patient is very talkative, use closed, focussed questions.
 Never forget your communication skills – introduce yourself properly, use the patients name, shake their hand, start with open
questions and find out their ideas, concerns and expectations.

© 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision
26.04.2013 15.42 29.11.2013 23.55
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 exacerbating or relieving factors
↘Constant ↘Severity 8/10
↘Exacerbated by inspiration and movement -Vomiting
↘Severity 4/10 ↘3 times today
-No SOB. No cough. No sputum/haemoptysis. No leg ↘Small volumes
swelling ↘Not related to food
-No Hx of recent long haul flights. No periods of ↘No blood/bile
immobility. -No change in bowel habbit. Last opened bowels this morning (normal
-Generally well. No fever. colour/consistency).
PMHx: -Mild asthma: Dx 2001, well controlled, never -No weight loss
required hospital admission -No urinary Sx → ˚Dysuria, ˚Urinary frequency
-Mild hypertension: Dx 2000, well controlled. -LMP 1 week ago. No PV discharge/bleeding. Using condoms for contraception.
DHx: -NKDA -Feels generally well, no fever/rigors
-Salbutamol inhaler PRN PMHx: -Type II Diabetes (diet controlled)
-Ramipril 10mg OD -Appendicectomy 1988
FHx: No FHx of atopy. No cardiac history. DHx: -NKDA
SHx: Works on building site. Independent at home with wife. -No regular medications
Smokes 10/day 30 years. No alcohol consumption. SHx: Solicitor, lives with husband and two children.
O/E: OBS: Sats 99% RA, RR 18/min, HR 90bpm, BP Never smoked. Drinks 2 glasses of wine each weekend – never drank
140/85mmHg, apyrexial excessively.
RS: No cyanosis, warm peripheries, cap refill <2s O/E: OBS: Sats 97% RA, RR 19/min, HR 92bpm, BP 170/95mmHg, T 37.0
Chest expansion normal Cap refill 4s, no jaundice, pallor +, dry mucus membranes
Resonant to percussion Chest: Chest clinically clear
Normal air entry, 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, no peritonitits
No peripheral oedema Tenderness and guarding over epigastrium and LUQ
Abdo: S.N.T. No masses/AAA/hernias
No masses/organomegaly. Epigastric percussion pain
Normal bowel sounds. BS present
NS: GCS 15/15. No focal neurology- moving all 4 limbs. BLOODS FROM A&E: Hb 135 WCC 30.2 CRP 67 Na+ 143 K+ 4.5 Ur 6.2 Cr 143 Amylase
∆∆: 1) Musculoskeletal chest pain 608
2) Small pneumothorax IMPRESSION: Pancreatitis
3) Viral pleurisy OTHER ISSUES: Acute kidney injury
4) P.E.- unlikley PLAN: -Investigations
PLAN: 1) Bloods (inc D-Dimer, PE Wells score = 0) ↘Urine dip + βHCG
↘USS abdomen mane - requested
2) CXR
↘APACHE scoring (inc ABG)
3) If all normal, reassure and discharge with analgesia
↘Add calcium to bloods
and smoking advice
-Management
CTN
↘IV fluids
C. Mansbridge
↘Analgesia
Medical FY1 Oncall (bleep 5211)
↘Anti-emetics, + NG tube if continued vomiting
↘Clear fluids only
↘Heparin (impaired RF) + Anti-embolism stockings
↘Admit to acute surgical team
CTN
C. Mansbridge
Surgical SHO Oncall (bleep 1226)

© 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision