Clerking Manual With TOC

HOSPITAL TENGKU
AMPUAN RAHIMAH,
KLANG HOUSE
OFFICER CLERKING
MANUAL
[Document Subtitle]
Peter Tan Guo Jeng
2015 Tan Guo Jeng All rights

reserved
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 patients
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
doesnt mean that he cant 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.
2
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
3
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 highrisk behaviour
8. Quality of life
9. Activities of daily living: bathing, dressing, sleep,
mobility, continence, going to the toilet, moving
around, cooking, feeding.
10. History of travel? To overseas? Jungle-trekking,
palm-oil estate, swamp?
Presenting complaints:
1. Chest pain
a. 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.
b. Musculoskeletal pain: history of heavy lifting,
unaccustomed exercise, reproducible pain,
muscle wall tenderness on palpation.
c. Gastro-oesophageal reflux disease:
epigastric pain, retrosternal burning sensation,
acid-brash, water-brash, dryness of throat,
wheezing.
d. Pneumonia: fever, cough, greenish/ yellowish
sputum, chills, rigors, loss of appetite, shortness
of breath, peuritic chest pain.
e. 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.
f. Dissection of the aorta: history Marfans
syndrome, pregnancy, severe tearing pain.
g. Pneumothorax: pleuritic chest pain, shortness
of breath.
2. Abdominal pain
a. Intestinal obstruction: no flatus or bowel
movement, vomiting, unable to tolerate orally,
abdominal distension.
b. Pancreatitis: epigastric pain radiating to the
back, relieved by bending forward, history of
chronic alcohol intake or dyslipidaemia, family
history of hyperlipidaemia.
c. Perforated ulcer: severe epigastric pain,
history of gastric ulcer, history of gastric
operation, air under diaphragm.
d. Biliary colic/ acute cholecystitis: right
hypochondrium pain, colicky, radiate to the right
tip of scapula, fever, jaundice.
e. Renal colic/ pyelonephritis: loin to groin pain,
colicky, flank pain, renal punch positive, fever,
sandy urine, passing stones, haematuria, history
of stones.
f. Acute urinary retention: unable to PU,

distended bladder, history of Foleys catheter,
history of urinary tract infection.
g. Acute myocardial infarction: epigastric pain,
symptoms of heart failure, radiation to left
shoulder and jaw, shortness of breath, nausea,
diaphoresis.
h. Gastric cancer: early satiety, loss of weight,
loss of appetite, history of taking preserved
foods, anaemia, family history of gastric cancer.
i. Dengue: fever, rash, myalgia, arthralgia, from
dengue area, thrombocytopaenia.
3. Headache
a. 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.
b. Meningitis: fever, altered behavior, rash, neck
stiffness, photophobia.
c. 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.
d. 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.
e. Tension headache: begins after 20, nonthrobbing 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.
f. 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.
g. Sinusitis: history of sinusitis, rhinorrhea, pain
on the areas of sinus, fever.
h. Dental problems: poor dental hygiene, history
of caries, tooth extraction, discomfort on
chewing, unable to open the mouth.
i. Neuralgia: lightning-like momentary along the
territory of the nerve, excruciating, resolve
spontaneously, triggered by stimulation to the
trigger zone, may cause syncope.
j. 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.
k. Seizures: abnormal movements, tonic-clonic
movements, post-ictal drowsiness, incontinence,
drooling, up-rolling of eyes, post-ictal
drowsiness, history of epilepsy.
l. Ocular disorders: severe eye pain, decreased
vision, halo around lights, eye redness, nausea
and vomiting.
m.
Giant cell arteritis: jaw claudication,
amaurosis fugax, aching and morning stiffness
of the shoulders.
n. Hypertensive encephalopathy: history of
hypertension, non-compliance, bilateral, history
of phaeochromocytoma associated with
flushing, diaphoresis, palpitations.
o. Medications: nitrates, calcium channel
blockers, dipyridamole, tetracycline, vitamin A,
steroids.
p. Benign raised intracranial pressure:
Obesity, use of tetracycline and oral
contraceptive pill, blurring of vision on bending
down, headache worse on waking up, nausea,
vomiting.
4. Fever
a. Meningitis: altered behavior, photophobia,

