Of morning rounds, and silicone and plastic tubes

Dear House Officers,
When you see a patient in the morning:

1. List the problems:
• underlying chronic and long-standing problems (1 list headlined as PM)
• current acute problems (1 list headlined as Pb)
2. Ask:
• about the presenting symptoms 
• e.g. if the patient came in fever, cough and greenish sputum then ask about the whether the fever and cough is reduced and the sputum has turn white.
• the 5 basic functions of humans:
• eat
• drink
• pass motion
• pass urine
• sleep
3. Look at the observation chart
• the staff nurse already took the effort to take the blood pressure, pulse rate, respiratory rate, SpO2, temperature, pain score; input and output; vomit, stool, haemetemesis chart the least you can do is look at it and write down the latest reading.
• If you are excellent don't just take one reading in isolation but see the trend (up-going, down-going, stable)
• If anything is abnormal FIND THE CAUSE and add to your problem list above.
4. Examine:
• the presenting signs
• if the patient came in with crepitations ask yourself has it been reduced?
• Cursory look at the other systems:
• cardiovascular
• respiratory
• abdominal
• bed-sore
• count the number of plastic and silicone tubes in the patient, then ask yourself
• When was it set?
• Has been more than 3 days?
• is it necessary? 
• What was the original intentions? Is it still fulfilling its task?
• can I remove it? 
• Is it needed for anything important? Is it the only line for for patient for whom setting lines is a headache?
• should I remove it? 
• So even if it is necessary and the line can't be removed because it is literally a life-line but if it is infected and oozing with pus it should be removed.
• Please get an alternative line first before removing it.
5. Investigations:
• Trace all the results.
• If it is abnormal trace the baseline which is the result when the patient was well which is not the same as the admission results.
• If a result should be there but your colleague didn't take bloods please rectify the problem.
• Again do no look at it in isolation but determine the trend (up-going, down-going, static)
• Fill up your charts.
• Use a red pen to mark the whether the result is normal, high or low.
• If anything is abnormal add to your problem list.
• Write down the findings for the:
• Electrocardiogram
• X-rays
• Computed tomography
• Ultrasound
6. Medication chart:
• Is the medication correct?
• to treat the condition
• the form and method is correct.
• Is the dose correct?
• renal or hepatic adjustment.
• side-effects?
• contraindications?
• Is the medication served?
7. Plan:
• Think modularly.
• This is where your problem lists come in handy. 
• e.g. If the patient had chronic diabetes mellitus make sure you order for:
• refer for eye care, foot care, dietician and diabetic nurse counselling.
• Glucose monitoring
• Diabetic diet
• Start medications.
• Make sure every problem on the list has a plan to a solution.

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