Housemanship Guide: AM Reviews

This is for all the fresh graduates who just entered the workforce. Welcome to 2 years of hell. Seniors used to tell me it will get better, but did it really? In some ways it did, but for the most parts, it’s just the same shit, different things every day. But anyway, I guess one of the key lessons that nobody teaches you in medical school is reviewing patients. Sure, taking history and examining a patient is one key aspect, but when it comes to reviewing patients, asking relevant questions on a day to day basis, is a whole other continuum that nobody teaches you. It is as much common sense as it is practical experience that is to be gained throughout your internship. Before I lay out a format, here are some pointers.

Writing reviews are easy, it just takes a couple of practices, with familiarity and repetition, you’d do it like a robot (legit, same shit every day). But writing reviews aren’t as important as seeing your patient, assessing them and making sure they are making progress every day.

In Malaysia, as you know, we go to work on average 5AM everyday. In some departments you start taking blood before writing reviews. That may mean you’d actually have to come much earlier just so that you are able to finish taking all the bloods and completing all your reviews before your MO comes. My trick is (if I already know the patient) is to assess the patient as and when I’m taking their blood. A simple “how are you doing today?” is a good way to start. If you know this is a patient that came in for some cardiac issue, important questions to ask would be “any shortness of breath or chest pain?”. These questions become important when you document in your review later. The same applies to other organ systems.

A quick and simple assessment of your patient is CCTVR:

  • skin colour (C),
  • capillary refill time (normal <2 seconds) (C),
  • cold/ warm extremities (T),
  • pulse volume (V) and
  • rate (R).

Whenever you start writing your review, it goes in this order:

  • patient details/demographics
  • underlying conditions
  • issues
    • and relevant information
  • progress/current state
  • examination
  • impression (if a new issue pops up)
  • plan

Here is an example:

Ali
69 years old gentleman

Underlying
1. T2DM
2. Hypertension
3. Dyslipidemia

Issue:
1. NSTEMI
– Trop I (on admission) 4590 -> 3000 -> 2500
– Started DAPT (Tab cardiprin I/I OD and Tab clopidogrel 75mg OD)
– on S/C Clexane 60mg OD Day 3
– Planned for angiogram

2. Uncontrolled Diabetes
– HbA1C (2/2/2022) – 9.5%
– on S/C Insulatard 20units ON and SC Actrapid 14 units TDS

Currently,
Comfortable under room air
Tolerating orally well
No chest pain/SOB
BOx1 yesterday

On Examination,
Alert, conscious, CRT<2s, warm peripheries, good pulse volume, pulse is regular
JVP not raised.
Lungs: Clear
CVS: DRNM
PA: soft, non tender, not distended. No hepatomegaly

Plan:
1. Continue insulin regimen.
2. DXT QID, inform if DXT>12.
3. For cardio to review.
4. Inform if chest pain/SOB.
5. Continue DAPT.
6. Continue S/C Clexane.
An example of an AM review.

My example is of course an oversimplified version. A good and detailed version should entail home medications (prior to admission), years of illness, location of follow up under the underlying conditions. Your issues could probably be elaborated further, e.g initial presentation, progress in ward etc. And of course, your examination should be more comprehensive.

If this is your first time reviewing a patient, it is good to include the initial HOPI prior to your issues. This makes it easier to present your case later. It sets as a good reminder (assuming you’d be able to flip open your case notes for some pointers, which may not always be the case).

In an ideal world where admission clerking is perfectly done, your daily AM reviews need not be as detailed, but rather include information that constitutes the patient’s progress. This allows you to write a comprehensive discharge summary later on. I’ll probably write about this at some point later. I hope this helps all you juniors!

Cheers,
Darien

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