A suggested format for clerking patients with all the standard questions you might ever want to ask. this should be of help to medical students,trainee nurses and other general medical disciplines
Generally clerking is divided into two:
1. HISTORY TAKING
2. SYSTEMIC REVIEW
We'd begin with history taking
Introduction
Always begin by introducing yourself,develop a rapport. that the key to a successful history taking
all patients are humans and humans generally are apprehensive when giving out personal information so develop a rapport.
1. Introduce myself
2. Tell patient what U want to do
3. Ask patient if it is alright
4. Ask patient if they are comfortable
Preliminaries
After the rapport development and the introduction, its important you get the bio-data of the patient next.
follow either of the two format
1. Full name
2. Age
3. Occupation
4. Marital Status
5. Patient's Address & Telephone
6. Next of Kin's Address & Telephone
7. GP's name & area
8. Hospital consultant
or break it down into acronyms NASOMATI
N NAME
A AGE
S SEX
O OCCUPATION
M MARITAL STATUS
A ADDRESS
T TRIBE/RELIGION( DEPENDING ON YOUR LOCATION)
I INFORMANT...(its necessary to point out the person who answered the questions if twas the patient or the relation)
Presenting Complaint (PC)
ask the patient what brought him to the hospital...and categorize complain chronologically in descending order of date the complain started
its important that you put this in the patient own word.
History of Presenting Complaint (HPC)
1. Could you take me through everything leading up to you coming to hospital.
2. Symptoms most symptom can be exhausted under the acronym (SOCRATEIS)
Site
Onset (Sudden / Gradual)
Character
(Aching, Burning, Stabbing, Throbbing)
(Crushing, Constricting, Distending)
(Constant or Colicky)
(Deep or Superficial)
(Sharp or Dull)
Radiation
Alleviating factors
Time
Exacerbating Factors
Intensity / Severity
Associated features
Preceding events
Ever had it before?
Getting better / worse
Past Medical History (PMH)
1. Have you had any other problems requiring treatment or hospitalisation before?
2. IS THE PATIENT CURRENTLY ON TREATMENT FOR ANY CONDITION
3. Ask about :-
Rheumatic Fever
Diabetes
Jaundice Epilepsy
Tuberculosis
Hypertension
Asthma
Myocardial Infarction
Heart Disease Stroke
Chronic Bronchitis
Kidney Disease
Venereal Disease
Tropical Diseases
Operations )
Anaesthetic Problems (Anaes)
Immunizations (Imun)
Childhood Infections
(Measles, Mumps, Chicken Pox, German Measles)
(Diphtheria, Whooping Cough, Scarlet Fever)
Allergies / Drug Reactions
Anything else which I haven't mentioned or we haven't covered?
NEXT IS THE SOCIAL/FAMILY HISTORY
Ask about the family background of the patient,marital status, marital setting if married (monogamous/polygamous) number of children etc
Also ask about
Smoking
Drinking
Drugs
Allergies to either food and drugs
Review of Systems (ROS)
General
1. Weight Loss / Gain
2. Appetite / Diet
3. Thirst
4. Energy / Fatigue
5. Lumps
6. Fevers
7. Itches
8. Sleep
9. Night Sweats
Respiratory
1. Cough
2. Sputum
3. Haemoptysis
4. Dyspnoea
5. Wheeze
6. Chest Pain
7. Tachypnoea
Cardiovascular
1. Exertional dyspnoea
2. Paroxysmal Nocturnal Dyspnoea
3. Orthopnoea
4. Chest Pain
5. Palpitations
6. Ankle oedema
7. Intermittent Claudication
8. Headaches
9. Rheumatic Fever / Chorea
10. Pedal edema
Gastrointestinal
Upper Alimentary Tract :
1. Abdominal Pain
2. Appetite
3. Vomiting / Nausea
4. Vomit / Haematemesis
5. Belching / Flatulence
6. Water Brash
7. Heartburn
8. Indigestion
9. Swallowing / Dysphagia
10. Haemotypsis
Lower Abdominal Tract :1. Diarrhoea
2. Constipation
3. Stools (Steatorrhoea, Blood, Slime, Consistency, Colour, Flushing)
4. Pain
5. Frequency / Bowel Habit
6. Tenesmus / Urgency
Liver & Gallbladder :
1. Jaundice
2. Colour of Urine and Faeces
3. Itching Skin
4. Pain
Genito-Urinary System
Urinary :
1. Loin Pain / Dysuria
2. Oedema
3. Incontinence
4. Haematuria
5. Nocturia
6. Frequency
7. Polyuria / Oliguria
8. Hesitancy
9. Terminal Dribbling
Genital :
1. Vaginal / Urethral Discharge
2. Menses (Frequency, Regularity, Heavy or Light, Duration, Pain)
3. Perineal Pain / Swelling / Ulceration
4. Pregnancies (Gravida / Para)
5. Menarche / Menopause
6. Infertility
7. Sex Life / Dyspareunia
Neurological
1. Sight
2. Hearing
3. Taste
4. Touch
5. Smell
6. Epilepsy / Seizures
7. Faints / Blackouts
8. Headaches
9. Injuries
10. Parasthesia / Sensation
11. Motor Weakness / Muscle Twitches
12. Nausea / Vomiting
13. Paralysis / Stroke
14. Balance / Coordination
15. Speech
16. Higher Mental Function
17. Psychiatric Symptoms
(Anxiety, Phobias, Obsessive Thoughts, Compulsive Acts)
(Depression, Mania, Psychoses)
Musculo-Skeletal
1. Pain
2. Stiffness
3. Swelling of Joints
4. Functioning of Joints / Mobility
Skin
1. Rashes
2. Itching
3. Smell
4. Drugs
5. Hobbies / Occupation
6. Personal Hygiene
7. Allergies
systemic reviews comes next..
