Physician-Vorlage
Medical Clerking
Eine professionelle Physician-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
The Medical Clerking template is a comprehensive documentation tool used by physicians to record detailed patient assessments during hospital admissions. This template captures essential information such as the patient's presenting complaint, medical history, medication list, allergies, social history, and examination findings. It also includes sections for vital signs, investigations, clinical impressions, and management plans. This template is particularly useful for physicians in internal medicine and emergency departments, ensuring thorough and systematic patient evaluations. When used with Heidi, it facilitates efficient and accurate documentation, enhancing patient care and communication among healthcare providers.
Vorlagenvorschau
PC: Chest pain.
HPC: Patient presented on 1 November 2024 with a 3-day history of chest pain, which started suddenly and has been progressively worsening. The pain is sharp, located in the central chest, and radiates to the left arm. Associated symptoms include shortness of breath and sweating. Denied any nausea or vomiting.
PMH:
- Hypertension
- Type 2 Diabetes (on insulin)
- Atrial Fibrillation (on apixaban)
DH:
- Metformin 500 mg BD
- Lisinopril 10 mg OD
- Apixaban 5 mg BD
- Insulin glargine 20 units ON
Allergies / ADRs:
- Penicillin - Rash and swelling, occurred in 2020, required antihistamines
SH:
- Retired teacher
- Lives alone
- Smoker - 10/day - 20 pack years
- No significant alcohol consumption
O/E:
- General appearance: Alert, in mild distress
- HS I + II + 0
- Abdo SNT
NEWS 4 - BP 140/85 mmHg; HR 95 bpm; Sats 96% on RA; Apyrexial; Alert
Investigations
Bloods: CRP 5; Hb 13.5; WCC 7.0; Neut 4.5; Plt 250; INR 1.1; PT 12; APTT 30
Urea 5.0; Na 140; K 4.0; Creat 67 (baseline 65); eGFR 90 (baseline 92); cCa 2.2; Phos 1.0; Mg 0.8
ECG: Sinus rhythm with occasional PVCs
Chest X-ray: No acute changes
Impression:
- Acute coronary syndrome
- Hypertension
Plan:
- Admit to cardiology unit
- Start aspirin 300 mg stat
- Continue apixaban
- Arrange for urgent cardiology review
- Monitor cardiac enzymes and repeat ECG
- Follow-up with GP post-discharge
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