House officer clerking manual copy

© 2013 Tan Guo Jeng All rights reserved

HOSPITAL TENGKU AMPUAN RAHIMAH, KLANG HOUSE OFFICER

CLERKING MANUAL (beta 1.1 2)


The Art Of Clerking The art of clerking along with the art of examination are two of the

most vital arts a house officer must master in order to be successful. Both can only be improved with practice and seeing more cases. One cannot be without the other. If one does not see enough cases even if one is persistent and incessant with practice one cannot be successful and vice-‐versa.

This manual does not replace the House Officers’ need to practice and see lots of cases. However it is to improve the delivery of service and also to improve learning by providing a list of questions that will be most useful if asked. This is because the first clerking if done correctly will most often be the best as the patient’s relatives are still around and the sometimes because the patient is still conscious and able to answer questions.

To use this manual, one has to list down all the patients’ main presenting complaints and after asking the basic open questions, proceeds to ask the closed questions listed under that presenting complaint. For example if the person has chest pain, after asking some open questions the house officer will proceed to ask all the closed questions listed under that presenting complaint. By doing this the House Officer will realize what is the diagnosis and the way this manual is structured, the house officer is able group all relevant negatives into the major groups and thus present in a more concise manner.

For example, suppose a patients presents with chest pain and on further questioning it is noted that the chest pain is a heaviness with symptoms of heart failure and radiation to the left shoulder. From the history we can be confident that the diagnosis is acute coronary syndrome. But just because a person has acute coronary syndrome, it doesn’t mean that he can’t concurrently have other causes of chest pain so the good House Officer will also ask all the questions listed under the other possible causes of chest pain. These will form his relevant negatives and thus the House Officer can confidently reach a sensible and reasonable diagnosis while at the same time ruling out all the other differentials.

Tan Guo Jeng


House Officer Clerking Manual Name Age, Sex Premorbids: Use the mnemonic D2FMC3 which stands for duration, diagnosis (please ascertain whether the diagnosis was properly made), follow-‐up, medications, compliance, control and complications. All the following questions are based the above broad categories.

1. DM: duration, follow-‐up where, medications, compliance, control (ask patient their glucometer values and HBA1C), hypoglycaemic symptoms ( how often), diet, complications( nephropathy (baseline creatinine), retinopathy: how many photocoagulation?, follow-‐up under nephrology, ophthalmology, neuropathy, diabetic foot ulcer( how many admissions, amputations)

2. Hypertensions: duration, follow-‐up, medications, compliance, control, complications (stroke: ADL dependent, semi-‐independent, dependent, minimal sequelae, no sequelae)

3. Chronic kidney disease: duration, follow-‐up, baseline creatinine, old creatinine trend, DM, HPT, connective tissue disease, renal calculi, family history of renal disease, proteinuria, nephrotic syndrome, renal replacement therapy ( haemodialysis duration, where is the fistula, place of dialysis; CAPD)

4. Epilepsy: duration, follow-‐up, complications (mental retardation, unemployed, level of education, developmental delay), compliance

5. Asthma: duration, medication, follow-‐up, frequency of MDI, frequency of neb, daytime symptoms, night cough, exercise-‐induced, frequency of admission, ICU admission.

Presenting complaints: see next section


Drugs: traditional and herbal medications, current medications, compliance and reactions Allergy: Family history: please draw family tree, illness in the family Personal and social history:

1. Marital status and health of partner 2. other family members and medical problems 3. family and other support 4. accommodation: electricity, water, toilets-‐sitting or squatting,

double-‐storey? Wooden 5. current and past occupation, government servant or not, level of

pay 6. interests and hobbies and how illness affect it 7. alcohol, smoking, drug use, sexual, and other high-‐risk behaviour 8. quality of life 9. activities of daily living: bathing dressing sleep

Presenting complaints: 1. Chest pain

Acute coronary syndrome: positive family history, smoking history, left-‐sided/central chest pain, heaviness dullness, diaphoresis, radiation, nausea, vomiting, shortness of breath, palpitations, reduced effort tolerance, orthopnoea, paroxysmal nocturnal dyspnoea, pedal oedema. Musculoskeletal pain: history of heavy lifting, unaccustomed exercise, reproducible pain, muscle wall tenderness on palpation. Gastro-‐oesophageal reflux disease: epigastric pain, retrosternal burning sensation, acid-‐brash, water-‐brash, dryness of throat, wheezing. Pneumonia: fever, cough, greenish/ yellowish sputum, chills, rigors, loss of appetite, shortness of breath, peuritic chest pain. Pulmonary embolism: sudden shortness of breath, pleuritic chest pain, haemoptysis, history of cancer, history of DVT, history


immobilization, history of surgery or feacture, tachycardia, hypoxia, +/-‐hypotension. Dissection of the aorta: history Marfan’s syndrome, pregnancy, severe “tearing” pain. Pneumothorax: pleuritic chest pain, shortness of breath.

2. Abdominal pain

Intestinal obstruction: no flatus or bowel movement, vomiting, unable to tolerate orally, abdominal distension. Pancreatitis: epigastric pain radiating to the back, relieved by bending forward, history of chronic alcohol intake or dyslipidaemia, family history of hyperlipidaemia. Perforated ulcer: severe epigastric pain, history of gastric ulcer, history of gastric operation, air under diaphragm. Biliary colic/ acute cholecystitis: right hypochondrium pain, colicky, radiate to the right tip of scapula, fever, jaundice. Renal colic/ pyelonephritis: loin to groin pain, colicky, flank pain, renal punch positive, fever, sandy urine, passing stones, haematuria, history of stones. Acute urinary retention: unable to PU, distended bladder, history of Foley’s catheter, history of urinary tract infection. Acute myocardial infarction: epigastric pain, symptoms of heart failure, radiation to left shoulder and jaw, shortness of breath, nausea, diaphoresis. Gastric cancer: early satiety, loss of weight, loss of appetite, history of taking preserved foods, anaemia, family history of gastric cancer. Dengue: fever, rash, myalgia, arthralgia, from dengue area, thrombocytopaenia.

3. Headache Subarachnoid haemorrhage: ‘thunder-‐clap’ headache, sudden-‐onset, worst headache ever, not relieved by medication, neck stiffness, drowsiness, altered behavior, weakness, paraesthesia, change in nature from previous headaches: worsening. Meningitis: fever, altered behavior, rash, neck stiffness, photophobia.


