Clinical Clerking

OBJECTIVES
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To document the exact identity of the patient. To document the clinical problems faced by the patient. To prioritize the problems of patient. To find out and document the physical changes which has occurred in patient and correlate these with patients problems. To diagnose the problems with maximum certainty. To communicate with other colleagues or specialists. To be able to make a provisional diagnosis. To be able to make a plan of investigations. To counsel the patient and his/her relatives about patients condition and plan of management. To keep record and analyze various aspects of problems.

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Muhammad Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)

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INTRODUCTION & COUNSELING

Muhammad Shuja Tahir, FRCS (Eden), FCPS Pak (Hon)

History taking or interviewing the patient for making accurate diagnosis is usually the first and important encounter between patient and doctor. It needs creation of trust, dependability and doctorpatient relationship which affects the treatment, its compliance and outcome. One should introduce himself or herself to the patient and explain in simple words about history taking and examination. The doctor/medical student should be appropriately dressed. The patient should get the impression of dealing with a real and competent professional. It can be done easily if one is formally dressed. One should be very professional, formal and methodical in talking to the patient. The doctor / medical student should explain about the whole interview to the patient in the beginning. Then he/she should start asking questions in a planned and formal manner. Initial introduction and detailed explanation of interview helps the patient to relax. It helps to create adequate working relationship between patient and the doctor.
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Once the history has been completely documented, the doctor/medical student may inform the patient about possibilities of his/her problem. Simple problems may be discussed but serious illnesses such as malignancy/ diabetes/tuberculosis or heart problems may not be informed abruptly to avoid psychosocial problems. Patient should be given time to accept the problem and serious problems should only be informed after the examination and investigations has helped to reach a definite diagnosis. The patient may be prepared for the bad news

gradually and then the news may be broken to the patients and relatives. It should be done by the senior member of the team responsible for treating the patient or any other member designated for this purpose. It should not be informed by medical student or any junior member of the treating team to avoid poor communication and its devastating effects on the patient and his / her family. Any inaccuracy or inadequacy can lead to harmful consequences for the patient and may bring dishonor to the attending doctor.

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CLINICAL CLERKING
Muhammad Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)

INTRODUCTION Clinical clerking is the collection of information related to patients complaints or problems. Methodical collection of information and its correct analysis helps in the diagnosis and treatment. It can be noted in; Conventional style. Structured, problem based style.

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History taking and physical examination of the patient with accurate recording of details of patients problem and observations at physical examination are essential in the diagnosis of the disease. Correct diagnosis is most important for proper treatment. CONVENTIONAL CLERKING (HISTORY WRITING) It is collection of detailed information and analysis of the patients problems. Following information is collected; ! Patient's identification. ! Disease history. PATIENT'S IDENTIFICATION All possible information about the patient should be asked to identify him or her. It helps in passing on information to the patient or his/her kin when required.
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NAME Name of the patient with father's name or husband's name should be written so that two patients with similar names may not be mixed up and wrongly managed. This is the simplest observation but ignored very often leading to serious consequences and even death. The patients with similar names but different diseases may be present in the same ward at the same time and may be managed wrongly if correct identification is not done. Mismatched blood transfusions reactions are usually seen due to the administration of blood of dissimilar group to the person with similar name. Do not ignore this observation ever. AGE Correct age should be recorded. Even in female patients correct age recording is essential. More than just identification, it will help in the establishment of the correct diagnosis, appropriate treatment and calculation of the correct dosage of the medicine. SEX This should be asked and recorded. Just looking at the patient and writing the sex is incorrect. Woman dressed up like men or otherwise may be very deceptive. In children, spot diagnosis of the sex may be wrong, very often. MARITAL STATUS This information should always be asked and recorded. It helps in the diagnosis of many diseases such as infertility, sexually transmitted infections and psychological upsets due to bad marital relations.