neck stiffness, confusion, rash.
b. Upper respiratory tract infection: cough,
sore throat, running nose, ear pain.
c. Sinusitis: purulent rhinorrhea, pain on the
areas of the sinus, ear fullness, halitosis,
hyposmia.
d. Otitis: ear pain, loss of hearing, disequilibrium,
ear discharge
e. Pneumonia: cough, greenish or yellowish
sputum, chills, rigors, pleuritic chest pain,
haemoptysis.
f. Infective endocarditis: prolonged fever,
history of intravenous drug use, history of
valvular lesions, positive blood cultures, new or
changing murmur, heart failure, arterial emboli.
g. Septic arthritis: history of trauma or surgery
near the joint, monoarticular or pauciarticular
joint pain, swelling and redness, reduction in the
range of movement.
h. Urinary tract infection: frequency, dysuria,
urgency, suprapubic pain, flank pain, renal
punch positive, chills, nausea, vomiting.
i. 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.
j. Connective tissue disease: arthralgia,
myalgia, rash, mononeuritis (weakness of
numbness in the distribution of one nerve),
fatigue, Raynauds phenomenon, aphthous
ulcers, alopecia.
k. Dengue: myalgia, arthralgia, retroorbital pain,
headache, bleeding tendencies, living or
working in dengue area, history of fogging,
abdominal pain, vomiting, diarrhea,
thromboytopaenia.
l. Leptospirosis: history of jungle trekking,

working in drains and sewers, exposure to
rodents, rigors, myalgia, headache, sore throat
abdominal pain, conjunctival suffusion,
hepatosplenomegaly, lymphadenopathy.
m.
Scrub typhus: history of travel to the
jungles or estates, headache, myalgia, eschar,
chills, anorexia.
n. 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
a. Dengue: myalgia, arthralgia, retro-orbital pain,
thrombocytopaenia.
b. Leptospirosis: history of jungle trekking,
working in drains and sewers, exposure to
rodents, rigors, myalgia, headache, sore throat
abdominal pain, conjunctival suffusion,
hepatosplenomegaly, lymphadenopathy.
c. Scrub typhus: history of travel to the jungles
or estates, headache, myalgia, eschar, chills,
anorexia.
d. Systemic lupus erythematosus: joint
swelling and pain, butterfly rash, discoid rash,
alopecia, aphthous ulcers,
e. HIV: high-risk behavior, lymphadenopathy,
fever and rash, sore throat, myalgia, fatigue,
nausea, anorexia, weight loss, headache
f. Typhoid fever: step-wise fever, chills, relative
g. 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.
h. Meningitis: altered behavior, photophobia,
neck stiffness, confusion.
6. Fever of unknown origin
a. Atypical infection: fever, myalgia, arthralgia,

headache, rash, travel history, high-risk
behavior, lymphadenopathy,
hepatosplenomegaly.
b. Connective tissue disease: arthralgia,
ulcers, alopecia.
c. 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.
d. 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.
e. 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
a. 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.
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b. 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.
c. Seizure: abnormal movements, post-ictal
drowsiness, urinary and fecal incontinence, uprolling of eyeballs, frothing in the mouth, postictal weakness, history of febrile seizures, family
history of mental retardation, sudden death, and
epilepsy; precipitated by flashing lights, sleep
deprivation, hunger, alcohol.
d. Arrhythmias: history of angina or heart failure,
palpitations, chest pain.
e. Stroke: hemiparesis, hemiparaesthesia,
slurring of speech, history of atrial fibrillation.
f. Postural hypotension: dizziness on changing
of position from lying to standing or sitting to
standing, history of diabetes mellitus or
Parkinsons disease.
g. 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.
h. Medications: oral hypoglycaemics, betablockers, ACEI, ARB, calcium channel blockers,
nitrates, anti-convulsants.
8. Dizziness and vertigo
a. Cerebellar stroke: hemiparesis,
hemiparaesthesia, slurring of speech, history of
atrial fibrillation, nystagmus, unsteady gait,
staccato speech, intention tremors, pastpointing.
b. 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.
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c. Labyrinthine dysfunction/ vestibular nerve:

