Basically, clerking a patient involves:
1) History taking
2) Physical examination
This entry only covers the history taking... So buckle up ^__^
Introduction
1) Always begin by introducing yourself.
"Assalamualaikum. My name is .... I am a medical student from VSMU."
2) Explain to the patient what do you want to do
" I would like to ask you some questions"
3) Ask the patient if it is alright.
Now that you introduced yourself, it's time to know your patient.
N Full name
A Age
S Sex
O Occupation
M Marital status
A Address and telephone number
T Tribe/Race (Malay, Chinese, Indian, etc)
I Informant (It is necessary to point out the person, who answered the questions if it was the patient or the relative/friend)
Presenting compaint (PC)
Ask the patient what brought them to the hospital.
"Could you take me through everything from the beginning leading up to you coming to the hospital?"
History of presenting complaint (HPC)
S Site
O Onset (Sudden or Gradual)
C Character
(Aching, Burning, Stabbing, Throbbing)
(Crushing, Constricting, Distending)
(Constant or Colicky)
(Superficial or Deep)
(Sharp or Dull)
R Radiation
A Alleviating factors
T Time/Duration
E Elevating factors
S Severity/Intensity (If pain, ask the patient the pain score from 0 - 10)
NB! Also don't forget to ask the patient about...
- Associated features
- Preceding events
- Ever had it before?
- Is it getting better or worse?
Past medical history (PMH)
1) "Have you had any condition that require treatment or hospitalization before?"
2) Is the patient currently on treatment for any condition (underlying diseases)?
3) Ask about...
Rheumatic fever
Diabetes mellitus / insipidus
Jaundice
Epilepsy
Tuberculosis
Hypertension
Asthma
Myocardial infarction
Heart diseases
Stroke
Chronic bronchitis
Venereal diseases
Tropical diseases
Operations
Anaesthetic problems
Immunizations
Childhood infections
(Measles, Mumps, Chicken pox)
(Diphtheria, Whooping cough, Scarlet fever)
Allergies / Drug reactions
Etc.
Family / Social History
1) Ask the patient about the family background, marital status, number of children, etc.
2) Ask female patient about...
- Gravidity (the number of times a woman has been pregnant, regardless of whether the pregnancies were interrupted or resulted in a live birth)
- Parity (the number of times a female has given birth to a baby)
3) Ask the patient about bad habits
- Smoking
- Alcohol consumption (Drinking)
- Drug abuse
4) Don't forget to ask about allergies to either food or drugs
Review of systems (ROS)
General
1) Weight loss / gain
2) Appetite / Diet
3) Thirst
4) Energy / Fatigue
5) Lumps
6) Fever
7) Itches
8) Sleep
9) Night sweats
Respiratory
1. Cough
2. Sputum
3. Haemoptysis
4. Dyspnoea
5. Wheeze
6. Tachypnoea
Cardiovascular
1. Exertional dyspnoea
2. Paroxysmal nocturnal dyspnoea
3. Orthopnoea
4. Chest pain / discomfort
5. Palpitations
6. Ankle edema
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. Haemoptysis
Lower abdominal tract
1. Diarrhoea
2. Constipation
3. Stools (Steatorrhea, 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
Urinary
1. Loin pain / Dysuria
2. Edema
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. Pigmentation (Hyperpigmentation, hypopigmentation)
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| Saya nk tny sikit ni... Pak cik sakit ape? |
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