“Dr GP is sending us a patient to be admitted for pain control. Sefkhet, can you clerk her in?” Yes. Yes, I can. I’ve, uh, I’ve never actually done it before, though. “Oh, it’s easy. Just do what it says on the form.” And so it came to pass that I found myself on the medical admissions unit, looking like someone who ought to have known what she was doing and gripping the clerk-in form like a security blanket. And thinking that it couldn’t possibly be as easy as my F2 had made it sound.
First, to explain something of what I’m talking about. The “clerking-in” is what happens when someone is being admitted to hospital. It is basically a full medical everything. From the patient’s point of view, this means being asked lots of questions that either don’t seem terribly relevant or were already asked by their GP and/or A&E and then being used as a pincushion
The clerk-in form is a magnificent invention that: a) provides a consistent format for recording screeds of information, and b) acts as a prompt for all the things that you would otherwise forget to do. However, it is not quite so simple as “just do what it says on the form”. I had an exceedingly cooperative patient who was being admitted for pain control on her arthritic shoulder. I made her sit through a full neurological examination but didn’t dare touch the shoulder.
1. read the old notes
Or the GP letter. Or the SBAR from A&E. Or whatever. At worst, it means that there’s verification of what they’ve told you. At best, it means that you don’t struggle through getting a medical history only to find later that the patient who looked completely sane was actually completely demented and making things up as she went along. Oh, but I did.
2. the end-of-the-bed test
There are some patients who just look sick. Like, really sick. Sometimes, it’s all right to stop your clerk-in and go to find a doctor.
3. sit down
It’s not a five minute job. It isn’t made more comfortable either for you or for the patient when you spend the entire half hour looming over them.
4. the form isn’t a substitute for knowing what to do
I’ve used clerk-in forms that have prompted everything — where the section for GI examination includes a blank schematic of the abdomen and space to comment on organ size and bowel sounds. And I’ve used clerk-in forms that have “GI Exam” and then some empty white space. Besides, being reminded to comment on the spleen only helps if you already know how to palpate for it. (I was worried about causing pain, but my bigger reason for not examining that patient’s shoulder was that I didn’t know how.)
5. presenting complaint
The presenting complaint is the thing that is wrong with the patient, in their words. Generally, appendicitis is not a presenting complaint — stomach pain is a presenting complaint. Mind, I once had a patient whose actual presenting complaint was atrial myxoma, but I suppose there are exceptions to every rule.
6. the concept of background history
The taught format for taking a medical history is very very structured. It works. In real life, things are a little more flexible. You’re allowed to record relevant details from other parts of the history under the presenting complaint. If a patient presents with crushing chest pain, their history of unstable angina and previous CABG is part of the presenting complaint. Yes, you have to write it down again under past medical history, but that’s okay.
7. the art of medicines reconciliation
If the patient offers a plastic bag full of their medications or a copy of their last prescriptions, take them. It’s a much easier and much more reliable way of getting an accurate drug history than expecting patients to remember the names and doses and times of all their drugs. Of course, not everyone is on seventeen different drugs. But the ones who offer usually are.
8. when not to do a neuro exam
As a general rule, everyone gets their heart and lungs listened to and a hand laid on their abdomen. As a general rule, not everyone needs to have a neuro exam. If they aren’t presenting with neurological symptoms, “grossly intact” or “alert and oriented / moving all four limbs” is usually enough.
9. think about getting the bloods first
Yes, they are at the end of the form. It doesn’t mean that they have to be done at the end. This is especially true when you’re at a hospital in the arse end of nowhere and there aren’t out-of-hours lab facilities and your patient turns up at 4pm on a Friday. Similarly, sending off the x-ray request first means that the patient might actually get their x-ray before all the radiologists go home. Again, especially if you’re at a hospital in the arse end of nowhere.
10. find someone to present it to
It is not quite so simple as “just do what it says on the form”, but that’s the only way you ever really learn how to do it. You do what it says on the form. And then you present it to someone so that you can learn how to do it better next time.