Jason Wolfe's Patient Clerking Page

A suggested format for clerking patients with all the standard questions you might ever want to ask. I developed this in the months following starting the clinical part of the medical course at LHMC. It might for example be useful for medical students and perhaps 'Nurse Practitioners'.

Introduction

1.	Introduce myself
2.	Tell patient what I want to do
3.	Ask patient if it is alright
4.	Ask patient if they are comfortable

Preliminaries

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

Presenting Complaint (PC)

What exactly is the problem?

History of Presenting Complaint (HPC)

1.	Could you take me through everything leading up to you coming to hospital.
2.	Symptoms Site Character (Aching, Burning, Stabbing, Throbbing) (Crushing, Constricting, Distending) (Constant or Colicky) (Deep or Superficial) (Sharp or Dull) Radiation Intensity / Severity Duration Onset (Sudden / Gradual) Alleviating / Exacerbating Factors Associated features Preceding events Ever had it before? Getting better / worse
3.	Others Smoking Drinking Drugs

Past Medical History (PMH)

1.	Have you had any other problems requiring treatment or hospitalisation before?
2.	Are you visiting your GP about any other problems?
3.	Ask about :- Rheumatic Fever (RhF) Diabetes (DM) Jaundice (Jaun) Epilepsy (Ep) Tuberculosis (TB) Hypertension (High BP) Asthma (Asth) Myocardial Infarction (MI) / Heart Disease (HD) Stroke (CVA) Chronic Bronchitis (COAD) Kidney Disease (Renal) Venereal Disease (VD) Tropical Diseases (TD) Operations (Op) Anaesthetic Problems (Anaes) Immunisations (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?

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
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
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

Family History
1.	Could you tell me a little about the rest of your family. How well are they?
2.	Parents
3.	Siblings
4.	Children
5.	Ages
6.	Diseases
7.	Causes of Death
Social and Occupational History
1.	Marital status
2.	Spouse - Health and Job
3.	Past & Present Jobs
4.	Housing (Stairs to Climb ?)
5.	Support (Shopping & Cooking, Home help, Meals on wheels, District Nurse)
6.	Visitors
7.	Social Life
8.	Hobbies / Pets
9.	What patient can and can't do because of illness
10.	Diet
11.	Alcohol / Tobacco / Drugs of Abuse

Treatment History

1.	Past & Present Drugs
2.	Allergic Reactions to Drugs
3.	Other Reactions to Drugs

Examination

General

1. Look patient all over

Build
State of Nutrition / Obesity
Dehydration
Cyanosis
Anaemia
Jaundice
Pigmentation / Skin Colour
Skin Lesions
Skin Rashes
Petechiae
Spider Naevi
Body Hair
Deformities / Swellings
Tremor

2. Put thermometer in mouth

3. Nails and Hands

Palmar Erythema
Proximal & Distal Interphalangeal joints
Dupuytren's Contracture
Nail Pitting
Clubbing
Splinter Haemorrhages
Leuconychia
Koilonychia
Nail fold infarcts / Vasculitis

4. Arms

Pulse rate
Rhythm / Volume / Character
Respiratory rate
Radial / Brachial Pulses

5. Blood Pressure

6. Eyes

Lids  (Entropion, Ectropion, Cysts)
Conjunctiva  (Anaemia, Conjunctivitis)
Sclerae  (Jaundice, Scleritis)
Cornea  (Scarring & Ulceration)
Iris  (Reaction to light, Nodules)
Lens  (Cataracts)
Intra-Ocular Pressure  (Glaucoma)

7. Read thermometer

8. Mouth and Tongue

Cyanosis
Tongue texture (Smooth, Furred, Beefy)
Colour

9. Neck

Lymph nodes
Goitre

10. CVS Examination

a.      Lean patient at 45 degs

Carotid pulse
    (Irregularly irregular / Regularly irregular)
    (Bounding / Weak)
    (Slow rising / Quick falling / Bisferens pulses)
    (Pulsus paradoxus / Pulsus Alterans)
    (Aortic stenosis)
Jugular Venous Pressure (JVP) and Waveform
Feel Apex Beat  (Character & Position)
Precordial Thrills
Parasternal Heave
b.      Auscultation

