Here we assume you know the basics, and instead we focus on the common pitfalls with tips on how to be safe & well reasoned. Not all FY1s have the opportunity to clerk patients but the underlying principles are of great value if you’re doing an FY1-led ward round.
The expectation is that you are slow and thorough – if you rush you can make mistakes & you end up spending more time worrying than seeing patients. It might be the only time during their admission, that all their information is collated from the multitude of useful sources of information: relatives, clinic letters, their medications, discharge summaries and GP records if available. Future teams of doctors caring for the patient will refer back to your information to ask important questions to inform their management, such as past medical history, allergies and functional baseline prior to admission.
It will get easier
As we are mostly taught about diseases in vertical streams (pathophysiology, presentation and management of one condition), switching to a presenting complaint and working through the differentials can be difficult. It can feel challenging integrating your prior knowledge at the beginning. Be reassured that this gets easier with time and take satisfaction from becoming more confident with the more frequent and straightforward presentations, such as community-acquired pneumonia.
Have a proforma so you don’t miss things
Save a proforma (if electronic documentation) or print one out. Don’t forget to include:
- History (red flag symptoms & systems review, in anyone elderly, always do a cognitive assessment such as an AMTS)
- Past medical history (is this a new problem? Anything that impacts on your treatment: e.g. dyspepsia during treatment for ACS)
- Social history (What is their functional baseline – carers, dependency on ADLs?)
- Medication history (compliance in diabetes, heart failure & allergies)
- Examination (always include what they look like e.g. quiet, looks unwell, not engaging in eye contact and making incomprehensible sounds – really helpful for the person who sees them tomorrow and can’t tell if they’re better or worse! Also always do a thorough examination – peripheral vascular for leg pain or neurological exam in back pain. Include any difficulties you had because of challenging behaviour for example)
- Venous thromboembolism prophylaxis
- Treatment escalation planning
- Your bleep & details
Aim to make an issues list & differential before seeing the patient
People often ask, “why are we seeing them if A&E doctors already have?”. You see patients generally with the results of their investigations, have the time to dig deep into their records & see them with a focus of “what holistic approach will give them the right treatment?”. A&E is predominantly about making decisions of who can be safely discharged, triaged to ambulatory care or other services or which specialty they should be admitted under having received initial treatment. For safety, they will frequently start very broad-spectrum antibiotics for example.
- What are your differentials? What questions do you need to ask to navigate these? What examination finds are you expecting? What investigations are helpful?
- What are the other issues that have resulted in admission? Prioritise these & ask the relevant information. If they have had a fall, for example, is it equipment they need or support with daily activities or is it a pacemaker for an underlying heart block.
An impression is the most helpful part
As juniors, we are often tempted to skip over this for fear of being wrong, especially if the patient is complex or the presentation is ambiguous. Always right an impression & always elaborate on your reasoning (as this helps doctors reading your clerking). Anyone can collate information & indeed computers can come up with a plan from a diagnosis. You are a doctor for your ability to process it.
“Unable to clean house due to increasing frailty. Fall from increased clutter around the house, resulting in a long lie as unable to get up that has caused rhabdomyolysis resulting in acute kidney injury.”
Note how this tells me that I need to treat with fluids, whilst his home is assessed & his mobility optimised with equipment as appropriate and carers if needed. Even “raised inflammatory markers, but without focal symptoms/signs to suggest chest/abdominal or urinary involvement” is of great value!
Use this to make a plan that deals with each issue. But remember you’re not there to fix everything, but perform the correct investigations & optimise the initial treatment
Prove to yourself it isn’t something else
Be aware of your biases. You are more likely to diagnose a condition that A&E have suggested, something you have seen recently, or something emotive (e.g., a previously missed diagnosis leading to patient harm). These biases come about owing to system 1 thinking: fast, instinctive and unconscious. Examples include relying too heavily on pattern recognition and deciding on a diagnosis too early. We can try to overcome them by boosting our system 2: slower, logical and conscious thinking. Keep your differentials broad and take new information on board.
Remember, there could be more than one problem going on. When looking through investigation results, think ‘what does not fit in with my theory?’ It can be tempting to ignore these results and press on regardless, but maybe you’re missing a second diagnosis, or maybe your initial diagnosis does not take the whole picture into account.
Don’t assume there is something going on that you have never heard of. There can be unusual presentations of common conditions and, in general, this is more likely than a rare condition.
To treat, you don’t need the diagnosis
Ultimately, you do not need to be the best diagnostician! Your job is to gather as much information as you can and present this to your seniors as succinctly as possible. If you have gone in the wrong direction you can go back to your initial history and examination findings. Most patients need simple, straightforward management before the post take ward round. If they are dehydrated: give fluids; if they are in pain: give analgesia; if there’s an infection of unknown source: do a thorough examination & take cultures and samples from everywhere you can.
After you see a patient, they will be reviewed by the consultant with you; this is called a “post take”. It can feel a little daunting but getting the simple things organised can really help. Know where your patients have moved to. Get the notes early so you’re not searching for these. If you have specific questions that need answering, for example, regarding anticoagulation, write these down so you do not forget. Like any ward round, be clear on their reasoning and why they have recommended certain investigations, both for your learning and for ease of doing the jobs later.
- For more information on potential biases, read Thinking Fast and Slow by Daniel Kahneman
- For more information on clinical decision making, see: Trimble M & Hamilton P (2016). The thinking doctor: clinical decision making in contemporary medicine. Clinical Medicine 16(4), 343-346
- For the basics, see Geeky Medics
Written by Dr Sarah Freeston FY2
Editing by Dr Akash Doshi CT2
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