Space-‐occupying lesion/intracranial mass: early morning headache on waking up, blurring of vision, blurring of vision when bending down, projectile vomiting, altered behavior, reduced cognition, focal neurological signs. Migraine: last 12 to 24 hours, throbbing headache on one side of the head, aura: strobing lights, altered vision, precipitated by noise, stress coffee, cheese, photophobia, need for quiet place, worsen by sound, nausea, vomiting, hemiparesis, slurring, vertigo which gradually resolve. Tension headache: begins after 20, non-‐throbbing bilateral occipital head pain, no nausea, no vomiting, no prodromal visual disturbance, tight band around the head, women more than men, worse at the end of the day. Cluster headache: men>women, after 25, brief severe, unilateral constant non-‐throbbing, few minutes to 2 hours, usually same side, occurs at night, waking the patient, occur same time, several times a day for weeks to months then free for months to years, burning sensation, lacrimation. Sinusitis: history of sinusitis, rhinorrhea, pain on the areas of sinus, fever. Dental problems: poor dental hygiene, history of caries, tooth extraction, discomfort on chewing, unable to open the mouth. Neuralgia: lightning-‐like momentary along the territory of the nerve, excruciating, resolve spontaneously, triggered by stimulation to the trigger zone, may cause syncope. Post-‐herpetic neuralgia: constant, severe, stabbing or burning in the elderly, lasting months to years in areas previously infected by herpes zoster, follows the distribution of the nerve, decrease sensitivity to pin-‐prick. Seizures: abnormal movements, tonic-‐clonic movements, post-‐ictal drowsiness, incontinence, drooling, up-‐rolling of eyes, post-‐ictal drowsiness, history of epilepsy. Ocular disorders: severe eye pain, decreased vision, halo around lights, eye redness, nausea and vomiting. Giant cell arteritis: jaw claudication, amaurosis fugax, aching and morning stiffness of the shoulders.


Hypertensive encephalopathy: history of hypertension, non-‐compliance, bilateral, history of phaeochromocytoma associated with flushing, diaphoresis, palpitations. Medications: nitrates, calcium channel blockers, dipyridamole, tetracycline, vitamin A, steroids.

4. Fever Meningitis: altered behavior, photophobia, neck stiffness, confusion, rash. Upper respiratory tract infection: cough, sore throat, running nose, ear pain. Sinusitis: purulent rhinorrhea, pain on the areas of the sinus, ear fullness, halitosis, hyposmia.

Otitis: ear pain, loss of hearing, disequilibrium, ear discharge Pneumonia: cough, greenish or yellowish sputum, chills, rigors, pleuritic chest pain, haemoptysis. Infective endocarditis: prolonged fever, history of intravenous drug use, history of valvular lesions, positive blood cultures, new or changing murmur, heart failure, arterial emboli. Septic arthritis: history of trauma or surgery near the joint, monoarticular or pauciarticular joint pain, swelling and redness, reduction in the range of movement. Urinary tract infection: frequency, dysuria, urgency, suprapubic pain, flank pain, renal punch positive, chills, nausea, vomiting. Infective diarrhea: history of eating out, contacts with diarrhea, contact with water source or source of infection i.e. animals, history of travel, fever later, anorexia, crampy abdominal pain, number of times, consistency of stools, blood, mucus, vomiting frequency and content, nausea. Connective tissue disease: arthralgia, myalgia, rash, mononeuritis (weakness of numbness in the distribution of one nerve), fatigue, Raynaud’s phenomenon, aphthous ulcers, alopecia. Dengue: myalgia, arthralgia, retroorbital pain, headache, bleeding tendencies, living or working in dengue area, history of fogging, abdominal pain, vomiting, diarrhea, thromboytopaenia.


Leptospirosis: history of jungle trekking, working in drains and sewers, exposure to rodents, rigors, myalgia, headache, sore throat abdominal pain, conjunctival suffusion, hepatosplenomegaly, lymphadenopathy. Scrub typhus: history of travel to the jungles or estates, headache, myalgia, eschar, chills, anorexia. Typhoid fever: step-‐wise fever, chills, relative bradycardia, constipation more often than diarrhea, rose spots (salmon-‐coloured rash), hepatosplenomegaly, haematochezia, headache, abdominal distension and pain.

5. Fever and rash Dengue: myalgia, arthralgia, retro-‐orbital pain, headache, bleeding tendencies, living or working in dengue area, history of fogging, abdominal pain, vomiting, diarrhea, thrombocytopaenia. Leptospirosis: history of jungle trekking, working in drains and sewers, exposure to rodents, rigors, myalgia, headache, sore throat abdominal pain, conjunctival suffusion, hepatosplenomegaly, lymphadenopathy. Scrub typhus: history of travel to the jungles or estates, headache, myalgia, eschar, chills, anorexia. Systemic lupus erythematosus: joint swelling and pain, butterfly rash, discoid rash, alopecia, aphthous ulcers, HIV: high-‐risk behavior, lymphadenopathy, fever and rash, sore throat, myalgia, fatigue, nausea, anorexia, weight loss, headache Typhoid fever: step-‐wise fever, chills, relative bradycardia, constipation more often than diarrhea, rose spots (salmon-‐coloured rash), hepatosplenomegaly, haematochezia, headache, abdominal distension and pain. Steven-‐Johnson syndrome: malaise, fever, maculo-‐papular rash with ulceration, conjunctivitis, mouth ulcers, genital ulceration, history of drugs such as allopurinol, carbamazepine, sulfonamide, new drug started. Meningitis: altered behavior, photophobia, neck stiffness, confusion.

6. Fever of unknown origin


Atypical infection: fever, myalgia, arthralgia, headache, rash, travel history, high-‐risk behavior, lymphadenopathy, hepatosplenomegaly. Connective tissue disease: arthralgia, myalgia, rash, mononeuritis (weakness of numbness in the distribution of one nerve), fatigue, Raynaud’s phenomenon, aphthous ulcers, alopecia. Neoplastic disorders: loss of weight, loss of appetite, hoarseness of voice, altered bowel habit, blood or mucus in stools, early satiety, dysphagia, anaemia, mass, early morning headache and projectile vomiting. Haematological malignancies: reduced effort tolerance, pica, easy bruising, frequent infections, paleness, lymphadenopathy, hepatosplenomegaly, difficulty in stopping bleeding, conjunctival haemorrhage, loss of weight, loss of appetite, night fever, night sweat. Granulomatous diseases: fatigue, malaise, fever, weight loss, eye pain, erythema nodosum (painful erythematous maculo-‐papulor rash on the shins), epistaxis, isolated nerve palsy, numbness, hilar haziness on X-‐ray.

7. Syncope Vasovagal/ neurocardiogenic: prodromal symptoms; nausea, flushing, light-‐headedness, blurred vision; collapse on standing, hot environment, large meal, prolonged standing; after micturition, defecation, coughing or sneezing, pallor, like a dark curtain coming down, able to hear the surroundings. Cardiovascular structural disorders: syncope while supine, exertional syncope, chest pain, palpitations, murmurs, symptoms of angina, symptoms of heart failure, carotid bruit, dizziness on changing head position or lifting of arms. Seizure: abnormal movements, post-‐ictal drowsiness, urinary and fecal incontinence, up-‐rolling of eyeballs, frothing in the mouth, post-‐ictal weakness, history of febrile seizures, family history of mental retardation, sudden death, and epilepsy; precipitated by flashing lights, sleep deprivation, hunger, alcohol. Arrhythmias: history of angina or heart failure, palpitations, chest pain.