otalgia, otorrhoea, reduction in hearing, tinnitus,
facial nerve palsy, history of mastoiditis,
sinusitis, upper respiratory infection.
d. Seizure: abnormal movements, post-ictal
e. Subclavian steal syndrome: history of
artherosclerosis, history of ischaemic heart
disease, history of diabetes mellitus, history of
hypertension, symptoms precipitated by lifting
of arms.
f. Carotid artery stenosis: history of
artherosclerosis, history of Ischaemic heart
disease, history of diabetes mellitus, history of
hypertension, symptoms precipitated by head
movements.
g. Postural hypotension: dizziness on changing
of position from lying to standing or sitting to
standing, history of diabetes mellitus or
Parkinsons disease.
9. Weakness and paralysis
a. Stroke: hemiparesis, hemiparaesthesia,
slurring of speech, history of atrial fibrillation,
history of carotid bruit.
b. Transient ischaemic attack: symptoms of
stroke lasting less than 24 hours with full
recovery.
c. Reversible ischaemic neurological deficit:
symptoms of stroke recovery more than 24
hours but full recovery by one week.
d. 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
12
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.
e. 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, Lhermittes
sign, asymmetrical sensory and motor deficit,
wasting; Subacute combined degeneration:
slowly progressive weakness, sensry ataxia,
paraesthesia, spasticity, paraplegia,
incontinence, macrocytic anaemia.
f. 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.
g. 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).
h. Bells 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.
i. 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.
j. Periodic paralysis: sudden onset, respiratory
or bulbar muscles only mildly affected, several
hours, triggered by exercise, stress or high-
13
carbohydrate meal after few hours delay,

proximal more than distal.
10.
Gait and balance disorders
a. Parkinsons Disease: bradykinesia,

micrographia, rigidity, freezing, anterograde fall,
stooped posture, sialorrhoea, dysphagia,
asymmetrical, resting tremor, pill-rolling,
festinating gait, loss of arm swing, turning enbloc.
b. Cerebellar stroke: ataxia, nystagmus,
intention tremor, past-pointing, staccato speech.
c. 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.
d. Drug/toxic/metabolic: alcohol anti-psychotics,
dopamine agonists, steroid, recreational drug
use, vegan diet, B12 deficiency.
e. Multiple sclerosis: transient symptoms with
numbness, Lhermittes syndrome (electric shock
dysfunction.
f. Stroke: hemiparesis, hemiparaesthesia,
g. 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.
h. Stroke: hemiparesis, hemiparaesthesia,
carotid bruit, sudden onset.
14
i. Spinal cord ischaemia: sudden back pain,

bilateral flaccid weakness, loss of pain and
temperature sensation.
j. Guillain-Barre Syndrome: acute onset (<4
urinary retention.
11.
Numbness, tingling and sensory loss
a. Diabetic neuropathy: burning sensation at

night, walking on cotton, Charcots joint, history
of diabetic foot ulcer, polyuria, polydipsia, visual
disturbance, recurrent infections.
b. Medications: phenytoin, metronidazole,
pyridoxine, hydroxychloroquine, HAART,
amiodarone, isoniazid, leflunomide, vinblastine,
vincristine, cisplatin, oxaliplatin. Gold, alcohol
c. 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.
d. Stroke: hemiparesis, hemiparaesthesia,
carotid bruit, sudden onset.
e. Multiple sclerosis: transient symptoms with
numbness, Lhermittes syndrome (electric shock
dysfunction.
15
f. Radiculopathy: asymmetrical involvement of a

whole limb, worsen by coughing, sneezing and
straining; gradual persistent progression,
muscle wasting.
g. Spinal cord lesion: involvement of both lower
limbs, sensory level, incontinence, history of
trauma or fall, could be sudden onset associated
with back pain.
h. Guillain-Barre Syndrome: acute onset (<4
urinary retention).
i. Connective tissue disease: arthralgia,
ulcers, alopecia.
j. Hypocalcaemia: peri-oral numbness,
paraesthesia of the hands and feet, carpopedal
spasm, Chvosteks sign positive, Trousseaus
sign positive.
k. Hypothyroidism: lethargy, cold intolerance,
bradycardia, weight gain, dry and pale skin,
tiredness leg swelling, macrocytic anaemia.
l. Hereditary sensorimotor neuropathy: foot
deformity, family history.
12.
Confusion and delirium
a. Meningitis- altered behavior, photophobia,

