Medical Student Clerking Proforma
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- Frederick Fletcher
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1 1 of 11 Medical Student Clerking Proforma Episode details Date patient arrived: (DD/MM/YY) Patient s location: Time patient arrived: Source of referral A&E/GP/Other Clerking student: Module: Firm: Date of clerking: Doctor reviewing case: Time of clerking Admission team Source of history Patient, relative, interpreter etc. Presenting complaint(s) [PC]
2 2 of 11 History of each Presenting Complaint [HPC] Include chronological sequence of each complaint; systems specific review; risk factors; relevant negatives;
3 3 of 11 Past Medical, Surgical and Mental History [PMH] None Cardiovascular problems Respiratory problems Hepatic problems Renal problems Neurological problems Diabetes mellitus Type1 Type 2 Previous surgeries: Include dates/operations (N.B. insulin treament does not necessarily = T1) Malignancy Any other conditions:
4 4 of 11 Drug History [DH] Include dose/frequency/self-medication/over the counter medication/ inhalers/ oxygen/nebulisers in CAPITALS Allergies and adverse reactions Include details of reaction Family History [FH]
5 5 of 11 Social History [SH] Smoking status Current smoker per day for years Ex-smoker Never smoked Alcohol consumption units per week= Recreational drugs: Recent foreign travel (if relevant) Social circumstances/services and carers Housing: House Nursing Residential Flat (floor ) Lives alone? Yes/No Stairs? Yes/No Other Social support: Family Friend None Urinary incontinence? Yes/No Bowel incontinence? Yes/No Dependents: including pets Community support None Carers x per day Meals on wheels x per day Day centre x per day District nurse x per day Community matron x per day Specialist nurse x per day Others Mobility: Independent With stick/frame Wheelchair Hoist Assistance x Falls risk? Yes/No Other Activities of daily living (ADL): Independent Assistance Details Other Relevant legal information: Advanced decisions to refuse treatment, lasting power of attorney or deputy, organ donation, mental capacity, memory loss, confusion
6 6 of 11 Systems Review [SR] Tick and write details alongside General Weight loss Night sweats Fevers Rashes Mood CVS Chest pain Palpitations Claudication SOB PND Ankle oedema GU Haematuria Dysuria Frequency Voiding difficulty PV discharge Reminder before x-ray Date of last menstrual period / / RS Cough Other relavent history: Sputum Haemoptysis Wheeze Exercise tolerance GI Appetite change Vomiting Haematemesis/ melaena Rectal bleeding Bowel habits (any change?) Abdominal pain CNS Headaches Visual disturbances Syncope Weakness Paraesthesia Fits/syncope Locomotor Joint pain Stiffness Swelling Patient or carer s concerns, expectations and wishes
7 7 of 11 On Examination [O/E] Observations: SpO2: (on %O2) RR: HR: BP: Temp: C Blood glucose: mmol/l GCS: E V M /15 Urine output: ml/hour Abbreviated mental test score (AMTS) for everyone over age 75 Age DOB Year Time Place Address for recall 2 people Monarch WWII 20-1 Total= ( 8 =confusion) General appearance: well / ill / moribund pale / cyanosed / clubbed / jaundiced / lymphadenopathy Cardiovascular System [CVS]: Capillary refill time (normal<2s): Pulse: BP (erect/supine): Jugular venous pressure: Oedema: Respiratory System [RS]: Respiratory rate: Trachea/position: Expansion: Percussion notes: Breath sounds: Added sounds: Gastrointestinal System [GI]: Distension: Tenderness: Guarding: Palpable organs: Bowel sounds: Scars: Hernial orifices: External genitalia: Peripheral pulses and bruits Heart sounds: Rectal Examination: Indicated: Yes/No Chaperone name: Findings: Inspection/tone/sensation/prostate/stool/melaena
8 8 of 11 Locomotor: ( GALS screen) (tick if normal- cross if abnormal) GALS screen Appearance Movement Arms Legs Spine Comments: Nervous system [NS]: Cranial nerves [CN] Right Left I II III, IV, VI V VII VIII IX- XII Fundi Acuity Pupils Fields Upper limb Right Left Tone ( /N/ ) Power (0-5) Shoulder Abduction (C5) Elbow Wrist Fingers Adduction Flexion (C5/C6) Extension (C6-C8) Flexion Co-ordination Extension (C7) Flexion (C8) Extension (C7) Reflexes (+++/++/+/-) Biceps (C5/C6) Supinator (C5/C6) Triceps (C7) Knee (L3/L4) Ankle (S1) Plantar Lower limb Right Left Tone ( /N/ ) Power (0-5) Hip Flexion (L1/L2) Knee Extension (L5-S2) Flexion (L5/S1) Extension (L3/L4) Ankle Dorsiflexion (L4/L5) Co-ordination: Gait Plantarflexion (S1) Sensation Right Left
9 9 of 11 Muscle strength score 0 No movement 1 Flicker is detectable 2 Movement only if gravity is eliminated 3 Can move limb against gravity 4 Can move against gravity & some resistance exerted by examiner 5 Normal power Other examinations: if appropriate e.g. hydration/skin and pressure areas/joints/thyroid/mouth/tongue/ teeth/ears/hearing/vision/nose/throat Glasgow Coma Scale Eyes Voice Motor 1 Closed No sound No movement 2 Open to pain Groans Extends to pain 3 Open to voice Confused words Abnormal flexion to pain 4 Open spontaneously Confused speech Flexion/ withdrawal to pain 5 Orientated Localises to pain 6 Obeys commands Reflexes - Absent + Reduced ++ Normal +++ Brisk ± Present with reinforcement Tone N Reduced Normal Increased If increased, state if the tone is spastic or rigid Breasts (If indicated): Chaperone name:
10 10 of 11 Investigations [Ix]: Blood results: Urine: ECG: Imaging: Blood Gas:
11 11 of 11 Differential Diagnosis [DDx]: Problem List: Management Plan: Has your management plan considered the following? 1. Drug chart/vte/imaging/ urgent referral 2. Start treatmentfluids/medication 3. Microbiology e.g.swabs, blood cultures, sputum 4. Discuss ceiling of care with senior 5. Confirm management plan with senior Name: Signature: Date: Role:
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