Structured clerking for ED / ward admissions.
History
- • PC + HPC (SOCRATES for pain)
- • PMH, drug history + allergies, family + social, ICE
- • Systems review
- • Functional baseline + collateral
Examination
- • General + vital signs
- • Cardio, resp, abdo, neuro as relevant
- • Targeted exam for presenting complaint
Investigations
- • Bedside: ECG, urine dip, glucose, blood gas
- • Bloods: FBC, U&E, LFT, CRP, coag, group & save
- • Imaging: CXR, AXR, USS, CT as indicated
- • Microbiology if febrile
Impression + plan
- • Differential diagnosis in order of likelihood
- • Immediate management, fluids, analgesia, oxygen
- • Anticipated investigations + referrals
- • VTE prophylaxis, gastric protection, glucose plan
- • Escalation / DNACPR, capacity, safeguarding
- • Communicate plan to patient + family