neck stiffness, confusion
b. Acute confusional state: elderly patients in
sepsis, post-surgery, in pain or acute urinary
retention.
c. Drugs: insulin, oral hypoglycaemics, digoxin,
lithium, opiates, benzodiazepines, barbiturates,
anti-cholinergics: procyclidine, banzetropine,
amitryptilline, imipramine, citalopram,
sertraline, oxybutynin, levodopa, corticosteroids.
16
d. Metabolic: electrolyte imbalance,

hypothyroidism.
e. Cerebral lupus: arthralgia, myalgia, rash,
mononeuritis (weakness of numbness in the
distribution of one nerve), fatigue, Raynauds
phenomenon, aphthous ulcers, alopecia, history
of SLE diagnosis.
f. Stroke: hemiparesis, hemiparaesthesia,
g. Endocrinological: hypoglycaemia,
hyperglycaemia, change in medications,
increased in dosages of insulin or oral
hypoglycaemics
h. Head injury: history of alleged falls, alleged
assaults, and alleged motor-vehicular accidents.
i. Seizure: abnormal movements, post-ictal
j. Urinary tract infection: fever, dysuria,
frequency, unsatisfactory voiding, urgency.
k. Chest infection: fever, cough, chills, rigors,
productive sputum.
l. Pulmonary embolism: pleuritic chest, pain,
shortness of breath, haemoptysis.
m.
Congestive cardiac failure: reduced
effort tolerance, NYHA class, orthopnoea,
paroxysmal nocturnal dyspnea, bilateral pedal
oedema, history of acute coronary syndrome.
n. 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.
o. Hepatic encephalopathy: jaundice,
abdominal distension, history of alcohol abuse,
Wilsons disease, viral hepatitis,
haematochromatosis
17
13.
Memory loss
a. Stroke-hemiparesis, hemiparaesthesia, slurring

of speech, history of atrial fibrillation.
b. Depression-anhedonia, sleep disturbances low
energy, low mood, poor concentration, guilt,
suicidal ideation.
c. Alzheimers Disease: anterogade episodic
memory loss, disinhibition, aggression.
d. Subdural haemorrhage: history of trauma,
rapid decline of cognitive function over days and
weeks, elderly persons.
e. Space-occupying lesion: rapid decline in
cognition over months, weakness, sensory and
visual disturbances, headaches, seizures,
nausea, vomiting exacerbated by the change in
posture.
f. Normal pressure hydrocephalus: small steps
with broad based gait with loss of arm-swing,
urinary incontinence.
g. Medications: anticholinergics, opiates,
anxiolytics, antipyschotics, aluminium based
phosphate binders, recreational drugs.
h. Endocrine causes: hypothyroidism; weight
gain, hoarseness, lethargy, cold intolerance,
Cushings syndrome; inattention, weight gain,
hypertension, diabetes mellitus, muscle
weakness.
14.
Shortness of breath
a. Congestive cardiac failure-reduced effort

tolerance, NYHA class, orthopnoea, paroxysmal
nocturnal dyspnea, bilateral pedal oedema,
history of acute coronary syndrome.
b. Silent myocardial infarction- vague chest
discomfort, long history of diabetes mellitus,
palpitations, reduced effort tolerance, radiation
to the left shoulder and jaw, nausea,
diaphoresis.
c. Pneumonia-cough, sputum, colour of sputum,
history of taking antibiotics, chills and rigors.
18
d. Gastro-oesophageal reflux diseaseepigastric discomfort, aggravating and relieving

factor, timing of food, retrosternal burning
sensation, acid-brash, water-brash, bitter taste.
e. 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.
f. Muscle of respiration weakness- history of
myopathy, endocrinological problems,
electrolyte imbalance, ascending weakness with
areflexia, loss of sensation.
15.
Cough
a. Community acquired pneumonia: fever,

greenish or yellowish suptum, chills, rigors,
shortness of breath, pleuritic chest pain,
haemoptysis.
b. Partially treated pneumonia: history of
taking antibiotics.
c. Hospital acquired pneumonia: history of
admission within the last 2 months, antibiotics
taken.
d. Tuberculosis: prolonged cough, haemoptysis,
loss of weight, loss of appetite, night fever,
night sweat, history of tuberculosis contact.
e. Bronchial asthma: family history, childhood
asthma, allergic rhinitis, allergy, atopic
dermatitis, use of inhalers, frequency of nighttime cough, frequency of nebulisers, frequency
of admissions, history of ICU care, known
precipitating factors, pets, carpets, cockroaches.
f. Congestive cardiac failure: reduced effort
tolerance, orthopnoea, paroxysmal nocturnal
dyspnea, pedal oedema, history of ischaemic
heart disease.
g. 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.
19
16.
Palpitations
a. Acute coronary syndrome: central of leftsided chest discomfort, heaviness, shortness of