Stroke: hemiparesis, hemiparaesthesia, slurring of speech, history of atrial fibrillation. Postural hypotension: dizziness on changing of position from lying to standing or sitting to standing, history of diabetes mellitus or Parkinson’s disease. Hypoglycaemia: recent starting, increase or change in medications; fasting or poor oral intake, missed meals even after taking medications, recent urinary tract infection, feeling of hunger, cold sweat, hand tremors. Medications: oral hypoglycaemics, beta-‐blockers, ACEI, ARB, calcium channel blockers, nitrates, anti-‐convulsants.

8. Dizziness and vertigo Cerebellar stroke: hemiparesis, hemiparaesthesia, slurring of speech, history of atrial fibrillation, nystagmus, unsteady gait, staccato speech, intention tremors, past-‐pointing. Benign paroxysmal positional vertigo: diagnosis of exclusion, recurrent episodes of vertigo lasting a minute or less for weeks to months associated with certain positions of the head, nausea, vomiting, no other neurological symptoms. Labyrinthine dysfunction/ vestibular nerve: otalgia, otorrhoea, reduction in hearing, tinnitus, facial nerve palsy, history of mastoiditis, sinusitis, upper respiratory infection. Seizure: abnormal movements, post-‐ictal drowsiness, urinary and fecal incontinence, up-‐rolling of eyeballs, frothing in the mouth, post-‐ictal weakness, history of febrile seizures, family history of mental retardation, sudden death, and epilepsy; precipitated by flashing lights, sleep deprivation, hunger, alcohol. Subclavian steal syndrome: history of artherosclerosis, history of ischaemic heart disease, history of diabetes mellitus, history of hypertension, symptoms precipitated by lifting of arms. Carotid artery stenosis: history of artherosclerosis, history of Ischaemic heart disease, history of diabetes mellitus, history of hypertension, symptoms precipitated by head movements. Postural hypotension: dizziness on changing of position from lying to standing or sitting to standing, history of diabetes mellitus or Parkinson’s disease.


9. Weakness and paralysis

Stroke: hemiparesis, hemiparaesthesia, slurring of speech, history of atrial fibrillation, history of carotid bruit. Transient ischaemic attack: symptoms of stroke lasting less than 24 hours with full recovery. Reversible ischaemic neurological deficit: symptoms of stroke recovery more than 24 hours but full recovery by one week. Multiple sclerosis: transient symptoms with full or partial remission, dissemination of central nervous system lesions in time and space, age 15 to 50, eye pain on ocular movement, visual disturbances, internuclear ophthalmoplegia, numbness, Lhermitte syndrome (electric shock sensation on the flexion of the neck), fatigue, Uhthoff phenomenon (worsening of symptoms of exposure to heat and increased temperature), oligoclonal band on CSF, bowel, bladder dysfunction. Spinal cord problems: Spinal cord impingement: back pain, sharp, shooting pain down the back of the buttocks to the back of the legs, better at rest, reduced joint, proprioception and pain sensation; weakness atrophy, bladder dysfunction, asymmetrical neurological deficit; Cervical spondylosis: neck pain, Lhermitte’s sign, asymmetrical sensory and motor deficit, wasting; Subacute combined degeneration: slowly progressive weakness, sensry ataxia, paraesthesia, spasticity, paraplegia, incontinence, macrocytic anaemia. Motor neuron disease: asymmetrical limb weakness, manifest as upper or lower motor neuron, distal onset ore common, dysarthria, dysphagia, fasciculations, cramps, atrophy, emotional lability, constipation, urinary urgency. Guillain-‐Barre Syndrome: acute onset (<4 weeks), ascending motor weakness, recent respiratory or gastrointestinal infection, mild sensory symptoms, reduced or absent reflexes, dysautonomia (tachycardia, hypertension alternating with hypotension, bradycardia, urinary retention). Bell’s palsy: sudden onset of unilateral lower motor neuron facial weakness, no other neurological finding, progressive maxinal at 3 weeks, if evidence of herpes zoster then it is Ramsay-‐Hunt.


Myasthenia gravis: fluctuating muscle weakness, no feeling of tiredness, worse at the end of the day or after exercise, fatigability, dysarthria, dysphagia, ptosis, dyspnea, history of thymoma. Periodic paralysis: sudden onset, respiratory or bulbar muscles only mildly affected, several hours, triggered by exercise, stress or high-‐carbohydrate meal after few hours delay, proximal more than distal.

10. Gait and balance disorders Parkinson’s Disease: bradykinesia, micrographia, rigidity, freezing, anterograde fall, stooped posture, sialorrhoea, dysphagia, asymmetrical, resting tremor, pill-‐rolling, festinating gait, loss of arm swing, turning en-‐bloc. Cerebellar stroke: ataxia, nystagmus, intention tremor, past-‐pointing, staccato speech. Increased intracranial pressure: rapid decline in cognition over months, weakness, sensory and visual disturbances, headaches, seizures, nausea, vomiting exacerbated by the change in posture, urinary incontinence. Drug/toxic/metabolic: alcohol anti-‐psychotics, dopamine agonists, steroid, recreational drug use, vegan diet, B12 deficiency. Multiple sclerosis: transient symptoms with full or partial remission, dissemination of central nervous system lesions in time and space, age 15 to 50, eye pain on ocular movement, visual disturbances, internuclear ophthalmoplegia, numbness, Lhermitte’s syndrome (electric shock sensation on the flexion of the neck), fatigue, Uhthoff phenomenon (worsening of symptoms of exposure to heat and increased temperature), oligoclonal band on CSF, bowel, bladder dysfunction. Stroke: hemiparesis, hemiparaesthesia, slurring of speech, history of atrial fibrillation. Spinal cord impingement: back pain, sharp, shooting pain down the back of the buttocks to the back of the legs, better at rest, reduced joint, proprioception and pain sensation; weakness atrophy, bladder dysfunction, asymmetrical neurological deficit. Stroke: hemiparesis, hemiparaesthesia, slurring of speech, history of atrial fibrillation, carotid bruit, sudden onset.


Spinal cord ischaemia: sudden back pain, bilateral flaccid weakness, loss of pain and temperature sensation. Guillain-‐Barre Syndrome: acute onset (<4 weeks), ascending motor weakness, recent respiratory or gastrointestinal infection, mild sensory symptoms, reduced or absent reflexes, dysautonomia (tachycardia, hypertension alternating with hypotension, bradycardia, urinary retention.

