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
0 URTI Sx
+ LOA / LOW
+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
NKMA / NKFA
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
CVS DRNM
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)
IX
FBC/COAG
RP/LFT/CE
Dengue IGM
VBG
Serum Lactate
GSH
ECG
DXT : 7.0 mmol/l
Plan
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
CVS : DRNM
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.