Clerking key points:
- age/ race/gender
- chief complain
- presenting history (how it happens-where they fall, how, why; pain-what kind of pain-location, intensity, relieving factors)
- other related signs and symptoms: LOC(loss of consciousness), headache, N&V(nausea and vomiting)
- treated by any other hospital?
- past medical history: underlying disease? DM/HPT? well controlled?
- Social hostory: ADL, who he is staying with?
- P/E- relevant and related: Observe, palpate, motor: Range of movement of limbs, sensitivity, neurological
- report any X-ray or CT scan done
Review pt in the morning.
- the header is S/B Dr. XXX or <AM review>
format:
- age/race/gender
- Post operation Day/ Day admission, what kind of surgery,
- pt condition: oral and toiletry, SOB, fever, cough/flu, pain(pain score),
- vital signs: BP, Pulse, T
- P/E: dressing, wound/condition
- Plan: continue previous meds, change dressing, physio referral, feeding, pain medication
Must know: (for ortho)
- how to read the spine X-ray/ any xray
- check alignment
- body: vertabral body, spinous process, antevertebral body, 4 lines of X-ray,
- any burst /compression fracture
- to determine via TLCIS if the person with thoracolumbar injury needs surgery or not.
- physical examination
- motor, sensory and neurological: any abnormalities, know what is it testing for
- differences between Upper Motor neuron and Lower Motor Neuron,
- Cauda Equina
- end of UMN is L2
COMMON TO DO LIST
- TO do ABG, use the blue needle and syringe to extrct the blood
- to do line, use pink needle, find the vein on pt hand, feel and put it in.
- to do slap, need a friend to help with releasing the water from the back slap(10 layers)
- to do skin traction: prepare the cover and weight(10% of pt body weight)
- to be prepared always for mo who is coming for pt.