breath, radiation to left arm and neck,
diaphoresis, nausea, vomiting, symptoms of
heart failure, exertional angina.
b. Congestive cardiac failure: reduced effort
heart disease.
c. Thyrotoxicosis: weight loss, diarrhea, heat
intolerance, over-dosage of L-thyroxine,
agitation, tremors, neck swelling.
d. 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.
e. Hypoglycaemia: hunger, tremors, irritability,
fasting, poor oral intake, change in insulin or
oral hypoglycaemic dosages.
f. Phaeochromocytoma: headache, dizziness,
flushing, hypertension.
g. Medications: beta agonist, theophylline,
levothyroxine, monoamine oxidase inhibitor,
quinidine, amiodarone, erythromycin,
azithromycin, SSRI, tricyclic, domperidone,
recreational drugs, alcohol, caffeine.
17.
Dysphagia
a. Stroke: hemiparesis, hemiparaesthesia,

b. Parkinsons disease: bradykinesia,
20
c. 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.
d. Multiple sclerosis: transient symptoms with
numbness, Lhermitte syndrome (electric shock
Uthoff phenomenon (worsening of symptoms of
exposure to heat and increased temperature),
dysfunction.
e. Oesophagitis: odynophagia, epigastric
discomfort, retrosternal burning sensation,
worse on lying down, acid-brash, water-brash,
bitter taste in the mouth.
f. Diffuse oesophageal spasm: heart burn,
dysphagia, chest pain, regurgitation.
g. Achalasia: dysphagia for liquid and solid,
difficulty belching, abdominal distension, weight
loss, regurgitation especially on recumbency,
retrosternal burning sensation, heartburn,
h. Systemic sclerosis: sclerodactyly, digital
ulcers, cutis calcinosis, telangiectasia,
Raynauds phenomenon, reflux, oesophagitis,
interstitial lung disease: dyspnea, unproductive
cough; pulmonary hypertension, bird-like facies.
i. Sjogren syndrome: eye dryness, irritation,
grittiness, mouth dryness leading to difficulty
swallowing, salivary gland enlargement.
j. Drugs: doxycycline, bisphosphonate, NSAIDS,
ferrous sulphate, nitrates, calcium antagonist,
alcohol.
k. 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.
21
l. Structural cause: Plummer-Vinson syndrome;

pharyngeal web, anaemia, diverticula,
oesophageal web or ring
18.
Nausea and vomiting
a. 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.
b. Food poisoning: history of taking outside food,
other people with similar symptoms having
taken similar food, poor hygiene.
c. Adrenal insufficiency: hypotension, anorexia,
nausea, vomiting, abdominal pain, weakness,
fatigue, lethargy, confusion, hypoglycaemia,
history of tuberculosis, traditional medications,
septic shock, hyponatraemia, hyperkalaemia.
d. 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.
e. Acute gastroenteritis: diarrhea frequency,
consistency, colour of stools, mucus, blood,
vomiting frequency, content, dietary history,
travel history, contact with people with similar
symptoms.
f. Dengue: myalgia, arthralgia, retro-orbital pain,
thrombocytopaenia.
g. Pancreatitis: acute, severe epigastric pain,
radiating to the back relieved by bending
forward, nausea, vomiting, hypotension.
h. 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
22

dyspnea.
i. ENT problem: otalgia, otorrhoea, tinnitus, loss
or reduction in hearing, imbalance, dizziness.
j. 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
a. Gastroenteritis: diarrhea frequency,

