Clerkings JUST LOOK

Question 1

Checklist

Answer 1

Step 1: Get the History
Step 2: Medication Review
Step 3: Functional Inquiry
Step 4: Physical Examination
Step 5: Cognitive Testing
Step 6: Testing for Emotional Problems
Step 7: Targeted investigations
Step 8: Sharing of results with team
Step 9: Team plan, and follow-up

Date and Time of clerking

MRN number

Patient Age and Gender

PMHx
pre-morbid level of functioning
impact past and current problems have on family life

DHx
Names 
Dose
Frequency
Indication
Compliance aid
Dosette / Blister
Tablet burden

SHx
Home Environment

a list of differential diagnoses + reason (for/ against)

list of investigations + reason

mgx plan + reason

Current
level of functioning

Cognitive assessment + clock drawing

GDS/BASDEC Hamilton score

Collateral History
1)Ask about duration of symptoms e.g. Short Term Memory problems (time frame e.g. over six months)

2) Ask about progression e.g. gradual or progressive or sudden change
3) Mood or personality changes
4) Behavioural or psychiatric symptoms of dementia/psychosis e.g. Hallucinations/delusions

Wandering

Sleep disturbance

Calling out, screaming, swearing Inappropriate behavior

5)Ask about risks

kitchen safety such as leaving the gas on Wandering

Self neglect Abuse-financial, physical

6) How have the above impacted on your patients Activities of Daily living e.g. dressing/bathing/toileting

Ask about depression

7) Check PMH/Family history/head injury/vascular risk factors e.g. smoking/drugs
8) Alcohol history

Follow Up
-Subjective
what does the patient report,

-Objective
what are the obs,
new clinical findings,

-Assessment
what is the diagnosis

-Plan
what is your management plan

• Reflection

Question 2

Falls

Answer 2

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