On back, listen with bell to apex
On left lateral position, listen with bell to apex  (Mitral valve)
On left lateral position, listen with diaphragm to
    Aortic Valve
    Pulmonary Valve
    Tricuspid Valve

Sit patient up.  Listen in expiration to valves and murmurs.
c.      Sacral oedema  /  Ankle oedema

11. Respiratory Examination

a.      Inspection

Fever
Breathlessness
Cyanosis
Oxygen Saturation  (% O2 Sat)
Clubbing
Respiratory Distress
CO2 Retention  (Flap, Bounding Pulse)
Shape of Thorax
    (Barrel Chest, Pigeon Chest, Funnel Chest, Kyphosis, Scoliosis)
Patterns of Respiration
    Tachypnoea
    Cheyne Stokes Respiration
    Kussmaul Respiration
b.      Sitting up

Inspect Chest Expansion
Palpate Chest Expansion
Exhale Vital Capacity as fast as possible
Peak Flow
Percuss  (Front and Back)
Auscultate with bell  (Front and Back)
c.      Lying Down

Palpate
    Trachea
    Anterior Chest Expansion
    Tactile Vocal Fremitus  ("99")
    Apex Beat  (Shows position of mediastinum)
Percuss  (Normal, Resonant, Dull, Stony Dull)
Auscultate
    Breathe through mouth
    Vesicular / Bronchial Breathing
    Change in Volume & Character
Added Sounds
    Wheezes  (Rhonchi)
    Crepitations  (Crackles)
    Pleural Rubs
    Silent Chest
Vocal Resonance / Whispering Pectoriloquy  ("99")
d.      Sputum  (Pink, Clear, Yellow, Green, Blood)

12. Breasts & Axillary Lymph Nodes

Palpate all 4 quadrants & Axillary Tail
Areola & Nipple

13. Abdominal Examination

a.      Inspect

Spider naevi
Leukonychia  (Hypoalbuminaemia)
Liver Flap  (Asterixis)
Gynaecomastia
Jaundice
Palmar Erythema
        Abdomen

Visible Pulsation
Peristalsis
Scars
Striae
Masses
Distension / Size / Symmetry
Genitalia
Herniae
Superficial Abdominal Veins
b.      Palpation

Lie patient down with 1 pillow, arms by side
Warm hands
Look at face
        Note

Tenderness / Guarding
Splashing
Rebound Tenderness  (Peritoneal Inflammation)
Any Masses
        Abdomen

Each Quadrant  (Starting away from any pain)
Superficial
Deep
        Liver

Size / Smoothness / Tenderness / Swelling
Pulsatile?
Lower Border
Upper Border  (By percussion only; Upper limit 5th ICS)
Bruit
        Aorta  (Note Abdominal Aortic Aneurism  AAA)
        Spleen  (May need to lie patient on right lateral side)
        Kidneys

c.      Percussion

Upper Border of Liver
Spleen
Intestines
Shifting Dullness / Fluid Thrill
d.      Auscultation

Bowel Sounds
    Absence  (Paralytic Ileus)
    Enhanced  (Bowel Obstruction)
Bruits
e.      Hernial Orifices

Masses
Coughing
f.       Inguinal Lymph Nodes
g.      Genitalia

14. Legs

Swellings
Perfusion
Pulses
Ankle / Brachial Doppler Pressure Index
Oedema
Varicose Veins