consistency, colour of stools, mucus, blood,
vomiting frequency, content, dietary history,
travel history, contact with people with similar
symptoms.
b. Dengue: myalgia, arthralgia, retro-orbital pain,
thrombocytopaenia.
c. Laxative use: wanting to lose weight, history
of depression, anorexia, bulimia.
d. Malabsorption: steatorrhoea (pale, greasy,
voluminous, foul-smelling stools), abdominal
distension, flatulence, borborygmi, iron
deficiency anaemia, osteopaenia, weight loss
e. 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.
f. Malignancy: loss of weight, loss of appetite,
altered bowel habit, blood or mucus in stools,
early satiety, dysphagia, anaemia, mass,
nausea, vomiting, tenesmus, haematochezia.
g. Hyperthyroidism: weight loss, heat
intolerance, diarrhea, palpitations, sweating,
neck swelling, constipation alternating with
diarrhoea (spurious diarrhea).
23
h. Carcinoid syndrome: episodic flushing

associated with hypotension and tachycardia,
venous telangiectasia, diarrhea, bronchospasm,
cardiac lesions.
i. 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.
j. Medications: antibiotics, ACEI, digoxin, SSRI,
statins, proton pump inhibitors especially
lansoprazole, laxative, magnesium-based
medications.
20.
Constipation
a. 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.
b. 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.
c. Hypercalcaemia: depression, constipation,
anorexia, nausea, polyuria, nephrolithiasis, bone
pain, muscle weakness,
d. Drugs: opiates, iron, anti-cholinergic, tricyclics
anti-depressant, calcium antagonists.
e. Pelvic floor dysfunction: depression, anxiety,
history of sexual abuse, difficulty passing soft
and hard stools, difficult to relax, use finger to
help pass stools.
f. Typhoid fever: step-wise fever, chills, relative
21.
Weight loss
24
a. 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.
b. Chronic infection: history of travel, high-risk
behaviour
c. Hyperthyroidism: weight loss, heat
neck swelling
d. Diabetes mellitus: polyuria, polydipsia, thirst,
recurrent infection, slow healing wounds, history
of diabetic foot ulcer, non-compliance.
e. Malabsorption: steatorrhoea (pale, greasy,
voluminous, foul-smelling stools), abdominal
distension, flatulence, borborygmi, iron
deficiency anaemia, osteopaenia.
f. Tuberculosis: prolonged unproductive cough,
haemoptysis, loss of weight, loss of appetite,
night fever, night sweat.
g. Medications: SSRI, levodopa, metformin,
theophylline, digoxin; indirectly: anticholinergic,
diuretic, bisphosphonate, NSAID, theophylline
antibiotics, iron, azathioprine, metronidazole,
HAART, cocaine, amphetamine.
h. Neurological diseases: different causes of
dysphagia; muscle weakness, choking on
swallowing, muscle wasting and atrophy,
tremors.
22.
Jaundice
a. Hepatitis: fever, jaundice, tattoos, shared

needles, medical and dental treatment abroad,
history of transfusion, family history, sexual
history, high-risk behaviours.
b. Drugs: rifampicin, isoniazid, pyrazinamide,
nitrofuratoin, phenytoin, valproate,
paracetamol, diclofenac, methyldopa, statins,
amiodarone, halothane, methotrexate,
amiodarone, erythromycin,penicillins,
25
chlorpromazine, carbamazepine, oestrogens,

steroid, sulphonylureas, allopurinol.
c. Cholangitis/cholecystitis: fever, history of
biliary stones, jaundice, right hypochondrium
pain radiating to the tip of the scapular,
Murphys sign positive.
d. 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.
e. Choledocholithiasis: dyslipidaemia, biliary
colic, right hypochondrium pain radiating to the
tip of scapula, nausea.
f. Alcohol: how long, number of units a week,
type of alcohol, attempts at quitting, last drink.
g. Budd-Chiari syndrome: usually middle-aged
women, associated with myeloproliferative
disorders, sudden-onset ascites, hepatomegaly
and abdominal pain, variceal bleed, portal
hypertension, cirrhosis.
h. Hereditary: Wilsons 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.
i. 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.
26
j. Malignancy: loss of weight, loss of appetite,

onset weeks to months, abdominal distension,
family history of cancer, abdominal pain
k. Haemolysis: pica, reduced effort tolerance,
palpitations, fever, splenomegaly, history of
sickle cell disease, haemaglobinopathy.
l. Disorders of bile transport: family history
m.
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
a. Chronic liver disease: history of viral

