First Clerking: Not Apparently Well

Clerking is one of the necessary evils in medical school.

My first clerking in medical school was an epic disaster. If a compilation of worst clerkings was done, mine should get a prize. It should be placed in a hall of fame. OK maybe I’m being hyperbolic. But you will agree with me (if you’ve ever clerked) that your first is probably your worst. And there are some common themes in almost every medical student’s first clerking.

The H. O sent the list of patients the unit is managing to us to share amongst ourselves. And I immediately went for the two with the simplest diagnoses. First, A CKD + T2DM patient in renal ward and the second patient a lady with GDM in postnatal ward.

I had read all I believed I needed to read on diabetes but nothing prepared me for everything that transpired when I stood face to face with my patient that day.

We paired ourselves once patients are shared. You don’t want to be going to do your first clerking alone. A lot could go wrong. So alongside my partner, I proceded to clerk. We started with the one at renal ward.

The woman was in her late 60s.

We all did these things…

Every rookie’s first clerking starter pack: a text in hand (usually Falase), a jotter and pen, a stethoscope (preferably around the neck), another text (usually Hutchinson) open and on standby on your phone or tab and a clerking partner.

I had mentally revised my opening lines before entering the ward.

Greet, introduce, explain what I’ve come to do and seek consent. We’ve been taught multiple times in posting. Biodata follows; no way I’m forgetting NASOMART. That went so well, I was scribbling so fast, too fast. So what followed made everything look like a graph of a spiking fever that suddenly dropped.

I had been encouraged by her response to the biodata questions that I enthusiastically proceeded to the next step. Presenting complaint. So, I threw the well known line at her. Her response knocked me off. She said nothing was wrong with her. And she stood by her words.

“What brought you to the hospital?”

“Ko si nkankan to se mi, there’s nothing wrong with me.”

Everything went downhill from there. I couldn’t cajole a presenting complaint out of her. With her were 3 of her relatives who kept convincing her to be cooperative that ‘these are doctors who have come to help.’

Consultants disliked hearing the excuse that ‘patient didn’t allow you to clerk her.’ So I persisted.

“Why are you in the hospital?”

I stood for an awkward moment semi angry, semi frustrated. I peeped into Falase for help. These textbooks don’t tell you how to handle non-cooperative patients.

I had seen somewhere that the common presenting complaints of diabetes are polyuria, polydipsia and polyphagia. I asked if she has any of these symptoms. Her response, which came back negative, was inconsequential because I already wrote polyuria, polydipsia and polyphagia down as her presenting complaints (Forgive me Hippocrates).

Common rookie mistakes

I made every rookie mistake possible.

Glanced into my text & phone whenever I couldn’t think of the next question. Turned to my partner with a what-else-do-you-think-we-should-ask-im-out-of-my-depths glance. And all these happened so often I’m sure the relatives suspected we were amateurs and probably took back their words.

Patient was on urethral catheter. I jotted this down. I wrote it under history of presenting complaint. ‘She’s obese’ my partner whispered. I jotted that too. Wrote it multiple times as it was consistent with the risk factors of her condition.

I did general physical examination when I couldn’t think of anything to ask. Even that was done with so much fuss you would think general physical exam was one complex algorithm. My backpack was on and this got in the way. I palpated for peripheral lymphadenopathy like someone looking for hidden gems. Pulled her eyelids up & muttered anicteric to my partner with a nod as if that was the defining finding. The relatives must have looked at me in awe. I glanced at her feet, pressed my thumbs against her medial malleoli before scribbling ‘pedal edema present’ in my jotter.

The clerking was haphazard, my jotting disjointed.

I would get home before discovering all the things I forgot to ask. Didn’t take family and social history. Didn’t ask for past medical history. No review of system. Man, I’m going to be skinned alive if I present this to a consultant.

Of course I didn’t go back to ask those questions. I put the clerking into writing, with plenty of cooking. Folded the clerking sheet into my bag and went to bed. I had done my job, as far as I was concerned. I had clerked.

Recently came across the clerking sheet, the manuscript, and I cringed😂.

Lessons in Retrospect

Few observations in retrospect. First, have a systematic way of doing your clerking. Mnemonics help too. This will save you a lot of troubles. Regs and SR’s use and recommend mnemonics. With practice comes improvement. Clerk more. There’s nothing like perfection in clerking.

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