Problems of unmarried patients are some times different. OCCUPATION Many diseases are related to the occupation. It should always be noted correctly. Records such as government servant, laborer or businessman are incorrect and misleading. The nature of occupation must be mentioned. Government servant may be a chemical engineer working with chemicals or a scientist working at atomic energy center or a doctor working as radiologist. All these persons can have diseases related to their type of work. Similarly laborer might be doing any type of work. A businessman may be sitting whole day in a shop or might be traveling the whole world smuggling heroin or may be walking and selling his goods on foot. Diseases and problems are very different in different situations. DATE AND MODE OF HOSPITALIZATION This information should be recorded very carefully. It helps to evaluate the intensity of the disease process. It has got medico-legal importance and helps in clinical audit. It also helps to evaluate the morbidity & outcome of management. ADDRESS, WARD NUMBER, BED NUMBER This information should be very clearly recorded. It helps in correct identification of the patient. It is very much useful in follow up of the patients in future.

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Telephone number/fax number/e-mail address should be noted for further communication. All features of identification should be considered jointly for correct identification of the patient. The site and side of lesion (diseased part) should be marked with non removable soft marker at the time of the examination when the patient is still conscious and is able to confirm the accuracy of marking. It will help in correct treatment even when the patient is unconscious or anesthetized. DISEASE HISTORY The conventional method describes the complaints in detail with their duration in patients own words. COMPLAINTS These should be asked from the patient. Patient describes his problems in his own language. The doctor should try to understand patients problem very carefully. If the patient is unconscious or unable to give this information, his attendants and relatives should be asked about the complaints. The complaints should be written in order of presentation (Chronological order). The leading complaint may either be underlined or written in block letters for better management of the patient. An intelligent doctor always asks simple questions to clear the nature and duration of the complaints.

HISTORY OF PRESENT ILLNESS AND SYSTEMIC INQUIRIES Objectives of history of present illness are; Establishing a diagnosis, working diagnosis or differential diagnosis in such a way that one should have answers to the following questions; ! The presenting complaints belong to which system? ! Which part of the system is most probably involved? Whether complaints are; ! Inflammatory (acute/chronic) ! Traumatic ! Congenital ! Neoplastic (benign/malignant) ! Miscellaneous in origin Whether symptoms are due to primary disease or secondary to some systemic disease? These questions are answered by asking questions relating to all systems (systemic inquiries). One should think for a while after listening to patients presenting complaints before taking a detailed history of disease to be able to answer all these questions; EXAMPLE A 60 years old man presents with a lump in right hypochondrium for the last two months. Now before asking questions blindly about the lump, one should think analytically that what conditions can cause a lump in right hypochondrium in a 60 years old man such as; ! Colonic mass. ! Renal mass.

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Liver mass. Primary tumor. Secondary tumor. Gall bladder mass. Soft tissue mass (related to abdominal wall).

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The detailed history (history of present illness) elaborates the system involved. If other symptoms are bowel related in the absence of renal symptoms, it will be a colonic mass. If features of inflammation or neoplasia are present, these will point towards the nature of this mass. The same principles should be applied to all presenting complaints as the correct diagnosis is based on; ! Detailed and realistic analysis of the patients complaints (disease history). ! Correct, methodical & scientific observations. (clinical examination). ! Selection and interpretation of specific investigations. Detailed analysis of patients complaints is performed by conducting systemic inquires. The questions to explore all the systems should be asked and positive points of any system are written in sequence. Relevant negative points are also written in sequence. If a patient seems to have complaints related to alimentary system, probing questions related to this system should be asked such as history of; ! Abnormal or excessive food intake. ! Drug intake.

Increased or decreased appetite. Dyspepsia and flatulence. Presence or absence of nausea or vomiting. Observation of the nature of vomitus? Frequency of vomiting. Is vomitus stained with fresh blood or altered blood?

Pain or discomfort in relation to the intake of meals or empty stomach. Pain or discomfort associated with the movement of the bowel. Bowel habits (constipation, loose motions, melaena, bleeding per rectum, mucous discharge, tenesmus or recent alteration in bowel habits). If a patient complains about problems related to urinary system, questions related to this system should be asked such as; ! Amount of urine passed in 24 hours. ! Frequency of micturition (number of times urine passed during the day time). ! Nocturia (number of times urine passed during night). ! Urgency of micturition (Inability to wait). ! Hesitancy of micturition (Inability to start quickly). ! Intermittency (Inability to pass urine continuously). The micturition is interrupted few times and is intermittent. ! Difficulty of micturition and pain associated with micturition. ! Burning micturition. ! Dribbling of urine. ! Incontinence of urine (inability to hold urine).

