What is the presentation of this patient requiring a medical clerking (medical history taking)?

From the Guidelines

A medical clerking should be written in a structured format, prioritizing the patient's history of present illness, to ensure comprehensive documentation and effective communication between healthcare professionals. When writing a short medical clerking, it is essential to begin with patient demographics, including name, age, gender, and hospital number. The presenting complaint should be documented in the patient's own words, followed by a history of presenting illness detailing symptom onset, duration, and progression, as emphasized by 1.

Key Components of a Medical Clerking

• Patient demographics: name, age, gender, hospital number
• Presenting complaint: in the patient's own words
• History of presenting illness: symptom onset, duration, progression
• Relevant past medical history, medications, allergies, family history, and social history (smoking, alcohol, occupation)
• Vital signs: blood pressure, pulse, temperature, respiratory rate, oxygen saturation
• Examination findings: systematic documentation by body system, focusing on relevant areas
• Investigations and results
• Assessment: working diagnosis or differential diagnoses
• Management plan: medications prescribed (with names, doses, routes, and durations), investigations ordered, referrals made, and follow-up arrangements

As noted in 1, the history of present illness is a crucial component of the clinical evaluation, driving the remainder of the examination, assessment, and decision-making process. The goal is to obtain a comprehensive description of the patient's principal symptoms and their impact on daily function, interpersonal relationships, and comportment, as well as the time course of those symptoms, the existence and evolution of other relevant symptoms, and the pertinent medical history and risk factors, as highlighted in 1. By following this structured approach, healthcare professionals can ensure comprehensive documentation, maintain clinical focus, and facilitate continuity of care and effective communication.

From the FDA Drug Label

Stop use and ask doctor if • pain gets worse or lasts more than 10 days • fever gets worse or lasts more than 3 days • new symptoms occur • redness or swelling is present These could be signs of a serious condition.

WARNINGS Liver warning: This product contains acetaminophen. Severe Liver damage may occur if you take • more than 6 caplets in 24 hours, which is the maximum daily amount • with other drugs containing acetaminophen • 3 or more alcoholic drinks everyday while using this product Allergy alert: acetaminophen may cause severe skin reactions Symptoms may include: • skin reddening • blisters • rash If a skin reaction occurs, stop use and seek medical help right away

Medical Clerking:

• Chief Complaint: Patient presents with unspecified symptoms
• History of Present Illness: Unable to determine without further information
• Medications: Acetaminophen (PO)
• Warning Signs:
  • Pain lasting more than 10 days
  • Fever lasting more than 3 days
  • New symptoms
  • Redness or swelling
  • Severe liver damage if more than 6 caplets are taken in 24 hours, or with other acetaminophen-containing drugs, or with 3 or more alcoholic drinks per day
  • Severe skin reactions, including skin reddening, blisters, and rash 2 2
• Action Plan: Monitor patient for warning signs and seek medical help if they occur

From the Research

Patient History

• The patient's history is a crucial component of a medical clerking, as it helps to identify the underlying cause of their symptoms 3
• The mnemonic SOCRATES (Site Onset Character Radiation Association Time Exacerbating/relieving factor and Severity) can be used to differentiate cardiac from non-cardiac pain 3
• The patient's medical history, including any previous illnesses or conditions, should be taken into account when assessing their current symptoms

Physical Examination

• A physical examination is essential in assessing the patient's condition, including evaluation of vital signs, evidence of murmurs, rubs, heart failure, tension pneumothoraces, and chest infections 3
• The examination should also include an assessment of the patient's oxygen saturation levels, as hypoxemia can contribute to morbidity during cardiac procedures 4

Diagnostic Tests

• A 12-lead electrocardiogram (ECG) should be interpreted within 10 minutes of first medical contact to identify ST elevation myocardial infarction (STEMI) 3
• High-sensitivity troponins can be used to rapidly rule out myocardial infarction (MI) and confirm non-ST elevation MI (NSTEMI) 3
• Arterial blood gases analysis can be used to assess the patient's oxygenation status and guide oxygen therapy 5, 6

Oxygen Therapy

• Oxygen therapy should be provided to patients who require it, with the goal of maintaining an oxygen saturation level of 94-98% for most hospitalized patients 6
• High-flow oxygen (HFO) may be considered for patients who require high levels of oxygen therapy, particularly those who are critically ill or at risk of respiratory failure 6
• Humidification of supplemental oxygen may be considered for patients who require high flows of oxygen 6

Monitoring

• Patients receiving oxygen therapy should be closely monitored for signs of clinical deterioration, including changes in oxygen saturation levels, breathing frequency, and heart rate 5
• Automated and continuous monitoring of oxygen saturation levels and other vital signs can help to detect early signs of clinical deterioration 5