15. Neurological Examination

a. Cranial Nerves

I - Smell
II - Fundi, Fields & Acuity
Fundi
      Papilloedema
      Optic Atrophy
      Hypertensive, Diabetic, Uraemic Changes
Fields
      Test in the 9 Cardinal positions
      Central Vision
      Hemianopia  (Homonymous, Bitemporal, Unilateral)
Acuity
      Reading different sized print on a newspaper  /  Snellen Chart
Pupils  (Oculomotor, Sympathetic & Parasympathetic Nerves)
      Size, Shape, Symmetry
      Reaction to Light  (Direct & Consensual)
      Reaction to Accommodation
III  IV  VI - Ocular Movements
      III Palsy - Ptosis, Large Pupil, Eye down and out
      IV Palsy  - Diplopia on looking down or in
      VI Palsy  - Diplopia on lateral gaze
      Nystagmus
V - Facial Sensation  (3 Divisions)
      Corneal Reflex
      (Cotton wool on lateral margin of cornea, at conjunctival margin)
      Muscles of Mastication  (Jaw deviates towards side of lesion)
      Taste for anterior 2/3rds of tongue
      (Lingual Nerve - Chorda Tympani - Facial Nerve)
VII - Facial Movements
      Screw up Eyes
      Whistle
      Show Teeth
      Blow out Cheeks
      Eyebrows  (Up and Down)
      Weakness, Droop, Bell's Palsy
      Taste for anterior 2/3rds of tongue
      Resistance to loud noises - Stepedius
      LMN Lesion - Total Paralysis
      UMN Lesion - Frontalis Spared
VIII - Hearing
      Compare with self, each ear separately
      Tuning fork, or clock
      Conductive Loss  (Rinne's test, Weber's test)
      Neural Loss  (Loss of Hearing and Balance together)
      Tinnitus / Hyperacusis / Hallucinations of sound
      Balance - Vertigo (Room spinning)  /  Dizziness
IX - Palatal & Pharyngeal sensation
      Gag Reflex  (Cotton wool to pharynx and palate)
      Taste to posterior 1/3rd of tongue
X - Palatal, Pharyngeal & Laryngeal motor function
      Say "Ah!"  (Palate elevates centrally  /  laterally)
      Say "Rub"  (Paralysis of smooth palate - "Rum")
      Cough  (Paralysis produces ineffectual cough)
      Speech  (Paralysis - Characteristically ineffectual and muffled)
XI - Shrug shoulders  (Trapezius)
      Rotate chin  (Sternomastoid - Paralysis produces
      weakness of rotation towards opposite side)
XII - Protrude tongue out as far as possible
      In paralysis, tongue deviates towards side of lesion

b. Sensory System

Light Touch  (Cotton Wool)
Pain  (Pin prick & Deep muscle pressure)
Vibration  (128Hz Tuning Fork)
Joint Position Sense
Dermatomes
Stereognosis  /  Astereognosis
Temperature  (Hot & Cold Test Tubes)
Sensory Inattention  (Parietal Lesions)

c. Motor System

Muscle bulk  /  Wasting  /  Contracture
Involuntary Movements
      (Epilepsy, Myoclonus, Tremor, Athetosis, Chorea, Dyskinesia)
      (Hemiballismus, Tics, Metabolic flap = Asterixis, Tetany)

Tone
      Spasticity & Clasp Knife reaction  (Corticospinal Lesions)
      Clonus  (Corticospinal Lesions)
      Rigidity + Tremor  (Cogwheeling)  (Extrapyramidal lesions)
      Lead Pipe Rigidity  (Parkinsonism)
      Myotonia
Power
      Oppose muscle actions
      Check Myotomes
      Grade weakness
Coordination
      Ask them to touch their finger repeatedly between their nose & your finger
      Continue the above moving your finger about.
      Walk in a straight line
      Rub heel down shin of opposite leg
      Check for Dysdiadochokinesia
Reflexes
      Biceps  (C5-6)
      Triceps  (C7-8)
      Supinator  (C5-6)
      Knee  (L3-4 (L2) )
      Ankle  (S1-2)
      Abdominal  (Lost in UMN Lesions)
      Plantar  (Babinski Sign)
      Jendrassik's manoeuvre

