Clerking and General History Taking

Question 1

How should you begin clerking someone?

Answer 1

Introduce self and grade
Ask for name and DOB
Explain purpose of meeting

Question 2

What next?

Answer 2

Fill in proforma
Patient details
Time presented
Location

Question 3

What next?

Answer 3

Presenting complaint(s)
Short summary of what the patient has come in with

Question 4

What next?

Answer 4

History of presenting complaint

Include chronological sequence of each complaint; systems specific review; risk factors; relevant negatives

Question 5

What next?

Answer 5

Past medical/surgical/mental history

Use a systems review here if patient not forthcoming
JADE TAB MARCH

Question 6

What next?

Answer 6

Drug history
Allergies and adverse reactions

Include dose/frequency/self-medication/OTC medication/herbal/inhalers/oxygen/nebulisers

Question 7

What next?

Answer 7

Family history

Any conditions that run in the family
Parents

Question 8

What next?

Answer 8

Social history

Smoking/alcohol/recreational drugs
Living situation
Relationship
Dependents
Support network
ADLs
Mobility

Question 9

What next?

Answer 9

Systems review
General
RS
CVS
GI
CNS
MSK
GU

Question 10

What should enquire for general symptoms?

Answer 10

Weight loss
Night sweats
Fever
Rashes
Mood

Question 11

What should enquire for respiratory symptoms?

Answer 11

Cough
Sputum 
Haemoptysis
Wheeze
Exercise tolerance

Question 12

What should enquire for cardiovascular symptoms?

Answer 12

Palpitations
Chest pain
Claudication
Breathlessness
PND
Ankle edema

Question 13

What should enquire for gastrointestinal symptoms?

Answer 13

Appetite change
Vomiting
Haematemesis/ melaena
Rectal bleeding
Bowel habits (any change?)
Abdominal pain

Question 14

What should enquire for CNS symptoms?

Answer 14

Headaches
Visual disturbances
Syncope
Weakness
Paraesthesia
Fits

Question 15

What should enquire for locomotor symptoms?

Answer 15

Joint pain
Stiffness
Swelling

Question 16

What should enquire for genitourinary symptoms?

Answer 16

Haematuria
Dysuria
Frequency
Voiding difficulty
PV discharge
Date of last menstrual period

Question 17

What should you ask next?

Answer 17

Ideas
Concerns
Expectations

Question 18

What should you do next?

Answer 18

General appearance examination

well / ill / moribund
pale / cyanosed / clubbed / jaundiced / lymphadenopathy

Question 19

What should you do next?

Answer 19

CVS examination

Heart sounds:
Capillary refill time (normal<2s)
Pulse
BP (erect/supine)
Jugular venous pressure
Oedema
Peripheral pulses

Question 20

What should you do next?

Answer 20

Respiratory examination

Respiratory rate
Trachea/position
Expansion
Percussion notes
Breath sounds (wheeze, crepitations, bronchial breathing)
Added sounds

Question 21

What should you do next?

Answer 21

GI exam

Distension
Tenderness
Guarding
Palpable organs
Bowel sounds
Scars
Hernial orifices
External genitalia

Rectal Examination: Indicated: Yes/No

Inspection/tone/sensation/prostate/stool/melaena

Question 22

What should you do next?

Answer 22

MSK exam
GALS

Muscle strength score:
0 No movement
1 Flicker is detectable
2 Movement only if gravity is eliminated
3 Can move limb against gravity
4 Can move against gravity & some resistance exerted by examiner
5 Normal power

Question 23

What should you do next?

Answer 23

Cranial nerve exam
Peripheral nerve exam
GCS

Question 24

How do you classify reflexes?

Answer 24

- Absent
\+ Reduced
\++ Normal
\+++ Brisk
± Present with reinforcement

Tone
↓ Reduced
N Normal
↑ Increased
If increased, state if the
tone is spastic or rigid