Last Updated on August 19, 2026
STEP 1:
Background
×You have only less than 5 minutes to ask this!
You have only less than 5 minutes to ask this!
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
×Our aim is to discharge patients well and bring them back to their original status, if not better
Our aim is to discharge patients well and bring them back to their original status, if not better
• How is the patient before this current illness sets in? • Can he/she run a marathon or easily breathless going to the toilet?
•
ADL / Mobility
• Is the patient as normal as you are now, or totally bed-bound at home?
• Anyone taking care of him/her or he/she is totally independent?
Social history
• Is patient still working? Working as what? Important e.g. in evaluating cardiovascular risk especially in cases such as myocardial infarction
• Patient is staying with who?
• Is patient a
smoker
Female patients
• Ask about
LMP
• e.g. to roughly know whether patient is pregnant. If patient is pregnant, X-rays / any radioactive imaging needs to be counselled carefully and written consent to be signed prior to radioactive imaging
STEP 2: Reason for Admission
•
Elective
Patient comes for a specific reason e.g. for surgery, for procedure, for chemotherapy, for certain imaging etc. Patient comes with chief complaints and diagnosis may be not yet finalized
• “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
SOCRATES is a mnemonic used for pain assessment/description that we used since medical school • Site - where is the pain?
• Onset - when did the pain start? Did the pain start suddenly?
• Character - e.g. aching, stabbing, sharp, crushing, burning pain
• Associated symptoms - e.g. vomiting, weight loss, cough, fever etc.
• Alleviating factors - what makes the pain better? e.g. sitting up, walking around
• Time course - Does the pain get better / worse / same over time?
• Timing - Does the pain worsen at night / in the morning?
• Exacerbating factors - What makes the pain worsened? e.g. lying down, moving any body part
• Severity - On a scale of 0 - 10, with 10 being the worst pain imaginable
• 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
Dxt An abbreviation of Dextrostix, commonly referred to capillary blood glucose
• 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