11. Numbness, tingling and sensory loss Diabetic neuropathy: burning sensation at night, walking on cotton, Charcot’s joint, history of diabetic foot ulcer, polyuria, polydipsia, visual disturbance, recurrent infections. Medications: phenytoin, metronidazole, pyridoxine, hydroxychloroquine, HAART, amiodarone, isoniazid, leflunomide, vinblastine, vincristine, cisplatin, oxaliplatin. Gold, alcohol Migraine: last 12 to 24 hours, throbbing headache on one side of the head, aura: strobing lights, altered vision, precipitated by noise, stress coffee, cheese, photophobia, need for quiet place, worsen by sound, nausea, vomiting, hemiparesis, slurring, vertigo which gradually resolve. Stroke: hemiparesis, hemiparaesthesia, slurring of speech, history of atrial fibrillation, carotid bruit, sudden onset. Multiple sclerosis: transient symptoms with full or partial remission, dissemination of central nervous system lesions in time and space, age 15 to 50, eye pain on ocular movement, visual disturbances, internuclear ophthalmoplegia, numbness, Lhermitte’s syndrome (electric shock sensation on the flexion of the neck), fatigue, Uhthoff phenomenon (worsening of symptoms of exposure to heat and increased temperature), oligoclonal band on CSF, bowel, bladder dysfunction. Radiculopathy: asymmetrical involvement of a whole limb, worsen by coughing, sneezing and straining; gradual persistent progression, muscle wasting. Spinal cord lesion: involvement of both lower limbs, sensory level, incontinence, history of trauma or fall, could be sudden onset associated with back pain.


Guillain-‐Barre Syndrome: acute onset (<4 weeks), ascending motor weakness, recent respiratory or gastrointestinal infection, mild sensory symptoms, reduced or absent reflexes, dysautonomia (tachycardia, hypertension alternating with hypotension, bradycardia, urinary retention). Connective tissue disease: arthralgia, myalgia, rash, mononeuritis (weakness of numbness in the distribution of one nerve), fatigue, Raynaud’s phenomenon, aphthous ulcers, alopecia. Hypocalcaemia: peri-‐oral numbness, paraesthesia of the hands and feet, carpopedal spasm, Chvostek’s sign positive, Trousseau’s sign positive. Hypothyroidism: lethargy, cold intolerance, bradycardia, weight gain, dry and pale skin, tiredness leg swelling, macrocytic anaemia.

Hereditary sensorimotor neuropathy: foot deformity, family history. 12. Confusion and delirium

Meningitis-‐ altered behavior, photophobia, neck stiffness, confusion Acute confusional state: elderly patients in sepsis, post-‐surgery, in pain or acute urinary retention. Drugs: insulin, oral hypoglycaemics, digoxin, lithium, opiates, benzodiazepines, barbiturates, anti-‐cholinergics: procyclidine, banzetropine, amitryptilline, imipramine, citalopram, sertraline, oxybutynin, levodopa, corticosteroids. Metabolic: electrolyte imbalance, hypothyroidism. Cerebral lupus: arthralgia, myalgia, rash, mononeuritis (weakness of numbness in the distribution of one nerve), fatigue, Raynaud’s phenomenon, aphthous ulcers, alopecia, history of SLE diagnosis. Stroke: hemiparesis, hemiparaesthesia, slurring of speech, history of

atrial fibrillation. Endocrinological: hypoglycaemia, hyperglycaemia, change in medications, increased in dosages of insulin or oral hypoglycaemics Head injury: history of alleged falls, alleged assaults, and alleged motor-‐vehicular accidents. Seizure: abnormal movements, post-‐ictal drowsiness, urinary and fecal incontinence, up-‐rolling of eyeballs, frothing in the mouth, post-‐ictal weakness, history of febrile seizures, family history of mental


retardation, sudden death, and epilepsy; precipitated by flashing lights, sleep deprivation, hunger, alcohol. Urinary tract infection: fever, dysuria, frequency, unsatisfactory voiding, urgency. Chest infection: fever, cough, chills, rigors, productive sputum. Pulmonary embolism: pleuritic chest, pain, shortness of breath, haemoptysis. Congestive cardiac failure: reduced effort tolerance, NYHA class, orthopnoea, paroxysmal nocturnal dyspnea, bilateral pedal oedema, history of acute coronary syndrome. Myocardial infarction-‐ vague chest discomfort, long history of diabetes mellitus, hypertension, dyslipidaemia, palpitations, reduced effort tolerance, radiation to the left shoulder and jaw, nausea, diaphoresis, exertional angina shortness of breath. Hepatic encephalopathy: jaundice, abdominal distension, history of alcohol abuse, Wilson’s disease, viral hepatitis, haematochromatosis

13. Memory loss Stroke-‐hemiparesis, hemiparaesthesia, slurring of speech, history of atrial fibrillation. Depression-‐anhedonia, sleep disturbances low energy, low mood, poor concentration, guilt, suicidal ideation. Alzheimer’s Disease: anterogade episodic memory loss, disinhibition, aggression. Subdural haemorrhage: history of trauma, rapid decline of cognitive function over days and weeks, elderly persons. Space-‐occupying lesion: rapid decline in cognition over months, weakness, sensory and visual disturbances, headaches, seizures, nausea, vomiting exacerbated by the change in posture. Normal pressure hydrocephalus: small steps with broad based gait with loss of arm-‐swing, urinary incontinence. Medications: anticholinergics, opiates, anxiolytics, antipyschotics, aluminium based phosphate binders, recreational drugs. Endocrine causes: hypothyroidism; weight gain, hoarseness, lethargy, cold intolerance, Cushing’s syndrome; inattention, weight gain, hypertension, diabetes mellitus, muscle weakness.


14. Shortness of breath Congestive cardiac failure-‐reduced effort tolerance, NYHA class, orthopnoea, paroxysmal nocturnal dyspnea, bilateral pedal oedema, history of acute coronary syndrome. Silent myocardial infarction-‐ vague chest discomfort, long history of diabetes mellitus, palpitations, reduced effort tolerance, radiation to the left shoulder and jaw, nausea, diaphoresis. Pneumonia-‐cough, sputum, colour of sputum, history of taking antibiotics, chills and rigors. Gastro-‐oesophageal reflux disease-‐epigastric discomfort, aggravating and relieving factor, timing of food, retrosternal burning sensation, acid-‐brash, water-‐brash, bitter taste. Pulmonary embolism-‐haemoptysis, palpitations, risk of DVT: history of malignancy, surgery, bed bound, long distance travel, previous DVT, previous PE, tachycardia, tachypnea, pleuritic chest pain. Muscle of respiration weakness-‐ history of myopathy, endocrinological problems, electrolyte imbalance, ascending weakness with areflexia, loss of sensation.

15. Cough

Community acquired pneumonia: fever, greenish or yellowish suptum, chills, rigors, shortness of breath, pleuritic chest pain, haemoptysis.