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CLINICAL CLERKING
! ! ! ! !

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Retention of urine (inability to pass urine). Enuresis (bed wetting). Pneumaturia (passage of flatus through urethra). The stream of urine whether good, poor, improves on straining or not. Haematuria (presence of blood in urine) whether initial, mixed with urine or terminal, painless or painful. Pyuria or passage of pus in the urine.

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Fever. Headache. Weight loss or weight gain. Sleep disorders. Drug intake. Recent operations or hospitalization. Diabetes mellitus. Hypertension. Allergy. Asthma. Cardiac disease.

If the patient complains of symptoms related to respiratory or cardio-vascular systems following questions should be asked; ! Cough and sputum (details about sputum such as quantity, color, odor, timing and associations). ! Dyspnea and its association with the degree of exertion. ! Chest pain or discomfort. ! Sinking of the heart. ! Palpitation. ! Fainting attacks. If the patient has problems related to the central nervous system, following questions should be asked from attendants if he is unconscious to assess; ! Headache. ! Confusion. ! Altered behavior. ! Drowsiness. ! Dizzy spells. ! Black outs. ! Fits. ! Loss of consciousness. ! Weakness of any one of the limbs. Certain general questions should also be asked such as history of;

Details of complaints should be written in simple, precise and orderly manner. Let the patient describe his illness in his own words. Direct questioning of the patient may be required to clear the exact nature of the complaints. The common problems which are faced by the patients presenting to surgical department are as follows: PAIN The detailed analysis of the pain is essential to find out the cause of pain. Following information is required to establish correct diagnosis. What is it Like ? (nature of the Pain) The nature of pain should be clarified for the proper diagnosis. It should be noted whether the pain is; ! Continuous or is experienced in attacks. ! Aching / throbbing / cutting or pricking. ! Mild or severe. ! Dull or sharp. ! Is it associated with other feature like vomiting.

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The pain due to injuries and inflammatory lesions is usually continuous. The pain due to abscess is throbbing in nature. The pain due to obstructive lesions of hollow viscera (intestine, ureter) is usually felt in attacks (colicky pain). Where is the Pain ? (site of Pain) It is important to note the exact site of pain for proper diagnosis. This also helps to differentiate between the actual site of disease and the site of the referred pain. The pain due to appendicitis is felt in the epigastrium or umbilical region in the beginning. Later on it is localized in the right iliac fossa. The pain due to bladder stone is felt at the tip of penis in male patients and at the external urethral orifice in females. The pain due to ruptured spleen may also be felt at the tip of left shoulder (referred pain). The pain due to diseased hip is felt along the anterior aspect of the thigh while pain due to the compression of lumber vertebral disc is felt along the posterior aspect of the legs. How Did the Pain Start ? (cause of Pain) It is important to find out how the pain started. The pain may follow some injury. The pain may follow intake of fatty meals when it is related to the gall bladder disease. The pain due to gastritis follows soon after food intake. The pain due to ischaemia starts after exercise. When Did the Pain Start? (time of Pain) Exact time of the onset of the pain should be mentioned so that duration of pain can be assessed.

Although it seems very simple observation yet it is extremely helpful and essential in making the correct diagnosis. The pain due to duodenal ulceration occurs when the stomach has remained empty for a while. The pain due to gastritis follows soon after food intake. The renal pain is more common after fasting or when the patient has taken less fluids. The pain due to bladder stone is experienced at the end of micturition. The pain due to anal fissure starts with the defecation and continues for quite some time afterwards. What Makes the Pain Worse ? What Makes the Pain Better? (factors affecting pain) These are two very important questions to be asked from every patient suffering from pain. The pain following fractures is felt with slightest movement. When the ribs are fractured, breathing movements are so painful that the patient tends to breathe minimum leading to collapse of lungs and chest infection. When the abdominal pain is due to inflammatory lesions of the peritoneal viscera (appendicitis, cholecystitis), every movement makes the pain worse. Even the breathing causes pain at the site of lesion. When the pain is colicky, the patient rolls around and changes posture to make him/herself comfortable.

