NAME:

STUDENT ID: DATE: / / MODULE: PBL:

A. CLERKING PATIENTS

1. DEMOGRAPHIC DATA

NAME: _______________________________________________________________________________________________

AGE: ______ RACE: ___________________ SEX: ______________ OCCUPATION: _______________________________

ADDRESS: _____________________________________________________________________________________________

______________________________________________________________________________________________________

2. CHIEF COMPLAINT

Presenting complaint:

3. HOPI
Site Associated
symptoms
Onset Time/Duration

Character Exacerbating
Factors
Radiating Severity (Scale 1-
10)

4. PAST HISTORY
i. Any past medical problems? YES / NO

(if YES: _______________________________________________)

ii. Any past surgical procedures? YES / NO

(Date/Year of surgical procedures: _______________________________)

iii. Any medication history? Any allergic reactions towards medications? YES / NO

(Name of medications: __________________________ and types of reaction ______________________)

iv. Cigarette smoker? YES / NO

(if YES, number of packs per day: _______ and for how many years? __________)

v. Alcohol consumption? YES / NO

(if YES, how much per day/week/month: _____________)

AIDA ADRIANA ABD AZIZ |

vi. Obstetric (where appropriate)

Age at menarche: _____________

Last menstrual period: ______________

vii. Paediatrics (where appropriate)

Is the child meeting developmental milestones? YES / NO

Is the child up to take with their immunisations? YES / NO

viii. Any family members with similar presenting illness? YES / NO

B. PHYSICAL EXAMINATION

1. GENERAL EXAMINATION

Comments:

2. VITAL SIGNS
Body Temperature Pulse Rate Respiration Rate Blood Pressure

3. BEDSIDE EXAMINATION
EXAMINATION RESULTS

4. SYSTEMIC EXAMINATION
SYSTEMIC EXAMINATION RESULTS
Cardiovascular system

Respiratory system

Gastrointestinal system

Nervous system

Musculoskeletal system

AIDA ADRIANA ABD AZIZ |

 C. INVESTIGATION

1. LABORATORY
i. FULL BLOOD COUNT
PARAMETERS RESULTS
Red Blood Cell Count (RBC)
Haemoglobin (Hb)
Mean Corpuscular Volume (MCV)
Mean Corpuscular Haemoglobin
(MCH)
White Blood Cells Count (WBC)
Platelet Count
ii. RENAL PROFILE
PARAMETERS RESULTS
Na+
K+
Urea
Creatinine
iii. LIVER FUNCTION TEST
PARAMETERS RESULTS
Alanine aminotransferase (ALT)
Alkaline phosphatase
Bilirubin
Albumin
Gamma-glutamyl transferase (GGT)
iv. FASTING PLASMA GLUCOSE
PARAMETERS RESULTS
Glucose

2. IMAGING
IMAGING COMMENTS
X-ray

Ultrasound

CT scan

MRI

3. ADDITIONAL
INVESTIGATION COMMENTS

D. DIAGNOSIS

Diagnosis:

AIDA ADRIANA ABD AZIZ |