hepatitis, alcohol abuse, Wilsons disease,
haemachromatosis, jaundice, loss of appetite,
leuconychia, parotid swelling, easy bruising,
spider naevi, hepatomegaly, splenomegaly,
asterixis, fluid thrill, shifting dullness.
b. Neoplasm: loss of weight, loss of appetite,
blood and mucus in stools, post-menopausal
bleeding, intestinal obstruction, haematuria,
constipation, spurious diarrhea, intermenstrual
bleed, anaemia.
c. Tuberculous peritonitis: abdominal pain and
distension, loss of weight, loss appetite, history
of tuberculosis, night fever, night sweat.
d. Congestive cardiac failure: reduced effort
heart disease.
e. Renal failure: nausea, vomiting, itch, pedal
oedema, history of NSAID, traditional
medications, diabetes mellitus, hypertension
and connective tissue disease, proteinuria.
27
f. Pancreatitis: acute, severe epigastric pain,

radiating to the back relieved by bending
forward, nausea, vomiting, hypotension.
g. 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
a. Nephrotic syndrome: pedal oedema, ascites,

dyslipidaeamia, frothy urine, facial puffiness.
b. Post-streptococcal glomerulonephritis and
chronic GN: recent sore throat, fever, rash, cola
coloured urine, frothy urine, pedal oedema
c. Drug-induced or herbal nephropathy:
history of frequent NSAID, history of taking
traditional medications and herbs, supplements,
jamus.
d. Diabetic nephropathy: duration of diabetes,
control, compliance, frothy urine, frequency,
polyuria, polydipsia, recurrent infections.
e. Hypertensive nephropathy: duration of
hypertension, control and compliance.
f. 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
a. Nutritional deficiency: reduced effort

tolerance, palpitations, pallor, pica, poor dietary,
exclusive vegetarian diet, malnourishment.
b. Hypothyroidism: macrocytic anaemia,
constipation, weight gain, lethargy, slow speech,
cool, pale, dry skin, cold intolerance.
c. Hemoglobinopathy: family history, recurrent
transfusions, splenomegaly.
d. Menorrhagia: menarche, start of each cycle,
regularity, duration of cycle, number of pads a
day, overflow, clots, dysmenorrhea.
28
e. Blood loss: haematemesis, haematochezia,

blood mixed in stools, history of NSAID and
steroid use.
f. Marrow infiltration: history of malignancy,
symptoms of anaemia, recurrent infections,
easy bruising, difficulty in stopping bleeding,
bone pain.
g. Haematological malignancy: reduced effort
sweat.
26.
Polycythaemia
a. Smoking: number of years and pack, quit for

how long.
b. 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.
c. High altitude: place of birth, work and
training.
d. Cyanotic heart disease: history of congenital
heart disease, cardiac surgery history, valvular
disorder.
e. 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
a. Drugs: warfarin, enoxaparin, anti-platelets,

NSAIDs.
b. Platelet defects: family history.
c. Uraemia: nausea, vomiting, itch, pedal
oedema, orthopnoea, paroxysmal nocturnal
dyspnea, metallic taste.
29
d. Dengue: myalgia, arthralgia, retro-orbital pain,

thrombocytopaenia.
e. Marrow infiltration: history of malignancy,
symptoms of anaemia, bone pain, recurrent
infections, petechial rash, bruising.
f. Haematological malignancy: reduced effort
sweat.
28.
Thrombosis
a. 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.
b. 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.
c. 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.
d. Acquired thrombophilia: family history,
recent starting of warfarin, malignancy,
hyperviscosity, myeproliferative disorders,
nephrotic syndrome.
30
e. Drugs: oral contraceptive, hormone

replacement therapy, bevacizumab, tamoxifen.
29.
Splenomegaly
a. Lymphoma: reduced effort tolerance, pica,

easy bruising, frequent infections, paleness,
lymphadenopathy, hepatosplenomegaly, loss of
sweat.
b. 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.
c. Connective tissue disease: arthralgia,
ulcers, alopecia.
d. Chronic liver disease: history of alcohol
abuse, Wilsons disease, haematochromatosis,
leuconychia, loss of axillary hair, abdominal
distension, parotid enlargement, jaundice,
spider naevi, bruising.
e. Thalassaemia: recurrent transfusion, family
history, anaemia, splenectomy.
30.
Wheezing and shortness of breath
a. Bronchial asthma: family history, childhood

