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



2.    Put thermometer in mouth



3.    Nails and Hands



4.    Arms



5.    Blood Pressure



6.    Eyes



7.    Read thermometer



8.    Mouth and Tongue



9.    Neck



10.   CVS Examination

a.      Lean patient at 45 degs b.      Auscultation c.      Sacral oedema  /  Ankle oedema


11.   Respiratory Examination

a.      Inspection b.      Sitting up c.      Lying Down d.      Sputum  (Pink, Clear, Yellow, Green, Blood)


12.   Breasts  &  Axillary Lymph Nodes



13.   Abdominal Examination

a.      Inspect         Abdomen b.      Palpation         Note         Abdomen         Liver         Aorta  (Note Abdominal Aortic Aneurism  AAA)
        Spleen  (May need to lie patient on right lateral side)
        Kidneys

c.      Percussion d.      Auscultation e.      Hernial Orifices f.       Inguinal Lymph Nodes
g.      Genitalia


14.   Legs



15.   Neurological Examination

a.      Cranial Nerves

b.      Sensory System

c.      Motor System

d.      Meningeal Irritation

e.      Skull & Spine



16.     Gait



17.      Speech



18.      Higher Mental Function



19.      Perform Rectal and consider Vaginal Examination



20.      Examine Urine with dipstick and microscope if appropriate.




PostBox   To contact me : Email  

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

Top     Back to  Top of this page


   Last Modified : 5th June 1999