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Patient: Mrs Ellen

ID number: 123456

Ward: ABC​

06/09/22  12:00​

Ward round: Dr Sherif (Medical Consultant)

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Presenting Complaint and Past Medical History:

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Presenting Complaint and Past Medical History:

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28F admitted with SOB. Referred to Medicine for ?PE due to positive D-dimer. She has had x1 treatment dose of clexane

PMH: Previous DVT (inc year), previous investigations for asthma

Note: if this is clerking information you may require further information here, eg drug history, dosages of medications give, etc

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Inv:

D-Dimer - positive (inc. actual value)

Troponin - negative

CXR, ECG, other bloods in past 24 hours, etc

Any other investigations reviewed by senior clinician at time of ward round

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Today:

Still feeling short of breath, denies chest pain.

She is concerned about a clot in her lungs.​

CTPA discussed with her (make a note of verbal/written consent for any investigation/procedure that the patient consents for)           ​

​O/E:

NEWS = 4. 99% RA. HR 115, RR 22​

​Alert. Looks well. Speaking in full sentences​

Bilateral wheeze. No focal signs. Calves SNT​

Note: if other examinations are performed, document them too. If you are usure about an examination finding, ask the person examining.

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Note: you can reference investigations that you have reviewed on the ward round by stating which investigation it was, what time and date it was completed, and who it was reviewed by

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Note: you can reference investigations that you have reviewed on the ward round by stating which investigation it was, what time and date it was completed, and who it was reviewed by

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Imp: Need to exclude PE​

​Plan:

1. Salbutamol nebs ​

2. Peak flow pre/post nebs​

3. CTPA this morning (needs new cannula)​

4. If CTPA +ve may need anticoagulation – discuss with haematology​

5. Confirm above plan with supervising clinician​

Note: Impression can be a bit more explanatory/longer if required - remember, it's a way of explaining your thinking and justifying your plans/actions

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Signed by Medical Student

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Countersigned by supervising Medical Doctor with grade, GMC number, and bleep/contact number