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

Background: Previous DVT, previous investigations for asthma

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Looking at the example documentation above, do you think anything needs to be added?

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Patient: Mrs Ellen ID number: 123456​

06/09/22  12:00​

Ward round: Dr Sherif (Medical Consultant)

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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.           ​

​O/E:

NEWS = 4. 99% RA. HR 115, RR 22​

​Alert. Looks well. Speaking in full sentences​

Bilateral wheeze. No focal signs. Calves SNT​

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Inv: Troponin negative

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What else may have been useful to document in this under investigations?

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All relevant recent investigations that have been completed

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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​

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Does this student need to get a counter signature from their supervising clinician?

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Is the required information included in the initial ward round documentation?