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Food intake makes the pain of gastric ulcer worse while it makes the duodenal ulcer pain better. The intake of fatty food makes the pain of cholecystitis worse. The burning micturition gets better after drinking lots of fluids while restricted fluid intake makes it worse. SWELLING, LUMP MASS , (NATURE OF SWELLING) The patient should be asked about his own description of the swelling. Following observations are made ; Whether it is soft, firm or hard. ! Soft is similar to feel of cheek. ! Firm is similar to the feel of tip of nose. ! Hard is similar to the feel of forehead. Whether it is fixed or mobile. Whether it is fungating or ulcerative. Whether the swelling has changed its color or consistency. Is it increasing in size or decreasing in size? Where is it ? (site of swelling) The patient should be asked to show the swelling. Smaller swellings are best picked up by the patients. Deep and hidden swellings are also made more prominent by the patient him/herself. Many diseases present with multiple swellings such as neurofibromatosis. The site of the swelling should be seen and noted. This helps in the correct diagnosis of the disease. It also offers some indication of the anatomical structures which may be the cause of swelling. Whether it is superficial or deep. The swelling

should be marked on a diagram to keep the record of its site, size and shape for future reference. How many swellings are there ? (Number of swellings) The patient should be asked whether he has any other similar swelling on the body. The paired organs are checked simultaneously for similar swellings. When did the swelling appear ? (time of swelling) Exact time should be asked. It helps in the assessment of speed of growth of the swelling. It also indicates the duration of the swelling and helps in formulating the correct diagnosis. The neoplastic swellings grow slowly except when necrosis or hemorrhage has occurred in the swelling suddenly. The inflammatory swellings grow in size very quickly. The swellings of the covered parts of the body are usually detected quite late. Is the swelling painful or painless ? This is very important question. The painless swelling could be hernia, hydrocele, cystic growths ,neoplastic growth or enlargement of normal body viscera. The painful swellings could be inflammatory, obstructive or neoplastic lesions with necrosis, hemorrhage or degeneration. The painful swelling is detected early while the painless swelling may be missed for a certain

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period of time. Does the swelling disappear ? It is a very important question to be asked. The reducible hernias are the swellings which disappear on lying down. Similarly the mobile palpable kidney becomes impalpable on lying down. The small ovarian tumors disappear in the pelvis on standing up and become impalpable. Congenital hydrocele disappears on lying down. The smaller breast lumps many times disappear from the examining finger by change of posture. BLEEDING (HEMORRHAGE) It is loss of blood from the vascular system in a living person. It can be; REVEALED HEMORRHAGE It is the type of hemorrhage in which the bleeding is visible from the body wound after surgery, infection, injuries or accidents. CONCEALED HEMORRHAGE It is the type of hemorrhage in which the bleeding is not visible. It is present in following conditions; ! Ruptured ectopic pregnancy. ! Ruptured liver, spleen or aortic aneurysm. ! Intra-abdominal hemorrhage. ! Retro-peritoneal visceral injury and bleeding. Where is it from ? (site of hemorrhage) The site of bleeding should be clarified. Haematemesis is the bleeding coming from the upper gastro-intestinal-tract.

