An On-call day for the General Surgery Junior Doctor: Clerking a patient
On a regular on-call day ( once a week according to my Rota), you get patients referrals from the A&E department ( 3–4/ day in a small hospital to 10–15/day in a busy major hospital ).These patients need to be assessed by the junior doctor first before taking over their care and performing surgical intervention.
Let’s discuss a case of Intestinal obstruction which is commonly encountered in the general surgical practice. This is how I clerk a patient :
- Finding an examination room for the patient / knocking before entering the room if they are already there
- Introducing yourself ( your name , designation and purpose of being there)
- Confirming patient details ( their name, date of birth and hospital number/ NHS number)
- Asking the history of presenting complain:
‘ 92 years old lady developed acute onset, dull and generalized abdominal pain for the past 2 days. There is no radiation of the pain and the pain has been increasing since then . It is associated with nausea and vomiting ( 4–6 episodes a day with large amount of yellow-green colored vomitus ). She had last opened her bowels 3 days ago .There is no associated passage of flatus since then. No other systemic complains are associated with this episode.’
5. Asking the past medical history
‘ She has a medical history of hypertension, diabetes mellitus type 2, COPD and had a NSTEMI 4 years ago .’
6. Asking the past surgical history
‘ Patient had a cholecystectomy performed 48 years ago for acute cholecystitis. She also had a umbilical hernia repair performed 40 years ago.’
7. Asking medication history
‘ Patient currently take Aspirin, Beta-blockers, Ramipril , Spironolactone, Simvastatin, Metformin and Salbutamol inhalers ( with their dose and timing of administration )
8. Asking about history of smoking, alcohol use or other recreational drugs usage
‘Patient is an ex-smoker. She used to smoke 15–20 cigarettes a day everyday for 30 years when she stopped smoking at the age of 62. She occasionally takes a glass of red wine on the weekends . There is no other recreational drug usage history.’
9 . Asking about history of allergies
‘ Patient is allergic to Penicillin and Strawberries.’
10. Asking about their occupation
‘Patient has currently retired but she was a primary school teacher 40 years ago.’
11. Asking about their social history
‘ Patient lives alone in a bunglow. Her daughter lives close by and helps her with shopping and laundry. She has no other designated carers.'
12. Asking about their functional history
‘ She is usually mobile independently and walks using a zimmer frame inside her house. She prefers not to go outside often and is usually accompanied by her daughter when she does. She is able to perform her usual activities of daily living — washing, cooking , getting dressed etc.’
13. Ask about relevant family history
‘ Her mother died of colorectal carcinoma at 83 years of age.’
14. Ask about her marital history
‘ She lost her partner 14 years ago . He had end stage prostate carcinoma.’
15. Checking vitals signs ( combined to get NEWS score in the UK) and General Examination
Examination steps are explained clearly. Consent is taken before examination which is chaperoned by another female healthcare member.
Comment on Pallor, Icterus , Clubbing of fingers, Peripheral and Central Cyanosis and Pedal edema.
16. Abdominal Examination
‘ The abdomen is grossly distended with no localized swelling present. All quadrants move equally with respiration. There are no dilated abdominal veins. Post-cholecystectomy scar and peri-umbilical scar is visible from the previous surgery.
There is tenderness on deep palpation in the left iliac fossa and hypogastric region of the abdomen. There is no rigidity or rebound tenderness.
Bowel sounds are sluggish on auscultation.'
17. Per-rectal examination
'There are no peri-anal skin changes, tags or warts. No hemorrhoids are felt. An empty rectum is felt. There was no pain on examination and there is no fecal/ blood staining of the examining finger.'
18. Examination of other systems ( respiratory system, CNS etc.)
19. Collecting blood and urine samples , checking sample results and acting on them if deranged : FBC (check for bleeding), U&E ( check for electrolyte imbalance ) , CRP (will suggest inflammation/ infection) , Lactate ( will point towards strangulated bowel loops), ABG/VBG (will check for acid base disturbances ) , Cross-Match for possible surgery, Urine Dip stick test ( to check for possible infection if symptomatic )
20. Provisional diagnosis
‘ Possible intestinal obstruction’
21. Requesting required investigations
‘ Abdominal X ray followed by a CT scan of abdomen and pelvis’
22. Immediate interventions and informing the designated nurse about these
‘ Keep the patient nil per oral and start on IV fluids. Introduce a naso-gastric tube to prevent aspiration. Give pain relief with oral morphine and give anti-emetics (Cyclizine)’.
23. Prescribing medication and preparing a drug chart for the patient (Includes prescribing prophylactic dose of low molecular weight heparin and TEDS stocking for preventing thromboembolism)
24. Discussion of the patient’s case with your senior i.e. Registrar on-call , for review
25. Booking the patient for theatre if required and informing the theatre staff and the consultant on-call
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