Partially treated pneumonia: history of taking antibiotics. Hospital acquired pneumonia: history of admission within the last 2 months, antibiotics taken. Tuberculosis: prolonged cough, haemoptysis, loss of weight, loss of appetite, night fever, night sweat, history of tuberculosis contact. Bronchial asthma: family history, childhood asthma, allergic rhinitis, allergy, atopic dermatitis, use of inhalers, frequency of night-‐time cough, frequency of nebulisers, frequency of admissions, history of ICU care, known precipitating factors, pets, carpets, cockroaches. Congestive cardiac failure: reduced effort tolerance, orthopnoea, paroxysmal nocturnal dyspnea, pedal oedema, history of ischaemic heart disease.


Neoplasm: loss of weight, loss of appetite, hoarseness of voice, haemoptysis, ptosis, loss of sweating on one side, neck mass, history of smoking; number of years and packs, family history.

16. Palpitations

Acute coronary syndrome: central of left-‐sided chest discomfort, heaviness, shortness of breath, radiation to left arm and neck, diaphoresis, nausea, vomiting, symptoms of heart failure, exertional angina. Congestive cardiac failure: reduced effort tolerance, orthopnoea, paroxysmal nocturnal dyspnea, pedal oedema, history of ischaemic heart disease. Thyrotoxicosis: weight loss, diarrhea, heat intolerance, over-‐dosage of L-‐thyroxine, agitation, tremors, neck swelling. Arrhythmia: racing, tapping, missed beats, pounding in the neck, regularity, duration per episode, frequency, since when the start, triggers: exercise, emotions, stress, alcohol, coffee, cocaine, amphetamine, dypnoea, chest pain, nausea, relieving factors, symptoms of heart failure. Hypoglycaemia: hunger, tremors, irritability, fasting, poor oral intake, change in insulin or oral hypoglycaemic dosages.

Phaeochromocytoma: headache, dizziness, flushing, hypertension. Medications: beta agonist, theophylline, levothyroxine, monoamine oxidase inhibitor, quinidine, amiodarone, erythromycin, azithromycin, SSRI, tricyclic, domperidone, recreational drugs, alcohol, caffeine.

17. Dysphagia

Stroke: hemiparesis, hemiparaesthesia, slurring of speech, history of atrial fibrillation. Parkinson’s disease: bradykinesia, micrographia, rigidity, freezing, anterograde fall, stooped posture, sialorrhoea, dysphagia, asymmetrical, resting tremor, pill-‐rolling, festinating gait, loss of arm swing, turning en-‐bloc. Myasthenia gravis: fluctuating muscle weakness, no feeling of tiredness, worse at the end of the day or after exercise, fatigability, dysarthria, dysphagia, ptosis, dyspnea, history of thymoma.


Multiple sclerosis: transient symptoms with full or partial remission, dissemination of central nervous system lesions in time and space, age 15 to 50, eye pain on ocular movement, visual distrubances, internuclear ophthalmoplegia, numbness, Lhermitte syndrome (electric shock sensation on the flexion of the neck), fatigue, Uthoff phenomenon (worsening of symptoms of exposure to heat and increased temperature), oligoclonal band on CSF, bowel, bladder dysfunction. Oesophagitis: odynophagia, epigastric discomfort, retrosternal burning sensation, worse on lying down, acid-‐brash, water-‐brash, bitter taste in the mouth. Diffuse oesophageal spasm: heart burn, dysphagia, chest pain, regurgitation. Achalasia: dysphagia for liquid and solid, difficulty belching, abdominal distension, weight loss, regurgitation especially on recumbency, retrosternal burning sensation, heartburn, Systemic sclerosis: sclerodactyly, digital ulcers, cutis calcinosis, telangiectasia, Raynaud’s phenomenon, reflux, oesophagitis, interstitial lung disease: dyspnea, unproductive cough; pulmonary hypertension, bird-‐like facies. Sjogren syndrome: eye dryness, irritation, grittiness, mouth dryness leading to difficulty swallowing, salivary gland enlargement. Drugs: doxycycline, bisphosphonate, NSAIDS, ferrous sulphate, nitrates, calcium antagonist, alcohol. Malignancy: loss of weight, loss of appetite, hoarseness of voice, altered bowel habit, blood or mucus in stools, early satiety, dysphagia, anaemia, mass, early morning headache and projectile vomiting, neck mass. Structural cause: Plummer-‐Vinson syndrome; pharyngeal web, anaemia, diverticula, oesophageal web or ring

18. Nausea and vomiting

Uremia: history of NSAID abuse, history of traditional medications, history of connective tissue disease, diabetes mellitus, glomerulonephritis, pedal oedema, itch, metallic taste in the mouth. Food poisoning: history of taking outside food, other people with similar symptoms having taken similar food, poor hygiene.


Adrenal insufficiency: hypotension, anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, confusion, hypoglycaemia, history of tuberculosis, traditional medicaitions, septic shock, hyponatraemia, hyperkalaemia. Obstructive disorder: no flatus, no bowel movement, history of ovarian cancer, colorectal cancer, abdominal distension, blood or mucus in the stools, loss of weight, loss of appetite, previous surgery. Acute gastroenteritis: diarrhea frequency, consistency, colour of stools, mucus, blood, vomiting frequency, content, dietary history, travel history, contact with people with similar symptoms. Dengue: myalgia, arthralgia, retro-‐orbital pain, headache, bleeding tendencies, living or working in dengue area, history of fogging, abdominal pain, vomiting, diarrhea, thrombocytopaenia. Pancreatitis: acute, severe epigastric pain, radiating to the back relieved by bending forward, nausea, vomiting, hypotension. Acute coronary syndrome: exertional angina, central or left-‐sided chest discomfort heaviness, positive family history with smoking, diabetes mellitus and hypertension, radiation, diaphoresis, palpitations, reduced effort tolerance, orthopnoea, paroxysmal nocturnal dyspnea. ENT problem: otalgia, otorrhoea, tinnitus, loss or reduction in hearing, imbalance, dizziness. Raised intracranial pressure: early morning headache on waking up, blurring of vision, blurring of vision when bending down, projectile vomiting, altered behavior, reduced cognition, focal neurological signs.

19. Diarrhoea Gastroenteritis: diarrhea frequency, consistency, colour of stools, mucus, blood, vomiting frequency, content, dietary history, travel history, contact with people with similar symptoms. Dengue: myalgia, arthralgia, retroorbital pain, headache, bleeding tendencies, living or working in dengue area, history of fogging, abdominal pain, vomiting, diarrhea, thrombocytopaenia. Laxative use: wanting to lose weight, history of depression, anorexia, bulimia.


