Fear is the only thing that will deter people from stupidity. Hit your children more often. -HypoG

The art of Clerking; When Copy Paste Won’t help :(

Saturday, January 28th, 2012


So you spent the past few years taking photos of patients history files and copy pasted your friends work with minor tweaks? Well, when you start your career, you’ll feel like an idiot, and will most probably perform like an idiot clerking patients and subsequently reviewing them. Clerking is really simple. It’s simple enough even an idiot could do it {i.e. Me}, so all you smart kids shouldn’t have any problems.


Just follow 3 simple rules, concise, relevant, and accurate.

Concise: Don’t write an essay, get to the point.

Relevant: If patient comes in for APO, don’t order BFMP investigation.

Accurate: If for example a patient comes in with fever, it is vital to know the exact date of onset.


There are plenty of other nonsense but I’m sure you get a rough idea.


Before we begin, it’s important to identify our patient.

Since I’ve been recently working in the dengue ward, I’ll just use a Dengue Case as an example.

28/01/2012 @ 6.00 PM

30/M/F  K/C/O HPT

30 years old Malay Lady, Known Case of Hypertension


Next to get the chief complaint;

Fever x 4/7

Proceed to full clerking.

+Fever x 4/7

– A/W Chills and Rigor

+ Vomiting x 2/7

  – 3 Episodes Today (Induced by eating food)

  – Food Particles

  – 0 blood

+ Diarrhoea x 2/7

– 4 Episodes Today

-Brownish-Yellowish Stool

– 0 Blood

+ Arthralgia/Myalgia

+ Lethargy

+ Bleeding Gums x 1/7

– Occurs after brushing teeth.

0 Retro orbital pain

0 Headache

0 Abdominal Pain



+Tolerating Orally Minimally


Last PCM Intake: Today at E/D at 4.00 PM

0 H/o of IM Injections

0 h/o Jungle Trekking, Waterfall, or other such activities (TRO Leptospirosis)

+Lives in Dengue Endemic Area, Recent fogging.

+Menses started today, usual course 7 days, 2-3 pads a day, claims used 5 pads today.


0 Surgical H/o

Insignificant family h/o of hereditary disease.

0 Non Smoker / Alcohol Abuse



O/E Alert, Pink, Answers in Full Sentences, Full GCS, Fair Hydration

0 Pallor, 0 Ankle Oedema, 0 Jaundice

BP 130/86

PR 135 (Good Volume)

T’C 37.5

Lungs Clear, A/E Equal


CNS Grossly Intact

CRT < 2 Seconds

PA : Soft, Non-Tender. No Organomegaly

Diagnosis: Compensated DSS In Febrile Phase Day 4 with warning signs (Persistent Vomiting, Lethargy, Bleeding Tendencies)





Dengue IGM


Serum Lactate



DXT : 7.0 mmol/l



1) Notify Dengue

2) Ideal Body Weight (45.5 + 0.91(152.4-ht)). If difference between IBW and Real Weight is huge, just add IBW + Real Weight, divide 2, and take that value.

3) Run 10 CC/kg/hr NS for 1 hour, and review. (Compensated DSS)

4) T. Provera 10MG Stat then BD

5) IV. Maxolon 10mg stat then TDS

6) Encourage Orally

7) Tranexamic gargle TDS/PRN

8) ORS Per Purge

9) Pad Chart

10) Hourly Vital Sign Monitoring

11) Put in Acute Cubicle

12) Inform MO

13) Trace IX and Review

14) Withold Antihypertensives

15) IV Omeprazole 40mg BD

16) I/O Charting


That’s roughly the gist of how you clerk a patient. Probably not the best clerking ever, but it’s good enough to survive. So now we’ve got this patient on a bolus, it’s time to do a post bolus review.


28/1/12 @ 7.20 p.m.

<Post Bolus R/V>

30/M/F K/C/O HPT

Compensated DSS D4 in Febrile Phase with Warning Signs (Persistent Vomiting – Resolved) (Lethargy) (Bleeding Gums – Resolving)

C/ Completed 10cc/kg/hr NS x 1 hr

+ No more vomiting / No Nausea

0 Abd Pain

+Resolving Gum Bleed

0 Other Active Complaints


Blood IX

HB 13.0 WC 1.42 PLT 87 HCT 43 LACTATE 1.9 PH 7.33 HC03 22 CK 300

Noted Carditis

O/E Alert, Pink, Answers in Full Sentences, Full GCS, Fair Hydration

BP 120/80

PR 115 (Good Volume)

T*C  38.8

Lungs: Clear A/E Equal


PA : Soft/Non Tender. 0 Organomegaly

CNS : Grossly Intact

CRT < 2 Seconds


P/ 1. Cut down IVD to 7cc/kg/hr, and review in 1 hour

    2. Blood IX, FBC, LACTATE, VBG

    3. Trace IX




This would be a simple review. A patient that was running a 10cc bolus due to Compensated DSS, is now tapered down to a 7cc bolus as she is responding. You trace the 10cc bolus bloods and review the patient again in an hour and check all her parameters, if you like what you see, taper down your bolus again, if you don’t, restart a bolus.

As always, be careful when running bolus. Don’t wanna overload the patient, always auscultate the lungs for the dreaded bibasal crepts!


That’s all for now, I’m too tired. Bye kids! Hopefully this update isn’t incorrect, I’m as sleepy as hell while typing this.

Like a Boss

Friday, January 20th, 2012


I finally managed to ask the consultant today the outcome of my assessment. It appears I have passed. Woohoo! <— This is my celebrating.

Okay, now that I have sufficiently celebrated, it’s now to face the sad reality. The point of time between post-assessment and end-posting is generally considered critical. You have to make sure you don’t make any mistakes and try to fly under the radar! Any mistakes made will be exaggerated to be bigger than it really is and will do no good and may ultimately lead to an extension.

For those of you who know me, try as I may, it is close to impossible to fly under the radar. I could be quietly sitting down in the corner, with anti-detection gear and I’d still be said to be trying to infiltrate the white house. I stick out like a sore thumb.

So since flying under the radar isn’t a possibility, the only other option is to not make any mistakes. That sounds quite difficult as well, considering I’m only human!

This will be quite a challenge to get to the middle of February out of harms way, but we’ll just have to wait and see I guess.


Here’s another Woohoo! before I retire to bed, because, getting sufficient sleep is celebration enough!