This section will not go over the basic structure of the medical interview. Instead, it will focus on the basics that must be asked when you are clerking a patient requiring hand/plastic surgery services.
These are important things to ask and note down:
- Age, Handedness
- Mechanism of injury, time of injury, first aid/initial management
- If amputation: Time of amputation, warm ischemic time, cold ischemic time (if stored)
- Past medical/surgical history (esp. diabetes)
- Drug history (especially anticoagulants), tetanus immunization status
- Allergies (especially antibiotics)
- Social history: Occupation, Smoking status, EtOH, Sports
- Mobility and home situation (support, carers?) if elderly or anticipated self-care issues
- Telephone contact details
Below is an adaptation of a clerking proforma included in the Green's Operative Hand Surgery Textbook which can be used as a guide (2):