Malabsorption: steatorrhoea (pale, greasy, voluminous, foul-‐smelling stools), abdominal distension, flatulence, borborygmi, iron deficiency anaemia, osteopaenia, weight loss Inflammatory bowel disease: frequency, consistency, small amount, blood mucus in stools, mouth ulcers, eye pain, photophobia, urgency, tenesmus, incontinence, colicky abdominal pain, arthritis, erythema nodosum, anaemia, fistula, abscess, malabsorption. Malignancy: loss of weight, loss of appetite, altered bowel habit, blood or mucus in stools, early satiety, dysphagia, anaemia, mass, nausea, vomiting, tenesmus, haematochezia. Hyperthyroidism: weight loss, heat intolerance, diarrhea, palpitations, sweating, neck swelling, constipation alternating with diarrhoea (spurious diarrhea). Carcinoid syndrome: episodic flushing associated with hypotension and tachycardia, venous telangiectasia, diarrhea, bronchospasm, cardiac lesions. Diabetes gastropathy: polyuria, polydipsia, thirst, recurrent infection, slow healing wounds, history of diabetic foot ulcer, non-‐compliance, abdominal distension, early satiety, need to take small meals, feel full for long periods, diarrhea alternating with constipation. Medications: antibiotics, ACEI, digoxin, SSRI, statins, proton pump inhibitors especially lansoprazole, laxative, magnesium-‐based medications.

20. Constipation

Obstruction: no flatus, no bowel movement, history of ovarian cancer, colorectal cancer, abdominal distension, blood or mucus in the stools, loss of weight, loss of appetite, vomiting, nausea. Hypothyroidism: hoarseness of voice, lethargy, weight gain, dry hair and skin, cold intolerance, history of anti-‐thyroid medications, history of thyroidectomy, history of radioiodine, constipation, macrocytic anaemia. Hypercalcaemia: depression, constipation, anorexia, nausea, polyuria, nephrolithiasis, bone pain, muscle weakness, Drugs: opiates, iron, anti-‐cholinergic, tricyclics anti-‐depressant, calcium antagonists.


Pelvic floor dysfunction: depression, anxiety, history of sexual abuse, difficulty passing soft and hard stools, difficult to relax, use finger to help pass stools. Typhoid fever: step-‐wise fever, chills, relative bradycardia, constipation more often than diarrhea, rose spots (salmon-‐coloured rash), hepatosplenomegaly, haematochezia, headache, abdominal distension and pain.

21. Weight loss

Malignancy: how much weight in how much time, loss of appetite, hoarseness of voice, altered bowel habit, blood or mucus in stools, early satiety, dysphagia, anaemia, mass, early morning headache and projectile vomiting, family history. Chronic infection: history of travel, high-‐risk behaviour Hyperthyroidism: weight loss, heat intolerance, diarrhea, palpitations, sweating, neck swelling Diabetes mellitus: polyuria, polydipsia, thirst, recurrent infection, slow healing wounds, history of diabetic foot ulcer, non-‐compliance. Malabsorption: steatorrhoea (pale, greasy, voluminous, foul-‐smelling stools), abdominal distension, flatulence, borborygmi, iron deficiency anaemia, osteopaenia. Tuberculosis: prolonged unproductive cough, haemoptysis, loss of weight, loss of appetite, night fever, night sweat. Medications: SSRI, levodopa, metformin, theophylline, digoxin; indirectly: anticholinergic, diuretic, bisphosphonate, NSAID, theophylline antibiotics, iron, azathioprine, metronidazole, HAART, cocaine, amphetamine. Neurological diseases: different causes of dysphagia; muscle weakness, choking on swallowing, muscle wasting and atrophy, tremors.

22. Jaundice

Hepatitis: fever, jaundice, tattoos, shared needles, medical and dental treatment abroad, history of transfusion, family history, sexual history, high-‐risk behaviours. Drugs: rifampicin, isoniazid, pyrazinamide, nitrofuratoin, phenytoin, valproate, paracetamol, diclofenac, methyldopa, statins,


amiodarone, halothane, methotrexate, amiodarone, erythromycin,penicillins, chlorpromazine, carbamazepine, oestrogens, steroid, sulphonylureas, allopurinol. Cholangitis/cholecystitis: fever, history of biliary stones, jaundice, right hypochondrium pain radiating to the tip of the scapular, Murphy’s sign positive. Autoimmune: Primary biliary cirrhosis: jaundice arthralgia, itch, weight loss hepatomegaly; Primary sclerosing cholangitis: young men 25 to 40 years old, history of ulcerative colitis, raised alkaline phosphatase, fatigue, jaundice, weight loss, pruritus, hepatomegaly. Choledocholithiasis: dyslipidaemia, biliary colic, right hypochondrium pain radiating to the tip of scapula, nausea. Alcohol: how long, number of units a week, type of alcohol, attempts at quitting, last drink. Budd-‐Chiari syndrome: usually middle-‐aged women, associated with myeloproliferative disorders, sudden-‐onset ascites, hepatomegaly and abdominal pain, variceal bleed, portal hypertension, cirrhosis. Hereditary: Wilson’s disease: hepatitis, Kayser-‐Fleischer rings, chronic liver disease, jaundice, abdominal pain, depression, emotional ability, psychosis; haemachromaosis: transamnitis, lethargy, skin pigmentation, diabetes mellitus, arthralgia, impotence, family history. Infection: schistosomiasis: swimming in endemic areas with itch and Inflammation after that, fever, myalgia, urticarial, abdominal pain cough, headache, sweating, hepatosplenomegaly; malaria: chills, rigors, cyclical fever; toxoplasmosis: malaise, fever, headache, fatigue, muscle pain, painless lymphadenopathy, exposure t cats; leptospirosis: places with dirty water, exposure to rodents, fever, rash, eye redness, thrombocytopaenia. Malignancy: loss of weight, loss of appetite, onset weeks to months, abdominal distension, family history of cancer, abdominal pain Haemolysis: pica, reduced effort tolerance, palpitations, fever, splenomegaly, history of sickle cell disease, haemaglobinopathy.

Disorders of bile transport: family history Liver disorders in pregnancy: acute fatty liver of pregnancy: usually third trimester, nausea, abdominal pain, jaundice, associated with pre-‐eclampsia, may proceed to liver failure, disseminated


intravascular coagulopathy and encephalopathy; HELPP syndrome: haemolysis, elevated liver enzyme, low platelets, third trimester, abdominal pain, vomiting, history of pre-‐eclampsia; Obstetric cholestasis: second or third trimester, intractable pruritus, elevated bile acids.