d. Meningeal Irritation

Neck Flexion Test  (Stretches cervical spinal nerve roots)
Extend knee when hip is fully flexed  (Stretches sacral nerve roots)
Straight leg raising  (Tests for Sciatica)

e. Skull & Spine

Malformation
Signs of injury

16. Gait

Walk Normally  /  On heels  /  On toes
Check for Romberg's Sign
Spastic gait
Sensory Ataxia
Cerebellar Incoordination
Festinant gait  (Parkinsonism)
Waddling gait  (Proximal muscle weakness or
      Hip joint disease producing Trendelenburg's sign)
High Stepping gait  (Extensor weakness in Peroneal nerve palsy)

17. Speech

Dysphagia
Dysarthria
Dysphonia

18. Higher Mental Function

Conscious Level  /  AVPU Scale
      A  -  Alert
      V  -  Responding to Voice
      P  -  Responding to Pain
      U  -  Unesponsive
Glasgow Coma Scale

Eye Opening
      4  -  Spontaneous
      3  -  To Voice
      2  -  To Pain
      1  -  No eye opening
Speech
      5  -  Orientated
      4  -  Confused Conversation
      3  -  Inappropriate Words
      2  -  Incomprehensible Sounds
      1  -  No Response
Motor Function
      6  -  Obeys Commands
      5  -  Appropriate Localising Response to Pain
      4  -  Withdrawal Response
      3  -  Abnormal Flexion Response  (Decorticate rigidity)
      2  -  Abnormal Extension Response  (Decerebrate rigidity)
      1  -  No Response

Mini Mental Test Score  (MTS)

Name
Age
Date of Birth
Address
Time  -  Current Year  /  Day of Week  /  Time of Day
Place  -  Where are we ?
Person  -  Who am I ?   Who is that ?
Long Term Memory  -  Dates of the 2nd World War
Short Term Memory  -  Who is the Current Monarch  /  Prime Minister ?
Concentration  -  Count from 20 - 10 backwards.

Mental State Examination  (MSE)

Appearance  (Well kept  /  Dishevelled)
Speech  (Slow  /  Fast  /  Flight of Ideas)
Mood  (Happy, Sad, Depressed, Manic)
Abnormal Beliefs  (Psychoses)
Abnormal Experiences  (Hallucinations  /  Illusions  /  Voices)
Orientation in Time, Place & Person
Short & Long Term Memory
Concentration
Insight

Jason Wolfe's Patient Clerking Page

A suggested format for clerking patients with all the standard questions you might ever want to ask. I developed this in the months following starting the clinical part of the medical course at LHMC. It might for example be useful for medical students and perhaps 'Nurse Practitioners'.

Introduction

Preliminaries

Presenting Complaint (PC)

What exactly is the problem?

History of Presenting Complaint (HPC)

Past Medical History (PMH)

Review of Systems (ROS)

Treatment History

Examination

General

1. Look patient all over

Build State of Nutrition / Obesity Dehydration Cyanosis Anaemia Jaundice Pigmentation / Skin Colour Skin Lesions Skin Rashes Petechiae Spider Naevi Body Hair Deformities / Swellings Tremor

2. Put thermometer in mouth

3. Nails and Hands

Palmar Erythema Proximal & Distal Interphalangeal joints Dupuytren's Contracture Nail Pitting Clubbing Splinter Haemorrhages Leuconychia Koilonychia Nail fold infarcts / Vasculitis

4. Arms

Pulse rate Rhythm / Volume / Character Respiratory rate Radial / Brachial Pulses

5. Blood Pressure

6. Eyes

Lids (Entropion, Ectropion, Cysts) Conjunctiva (Anaemia, Conjunctivitis) Sclerae (Jaundice, Scleritis) Cornea (Scarring & Ulceration) Iris (Reaction to light, Nodules) Lens (Cataracts) Intra-Ocular Pressure (Glaucoma)