Haemoptysis is the bleeding from the respiratory tract. Haematuria is the bleeding from the urinary tract and blood is mixed with the urine. Urethral bleeding is from the urethra and is usually not mixed with the urine. Rectal bleeding is from rectum and lower colon. It is usually fresh and red in color. Jet black color bleeding (melaena) is from upper gastrointestinal tract. Vaginal bleeding may be from the uterus, cervix or vagina. When did it start? (time of hemorrhage) The time of onset of the bleeding and the duration of the bleeding helps in the assessment of the amount and rate of blood loss and the management of the patient. It also helps in arranging the blood for transfusion and in calculating the amount of blood to be transfused. It further helps to diagnose the type of bleeding whether primary, reactionary or secondary. It also clears the diagnosis in certain disease processes. PRIMARY HEMORRHAGE The bleeding is called primary hemorrhage which occurs at the time of injury, surgery or accident. Its cause is direct disruption of the vessel wall. REACTIONARY HEMORRHAGE The bleeding is termed as reactionary hemorrhage when it occurs 6-12 hours after surgery or accident. Its usual cause is slipping of a ligature or dislodgment of the clot from the site of disrupted vessel.

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SECONDARY HEMORRHAGE The bleeding is known as secondary hemorrhage when it occurs a week or ten days after the surgery or impact. It is caused by infection. How did it start? (cause of hemorrhage) The mechanism of the onset of bleeding is extremely important for the correct diagnosis. History of injury indicates primary hemorrhage. History of operation or injury few hours earlier indicates reactionary hemorrhage due to slipping of a ligature or dislodgement of a clot. History of the injury, surgery and fever for a week or earlier indicates secondar y hemorrhage due to infection. History of drug intake indicates gastric erosions (aspirin etc). History of major surgery, head injury (Cushings ulcers) or burns (Curlings ulcers) prior to haematemesis indicates stress ulceration. How much is the blood loss ? (amount of hemorrhage) The measurement of the amount of blood loss is most impor tant in making the correct assessment and management. The average loss of blood in an adult has been assessed in certain cases of closed fractures as; Fracture of the pelvis 2-3 liters Fracture of the femur 1-2 liters Fracture of tibia 0.5-1 liters Is it painful or not ? This is very useful information and helps in the

correct diagnosis. Painless hematuria in males is always pathological and indicative of the bladder growth while the painful hematuria may be due to stone, infection or tumor with infection. DEFORMITY If the patient complains of any deformity, one should always inquire as: How did it develop ? (cause of deformity) It should be clear without any doubt, what was the mechanism of deformity. Did it follow an injury (fractures) or a febrile illness (Inflammatory) or followed some disease process (metabolic). Where is it ? (site of deformity) The anatomical site of the deformity makes the diagnosis and management very simple. When did it develop ? (time of deformity) The time and duration of appearance of the deformity should be noted. It should be clearly noted whether the deformity is since birth (congenital) or it appeared afterwards (acquired). It helps in the diagnosis as well as in management of the deformity. BOWEL HABITS Exact history of the change in the bowel habits is important. Just saying constipation is present or absent is not enough.

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Many patients may be constipated from the childhood and may not signify any real problem while in other patients who have never been constipated before, history of increasing constipation may be very significant. PAST HISTORY Any relevant or serious illness in the previous years should be written such as; ! Diabetes mellitus. ! Hypertension. ! Myocardial infarction. ! Tuberculosis. ! Asthma. ! Jaundice. ! Venereal diseases. ! Rheumatic fever. ! Trauma and other relevant diseases. Previous operations should be mentioned. Previous hospitalization & its nature should be noted. PERSONAL AND SOCIAL HISTORY Following features should be mentioned. ! Occupation. ! Socio-economic status of the patient. ! Addictions. ! Smoking. ! Sleep habits. ! Appetite. PSYCHIATRIC HISTORY Marital status and relations. Relationship with rest of the family. Relations and problems at work. Any change in behavior or circumstances. FAMILY HISTORY Information about the problems in other family members, first degree relatives or second

degree relatives. Communicable diseases in the family, malignancy in the family, diabetes, hypertension, hemophilia and other familial disorders. MENSTRUAL HISTORY This information is obtained in females only. Age of Menarche Age at the time of first menstrual period is written. Menstrual Cycle This should be mentioned in following manner. Number of bleeding days / After how many days patient bleeds such as 3 - 4 / 28. Associations Associated abnormalities with menstrual cycle should be found and noted. Dysmenorrhoea whether pre- inter or postmenstrual. Pre-menstrual tension should be noted. Last menstrual period Correct date should be mentioned. It is the date when last menstrual period bleeding started. First day of menstrual bleeding (LMP). Menopausal age This should be mentioned in menopausal women. MEDICATION All medicines with dosage and duration of their use should be written. ALLERGIES It should be written at a very conspicuous site

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with red ink and in block letters so that it is never

missed.