23. Abdominal swelling

Chronic liver disease: history of viral hepatitis, alcohol abuse, Wilson’s disease, haemachromatosis, jaundice, loss of appetite, leuconychia, parotid swelling, easy bruising, spider naevi, hepatomegaly, splenomegaly, asterixis, fluid thrill, shifting dullness. Neoplasm: loss of weight, loss of appetite, blood and mucus in stools, post-‐menopausal bleeding, intestinal obstruction, haematuria, constipation, spurious diarrhea, intermenstrual bleed, anaemia. Tuberculous peritonitis: abdominal pain and distension, loss of weight, loss appetite, history of tuberculosis, night fever, night sweat. Congestive cardiac failure: reduced effort tolerance, orthopnoea, paroxysmal nocturnal dyspnea, pedal oedema, history of ischaemic heart disease. Renal failure: nausea, vomiting, itch, pedal oedema, history of NSAID, traditional medications, diabetes mellitus, hypertension and connective tissue disease, proteinuria. Pancreatitis: acute, severe epigastric pain, radiating to the back relieved by bending forward, nausea, vomiting, hypotension. Infection: malaria; fever, chills, rigors, history of travel to the jungle, jaundice myalgia, vomiting, kala-‐azar; fever malaise, weight loss, jaundice, darkening of skin, travel to India, oedema, ascites.

24. Azoteamia and urinary abnormalities

Nephrotic syndrome: pedal oedema, ascites, dyslipidaeamia, frothy urine, facial puffiness. Post-‐streptococcal glomerulonephritis and chronic GN: recent sore throat, fever, rash, cola coloured urine, frothy urine, pedal oedema Drug-‐induced or herbal nephropathy: history of frequent NSAID, history of taking traditional medications and herbs, supplements, ‘jamus’.


Diabetic nephropathy: duration of diabetes, control, compliance, frothy urine, frequency, polyuria, polydipsia, recurrent infections. Hypertensive nephropathy: duration of hypertension, control and compliance. Lupus nephritis and other connective tissue cause: alopecia, joint pains and stiffness and swelling, malar rash, discoid rash, ascites, mouth ulcers, conjunctivitis, uveitis, numbness in dermatomal distribution.

25. Anaemia Nutritional deficiency: reduced effort tolerance, palpitations, pallor, pica, poor dietary, exclusive vegetarian diet, malnourishment. Hypothyroidism: macrocytic anaemia, constipation, weight gain, lethargy, slow speech, cool, pale, dry skin, cold intolerance. Hemoglobinopathy: family history, recurrent transfusions, splenomegaly. Menorrhagia: menarche, start of each cycle, regularity, duration of cycle, number of pads a day, overflow, clots, dysmenorrhea. Blood loss: haematemesis, haematochezia, blood mixed in stools, history of NSAID and steroid use. Marrow infiltration: history of malignancy, symptoms of anaemia, recurrent infections, easy bruising, difficulty in stopping bleeding, bone pain. Haematological malignancy: reduced effort tolerance, pica, easy bruising, frequent infections, paleness, lymphadenopathy, hepatosplenomegaly, difficulty in stopping bleeding, conjunctival haemorrhage, loss of weight, loss of appetite, night fever, night sweat.

26. Polycythaemia Smoking: number of years and pack, quit for how long.

Polycythaemia rubro vera: headache, weakness, pruritus, dizziness, erythromyalgia (turning red of hands associated with burning sensation), high risk for thrombotic events such as stroke and myocardial infarction, transient visual disturbances.

High altitude: place of birth, work and training.


Cyanotic heart disease: history of congenital heart disease, cardiac surgery history, valvular disorder. COPD: number of years smoking, number packs a day, ever tried quitting, how long quit, history of nebulisers, history of admission, previous intubations, compliance to medications, influenza vaccination

27. Bleeding Drugs: warfarin, enoxaparin, anti-‐platelets, NSAIDs. Platelet defects: family history.

Uraemia: nausea, vomiting, itch, pedal oedema, orthopnoea, paroxysmal nocturnal dyspnea, metallic taste. Dengue: myalgia, arthralgia, retro-‐orbital pain, headache, bleeding tendencies, living or working in dengue area, history of fogging, abdominal pain, vomiting, diarrhea, thrombocytopaenia. Marrow infiltration: history of malignancy, symptoms of anaemia, bone pain, recurrent infections, petechial rash, bruising. Haematological malignancy: reduced effort tolerance, pica, easy bruising, frequent infections, paleness, lymphadenopathy, hepatosplenomegaly, difficulty in stopping bleeding, conjunctival haemorrhage, loss of weight, loss of appetite, night fever, night sweat.

28. Thrombosis Deep vein thrombosis: history of cancer, immobilization of the lower limbs, bed-‐ridden more than 3 days, major surgery within 4 weeks, calf swelling more than 3cm compared to the other leg, unilateral pitting oedema, tenderness in the venous system, superficial collateral veins. Anti-‐phospholipid syndrome: history of stroke, myocardial infarction, arterial embolism, deep vein thrombosis, 3 or more loss of pregnancy less than 10 weeks, or unexplained loss of morphologically normal fetus at more than 10 weeks, pulmonary embolism, thrombocytopaenia. Essential thrombocythaemia: headache, light-‐headedness, syncope, atypical chest pain, amaurosis fugax, erythromelagia (burning


sensation of the hands and feet with erythema, thrombosis (stroke, myocardial infarction, pulmonary embolism) and haemorrhage. Acquired thrombophilia: family history, recent starting of warfarin, malignancy, hyperviscosity, myeproliferative disorders, nephrotic syndrome. Drugs: oral contraceptive, hormone replacement therapy, bevacizumab, tamoxifen.

29. Splenomegaly

Lymphoma: reduced effort tolerance, pica, easy bruising, frequent infections, paleness, lymphadenopathy, hepatosplenomegaly, loss of weight, loss of appetite, night fever, night sweat. Infection: malaria; fever, chills, rigors, history of travel to the jungle, jaundice myalgia, vomiting, kala-‐azar; fever malaise, weight loss, jaundice, darkening of skin, travel to India, oedema, ascites. Connective tissue disease: arthralgia, myalgia, rash, mononeuritis (weakness of numbness in the distribution of one nerve), fatigue, Raynaud’s phenomenon, aphthous ulcers, alopecia. Chronic liver disease: history of alcohol abuse, Wilson’s disease, haematochromatosis, leuconychia, loss of axillary hair, abdominal distension, parotid enlargement, jaundice, spider naevi, bruising. Thalassaemia: recurrent transfusion, family history, anaemia, splenectomy.

30. Wheezing and shortness of breath

Bronchial asthma: family history, childhood asthma, allergic rhinitis, allergy, atopic dermatitis, use of inhalers, frequency of night-‐time cough, frequency of nebulisers, frequency of admissions, history of ICU care, known precipitating factors, pets, carpets, cockroaches. Chronic obstructive airway disease: smoking history, number of pack years, treatment, stopped smoking when and for how long. Occupational asthma: use of firewood for cooking, work in rubber-‐tapping, glove factory, exposure to pet birds or chickens, soldering, welding, exposure to chemicals and dust. Congestive cardiac failure: reduced effort tolerance, orthopnoea, paroxysmal nocturnal dyspnea, pedal oedema, history of ischaemic heart disease.


