Last Updated on May 26, 2022
STEP 1: Background
Comorbidities
• Ask about underlying medical illness(es) and the follow up. Which clinic, which hospital, government or private?
• Previous history of admission(s) and why
• Any recent admission?
• List down all current medications correctly
Pre-morbid functional status
• How is the patient before this current illness sets in?
• ADL / Mobility
Social history
• Is patient still working? Working as what?
• Patient is staying with who?
• Is patient a smoker? If smoker, number of pack years?
Female patients
• Ask about LMP
STEP 2: Reason for Admission
• Elective / Emergency?
• “A good clerking is when after 5 minutes of history taking, your mind has started listing down the PROVISIONAL & DIFFERENTIAL DIAGNOSIS” – Dr Aimir
STEP 3: History Taking + Physical Examination
History Taking
• HOPI in detail? Use SOCRATES for pain.
• What happened in ED? Management in ED?
• Other histories – past medical illness (as above), family history, social history etc.
Physical Examination
• General examination
• Systemic examination (as complete as possible especially lungs, cardiovascular, abdomen,)
• Regional examination e.g. if patient has leg problem, you must examine the leg as well
STEP 4: Outline Your Management
Investigations / Bedside Procedures
• ECG? Dxt?
• Blood taking e.g. FBC, RP, Coag, / pre-op blood
• Imaging e.g. chest X ray (mobile / standard?), abdominal X ray (mobile / standard?), CT scan
Treatment
• Oxygen supplement
• Feeding / Fluid: Encourage taking orally? Need to start IV drip maintenance? Need to start IV drip bolus?
• Medications? Endorse patient’s own medications from home e.g. anti-diabetics, anti-hypertensive etc.
• Monitoring e.g. strict I/O charting, fit charting
Further Reading
Adapted from FB Aimir Ma’rof