CONVENTIONAL HISTORY EXAMPLE

Ahmad Khan s/o Ali Raza 20 years old, male, unmarried, cook. Resident of 114 Gulberg-C Faisalabad. Tel: (233413). Cell: (03007634810). Email: iu-hospital@gmail.com Bed No. 26 Surgical U-II, Allied Hospital Faisalabad. COMPLAINTS Pain right lower abdomen Fever Nausea and vomiting respiratory system or central nervous system was present. PAST HISTORY No history of similar attacks in the past. No history of previous medication or operation. PERSONAL AND SOCIAL HISTORY Patient is cook by occupation. He belongs to low socio-economic group. Smoker(10/day for 6 years). Non alcoholic. No history of addiction. FAMILY HISTORY Two brothers -well and healthy. One sister- well and healthy. Mother and father both living, well and healthy.

2 days 2 days 1day

HISTORY OF PRESENT ILLNESS Two days back, the patient started feeling pain in the upper abdomen. It was not very severe. It was continuous. It became worse gradually. It shifted and settled in right lower abdomen. The pain got worse and unbearable on movements. The patient also felt feverish and unwell. The fever was continuous but there were no rigors or sweating. The patient lost his appetite and felt nausea at first then vomited twice. The vomitus contained only food and gastric secretions. No blood was seen in the vomitus. No urinary or bowel problems were felt. No complaint related to cardiovascular,

PSYCHIATRIC HISTORY No relevant problems. Lives with his family and has good relationship at work and home. MEDICATION None. ALLERGIES Allergic to sulpha drugs.

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PROBLEM BASED CLERKING

Muhammad Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)

The problem based disease history is relatively new style of collection of information and observations about patients problems. It provides realistic and problem solving approach. It is simple, precise and brief but it requires better understanding of various disease processes. It picks up all the relevant information and observations with their duration. It is written in the tabulated form. It analyzes and summarizes the whole problem and is convergent towards the correct diagnosis. It is more comprehensive and can be written and understood quickly. It is structured collection of patients problems. The problems are noted briefly. The problems are noted in order of intensity. (The worst problem is written on top and least problem at the lowest). Special problems may be highlighted or written in block letters. The positive features of information and observations are noted. The important and significant negative features are also noted in a way to converge on the correct diagnosis. It is conducted in an organized manner. The investigations may also be advised and interpreted to converge on to the correct diagnosis. The observations are noted on a diagram clearly indicating the anatomical site of problem. The problems are written in the order of intensity or significance.
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EXAMPLE PROBLEM BASED DATA COLLECTION

Ahmad Khan S/O Ali Raza 30 years male, unmarried cook of 114 Gulberg-C Faisalabad Tel: 233413 Bed No.26 Ward SW-II Allied Hospital, Faisalabad. Problems Pain in right lower abdomen Continuous & Progressive Gets worst on movements Gets better on lying still Fever Anorexia, nausea & vomiting No urinary symptoms No constipation 2 days Observations Fever100 oF Tenderness in right iliac fossa is positive Rebound tenderness is also positive Psoas test is positive Rovsings sign is positive McBurneys test is positive Sherrens trianlge is hyperaesthetic Provisional Diagnosis: Acute Appendicitis

2 days 2 days

Investigation: Urine C/E, Blood C/E, Ultrasound

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CLINICAL CLARKING
Identity Complaints Associated problems Who is the patient? (correct identification) What is the problem/problems? What are the co-morbid problems?
Nature Site Cause Affecting factors

Pain

Swelling

Nature Site Number

Bleeding

Site Duration Amount and speed

Deformity

Site Cause Duration

Systemic inquiries Past History Family History Personal History Menstrual History Drug history Allergies

(in females only)

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