Post-‐infectious bronchospasm: history of severe pneumonia, history of tuberculosis. Allergic broncho-‐pulmonary aspergillosis: history of exposure to fungal, work in dark dusty places, haemoptysis. Gastro-‐oesophageal reflux disease: epigastric pain, retrosternal burning sensation, acid-‐brash, water-‐brash, dryness of throat, wheezing.

31. Haemoptysis Neoplasm: loss of weight, loss of appetitie, cough, history of smoking, dilated veins, hoarseness of voice, ptosis and reduced sweating on one side. Bronchiectasis: cough, copious mucopurulent sputum production, dyspnea, rhinosinusitus, history of severe pneumonia, pertussis, tuberculosis, cystic fibrosis.

Pneumonia: fever, chills and rigors, greenish or yellowish sputum. Tuberculosis: night fever, night sweat, prolonged unproductive cough, loss of weight, loss of appetite. Vasculitic disorders: rash, fever, epistaxis, loss of appetite, loss of weight, muscle weakness, numbness in the territory of one nerve (mononeuritis), joint pain, petechial. Leptospirosis: fever, jaundice, history of exposure to rats, history of travel, history of going to waterfalls, sewers, drains, thrombocytopaenias with leukocytosis and raised creatinine kinase. Pulmonary embolism: shortness of breath, pleuritic chest pain, palpitations, risk factors for DVT or has DVT, tachypnoea, tachycardia, D-‐dimer is raised

32. Tremor Parkinson’s disease: bradykinesia, micrographia, rigidity, freezing, anterograde fall, stooped posture, sialorrhoea, dysphagia, asymmetrical, resting tremor, pill-‐rolling, festinating gait, loss of arm swing, turning en-‐bloc. Benign familial tremor/essential tremor: improves with alcohol, low amplitude, high frequency tremor, bilateral, not at rest, no other neurological findings, long duration, may have family history.


Multisystem atrophy: akinetic rigidity, cerebellar ataxia, postural instability, jerky postural and action tremor, pyramidal signs, presyncope, syncope, frequency, hesitancy, incontinence, constipation, impotence, sialorrhoea, nystagmus. Progressive supranuclear palsy: stiff broad-‐based gait, lurching, fall backwards, vertical gaze impairment, rigidity more apparent in axial muscles, bradykinesia, micrographia, freezing, stuttering, palilalia, emotional lability. Dementia with Lewy body: inattention and difficulty concentrating, rapid decline of cognitive function over months, visual hallucinations, fluctuating cognition, REM sleep disorder, syncope, autonomic dysfunction, depression. Cerebellar syndrome: ataxia, nystagmus, intention tremor, past-‐pointing, staccato speech. Hyperthyroidism: weight loss, heat intolerance, diarrhea, palpitations, sweating, neck swelling. Phaeochromocytoma: palpitations, headache, sweating, dizziness, hypertension. Wilson’s disease: drooling, dysphagia, dystonia, psychosis, depression, history of hepatitis. Medications: metoclopramide, prochlorperazine, chlorpromazine, haloperidol, phenytoin, valproate, lithium, salbultamol, salmeterol, tricyclics, levothyroxine.

33. Haematuria

Glomerulpnephritis: cola-‐coloured urine, hypertension, impaired renal function, symptoms of uraemia; nausea, vomiting, itch, loss of appetite, metallic taste. Pulmonary renal syndromes/vasculitis: rash, fever, epistaxis, loss of appetite, loss of weight, muscle weakness, numbness in the territory of one nerve (mononeuritis), joint pain, petechia, Raynaud’s phenomenon, easy bruising. Connective tissue disease: arthralgia, myalgia, rash, mononeuritis (weakness of numbness in the distribution of one nerve), fatigue, Raynaud’s phenomenon, aphthous ulcers, alopecia. Malignancy: loss of weight, loss of appetite, history of prostate cancer, renal cell carcinoma, frequency, nocturia, unsatisfactory


voiding, urgency, strangury, incontinence, poor stream, hesitancy, lower back pain. Infection: urgency, dysuria, frequency, fever. Renal calculi: sandy urine, loin to groin pain, history of gout, passage of stones, dysuria. Drugs: cyclophosphamide, warfarin. Radiotherapy

34. Seizure Epilepsy: abnormal movements, post-‐ictal drowsiness, urinary and fecal incontinence, up-‐rolling of eyeballs, frothing in the mouth, post-‐ictal weakness, history of febrile seizures, family history of mental retardation, sudden death, and epilepsy. Meningitis: fever, neck stiffness, altered behavior, photophobia, rash. Stroke: hemiparesis, hemiparaethesia, slurring of speech, history of atrial fibrialltion. Space-‐occupying lesion: early morning headache, blurring of vision, blurring of vision when bending down, projectile vomiting, altered behavior, reduced cognition. Head injury: history of alleged assault, history alleged motor vehicular accident, birth trauma, cerebral palsy. Alcohol withdrawal: units of alcohol consumed in a week, attempts to stop: when and for how long, type of alcohol consumed, last drink

Drug withdrawal: barbiturates, benzodiazepines. Drug overdose: lithium, neuroleptics, imipramine, recreational drugs, ciprofloxacin, imipenem, flumazenil. Non-‐compliance: reason for non-‐compliance, side-‐effects of the drug, patients’ ideas about the drugs and illness, TDM, regularity of follow-‐up.

35. Leg swelling Deep vein thrombosis: history of cancer, immobilization of the lower limbs, bed-‐ridden more than 3 days, major surgery within 4 weeks, calf swelling more than 3cm compared to the other leg, unilateral pitting oedema, tenderness in the venous system, superficial collateral veins.


Congestive cardiac failure: history of ischaemic heart disease, diabetes mellitus, hypertension, dyslipidaemia, reduced effort tolerance, NYHA class, orthopnoea, paroxysmal nocturnal dyspnea. Renal failure: history of traditional medications, NSAID abuse, connective tissue disease, nausea, vomiting, metallic taste, itch. Chronic liver disease: history of viral hepatitis, alcohol abuse, Wilson’s disease, haematochromatosis, abdominal distension, leuconychia, jaundice, gynaecomastia, bruising, spider naevi. Nephrotic syndrome: frothy urine, facial puffiness on waking up, recurrent infection, risk of deep vein thrombosis. Cellulitis: fever, leg swelling and redness, tenderness on palpation, history of insect bite or other wounds. Drugs: calcium channel blockers.

Reference:

1. UpToDate, Wolters Kluwer Health 2. Clinical Medicine for the MRCP PACES, vol. 2: history-‐taking,

communications and ethics, Gautam Mehta et al. Oxford Specialty Training.

3. Davidson’s Principles and Practice of Medicine, 21st edition, Nicki Colledge, et al. editors, Churchill Livingstone Elsevier.

4. Clinical Neurology, sixth edition, Michael J. Aminoff et al., Lange McGrawHill medical.

5. Essential Lists for MRCP, second edition, Stuart McPherson, Pastest.

House officer clerking manual copy

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