7. Read thermometer

8. Mouth and Tongue

Cyanosis Tongue texture (Smooth, Furred, Beefy) Colour

9. Neck

Lymph nodes Goitre

10. CVS Examination

11. Respiratory Examination

12. Breasts & Axillary Lymph Nodes

Palpate all 4 quadrants & Axillary Tail Areola & Nipple

13. Abdominal Examination

14. Legs

Swellings Perfusion Pulses Ankle / Brachial Doppler Pressure Index Oedema Varicose Veins

15. Neurological Examination a. Cranial Nerves

b. Sensory System

Light Touch (Cotton Wool) Pain (Pin prick & Deep muscle pressure) Vibration (128Hz Tuning Fork) Joint Position Sense Dermatomes Stereognosis / Astereognosis Temperature (Hot & Cold Test Tubes) Sensory Inattention (Parietal Lesions)

c. Motor System

d. Meningeal Irritation

Neck Flexion Test (Stretches cervical spinal nerve roots) Extend knee when hip is fully flexed (Stretches sacral nerve roots) Straight leg raising (Tests for Sciatica)

e. Skull & Spine

Malformation Signs of injury

16. Gait

Walk Normally / On heels / On toes Check for Romberg's Sign Spastic gait Sensory Ataxia Cerebellar Incoordination Festinant gait (Parkinsonism) Waddling gait (Proximal muscle weakness or Hip joint disease producing Trendelenburg's sign) High Stepping gait (Extensor weakness in Peroneal nerve palsy)

17. Speech

Dysphagia Dysarthria Dysphonia

18. Higher Mental Function

19. Perform Rectal and consider Vaginal Examination

20. Examine Urine with dipstick and microscope if appropriate.

To contact me : Email

My Website is at http://www.jwolfe.clara.net.

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Last Modified : 5th June 1999

Build
State of Nutrition / Obesity
Dehydration
Cyanosis
Anaemia
Jaundice
Pigmentation / Skin Colour
Skin Lesions
Skin Rashes
Petechiae
Spider Naevi
Body Hair
Deformities / Swellings
Tremor

Palmar Erythema
Proximal & Distal Interphalangeal joints
Dupuytren's Contracture
Nail Pitting
Clubbing
Splinter Haemorrhages
Leuconychia
Koilonychia
Nail fold infarcts / Vasculitis

Pulse rate
Rhythm / Volume / Character
Respiratory rate
Radial / Brachial Pulses

Lids (Entropion, Ectropion, Cysts)
Conjunctiva (Anaemia, Conjunctivitis)
Sclerae (Jaundice, Scleritis)
Cornea (Scarring & Ulceration)
Iris (Reaction to light, Nodules)
Lens (Cataracts)
Intra-Ocular Pressure (Glaucoma)

Cyanosis
Tongue texture (Smooth, Furred, Beefy)
Colour

Lymph nodes
Goitre

Palpate all 4 quadrants & Axillary Tail
Areola & Nipple

Swellings
Perfusion
Pulses
Ankle / Brachial Doppler Pressure Index
Oedema
Varicose Veins

15. Neurological Examination

a. Cranial Nerves

Light Touch (Cotton Wool)
Pain (Pin prick & Deep muscle pressure)
Vibration (128Hz Tuning Fork)
Joint Position Sense
Dermatomes
Stereognosis / Astereognosis
Temperature (Hot & Cold Test Tubes)
Sensory Inattention (Parietal Lesions)

Neck Flexion Test (Stretches cervical spinal nerve roots)
Extend knee when hip is fully flexed (Stretches sacral nerve roots)
Straight leg raising (Tests for Sciatica)

Malformation
Signs of injury

Walk Normally / On heels / On toes
Check for Romberg's Sign
Spastic gait
Sensory Ataxia
Cerebellar Incoordination
Festinant gait (Parkinsonism)
Waddling gait (Proximal muscle weakness or
Hip joint disease producing Trendelenburg's sign)
High Stepping gait (Extensor weakness in Peroneal nerve palsy)

Dysphagia
Dysarthria
Dysphonia