Writing Up Examination Findings

Record all your findings; if it isn’t written down then it didn’t happen. Remember to include normal findings as normality may exclude other diagnoses and provides an important baseline to refer to if the patient deteriorates later. For shorter clerkings it is possible to write up after seeing the patients; this is less distracting and builds better rapport. For longer clerkings it may be better to write as you go (or bring a friend in to document) but be careful not to forget the patient in front of you! In some parts of the hospital e.g. A&E, SEU, there may be a clerking proforma that can act as a prompt for what questions to ask and to aid in writing up. 

THE LEGAL BITS

  • Put the patient’s ID label (sticky label) on all sheets of paper you use

  • Write the date and time in the left hand column 

  • Along the top write “Medical student clerking, (clerking location)”

  • Patient’s age, gender, occupation and how they arrived e.g. GP referral, BIBA (brought in by ambulance) 

  • Who the history is from and if anyone else is present

  • The same principles apply to electronic clerkings. When using EPR you should still document your status as a medical student, and the full findings of your clerking history and exam, as clearly as possible. (See an ‘Introduction to EPR’ for more details on how to use EPR)

HISTORY 

  • Divide this into sections as detailed in the ‘Taking a history’ section

  • If there are multiple complaints (which you do not feel are connected) then number them and describe them separately 

EXAMINATION

General Impression

  • Alert/oriented/drowsy/confused (quantify with GCS or AVPU)

  • Comfortable at rest/respiratory distress/in pain etc

Observations

  • HR, BP, temperature, RR, SaO2 (on room air or oxygen and if so how much?)

Cardiovascular

  • Pulse- rhythm and volume

  • Thrills or heaves?

  • Heart sounds: “I + II + 0” means S1 and S2 are present with no added heart sounds.

    • If there are murmurs record as “I + II + ESM (ejection systolic)/ PSM (pansystolic murmur)/ EDM (early diastolic murmur) etc.” 

    • You can also draw murmurs as shown below: 

Respiratory 

  • Trachea central?

  • Expansion

  • Resonance on percussion

  • You can represent auscultation findings diagramatically: 


Abdominal

  • Soft, non tender (SNT)/distended/rigid/ signs of peritonism

  • °Masses, °AAA, °organomegaly- shorthand for no masses, no AAA, no organomegaly

  • Bowel sounds heard (BS+)

  • The location of any masses or tenderness can be described using the 9 regions (see abdominal examination section) or by dividing the abdomen into quadrants (left/right and upper/lower- LUQ, RUQ etc). 

  • The findings may also be shown diagrammatically: 


  • Scars to remember: 

  1. Kocher (cholecystectomy)

  2. Rooftop (liver surgery)

  3. Paramedian (surgery to spleen, kidney or adrenal gland)

  4. Loin incision (renal surgery) 

  5. Pfannenstiel (C-section, uterine or bladder surgery)

  6. Gridiron (appendicectomy)

  7. Lanz (appendicectomy)

  8. Laparoscopic port scars around umbilicus (plus other positions on abdomen, usually 3)

  9. (not shown) midline laparotomy (open abdominal surgery) 

Neurological

  • CN I-XII  intact?

  • Gait normal? 

  • Babinski sign: positive, negative, equivocal 

  • Limb findings can be represented in a table: 

IMPRESSION AND PLAN

  • List your differential diagnoses from most to least  likely

  • If there is a diagnosis that is only a possibility of that you are unsure about you can write it with a ? which is shorthand for query e.g. ?pneumonia

  • Plan: list what needs to be done in order of priority e.g. senior review, blood tests (specify which) and CXR

    • Make it clear you are a medical student - it is good practice making plans but also important that the patient isn’t managed on your word alone

  • To finish: sign the clerking, write your name, write your designation (medical student). Get a senior colleague to review and co-sign your write up. 

A to E APPROACH

It is best practice to document examination findings in full as explained above, especially if it is a clerking examination. However, in some cases, for example when reviewing a patient on the ward round, doctors document in an A to E fashion. This is illustrated below:

A 

  • Patient talking, airway patent, trachea central

B

  • RR, SAO2 (on room air/oxygen), expansion, resonance, auscultation 

C

  • HR, BP, pulse- rhythm/volume, thrills, heaves, heart sounds

D

  • AVPU, GCS, temperature, blood glucose level, neurological findings

E

  • Everything else of relevance e.g. abdominal examination, catheter and lines etc