asthma, allergic rhinitis, allergy, atopic
dermatitis, use of inhalers, frequency of nighttime cough, frequency of nebulisers, frequency
of admissions, history of ICU care, known
precipitating factors, pets, carpets, cockroaches.
b. Chronic obstructive airway disease:
smoking history, number of pack years,
treatment, stopped smoking when and for how
long.
c. 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.
31
d. Congestive cardiac failure: reduced effort

heart disease.
e. Post-infectious bronchospasm: history of
severe pneumonia, history of tuberculosis.
f. Allergic broncho-pulmonary aspergillosis:
history of exposure to fungal, work in dark dusty
places, haemoptysis.
g. Gastro-oesophageal reflux disease:
epigastric pain, retrosternal burning sensation,
acid-brash, water-brash, dryness of throat,
wheezing.
h. Obstructive sleep apnoea: obesity,
hypersomnolence, snoring, headache on waking
up, falling asleep while watching television,
driving, reduced effort tolerance.
i. Churgg-Strauss syndrome:
hypereosinophilia, rash, joint pain
31.
Haemoptysis
a. Neoplasm: loss of weight, loss of appetitie,

cough, history of smoking, dilated veins,
hoarseness of voice, ptosis and reduced
sweating on one side.
b. Bronchiectasis: cough, copious mucopurulent
sputum production, dyspnea, rhinosinusitus,
history of severe pneumonia, pertussis,
tuberculosis, cystic fibrosis.
c. Pneumonia: fever, chills and rigors, greenish or
yellowish sputum.
d. Tuberculosis: night fever, night sweat,
prolonged unproductive cough, loss of weight,
loss of appetite.
e. Vasculitic disorders: rash, fever, epistaxis,
loss of appetite, loss of weight, muscle
weakness, numbness in the territory of one
nerve (mononeuritis), joint pain, petechial.
f. Leptospirosis: fever, jaundice, history of
exposure to rats, history of travel, history of
going to waterfalls, sewers, drains,
32
thrombocytopaenias with leukocytosis and

raised creatinine kinase.
g. Pulmonary embolism: shortness of breath,
pleuritic chest pain, palpitations, risk factors for
DVT or has DVT, tachypnoea, tachycardia, Ddimer is raised
32.
Tremor
a. Parkinsons disease: bradykinesia,

b. 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.
c. Multisystem atrophy: akinetic rigidity,
cerebellar ataxia, postural instability, jerky
postural and action tremor, pyramidal signs,
presyncope, syncope, frequency, hesitancy,
incontinence, constipation, impotence,
sialorrhoea, nystagmus.
d. Progressive supranuclear palsy: stiff broadbased gait, lurching, fall backwards, vertical
gaze impairment, rigidity more apparent in axial
muscles, bradykinesia, micrographia, freezing,
stuttering, palilalia, emotional lability.
e. 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.
f. Cerebellar syndrome: ataxia, nystagmus,
intention tremor, past-pointing, staccato speech.
g. Hyperthyroidism: weight loss, heat
neck swelling.
33
h. Phaeochromocytoma: palpitations, headache,

sweating, dizziness, hypertension.
i. Wilsons disease: drooling, dysphagia,
dystonia, psychosis, depression, history of
hepatitis.
j. Medications: metoclopramide,
prochlorperazine, chlorpromazine, haloperidol,
phenytoin, valproate, lithium, salbultamol,
salmeterol, tricyclics, levothyroxine.
33.
Haematuria
a. Glomerulpnephritis: cola-coloured urine,

hypertension, impaired renal function,
symptoms of uraemia; nausea, vomiting, itch,
loss of appetite, metallic taste.
b. 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, Raynauds phenomenon, easy
bruising.
c. Connective tissue disease: arthralgia,
ulcers, alopecia.
d. 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.
e. Infection: urgency, dysuria, frequency, fever.
f. Renal calculi: sandy urine, loin to groin pain,
history of gout, passage of stones, dysuria.
g. Drugs: cyclophosphamide, warfarin.
h. Radiotherapy
34.
Seizure
a. Epilepsy: abnormal movements, post-ictal

34

epilepsy.
b. Meningitis: fever, neck stiffness, altered
behavior, photophobia, rash.
c. Stroke: hemiparesis, hemiparaethesia, slurring
of speech, history of atrial fibrialltion.
d. Space-occupying lesion: early morning
headache, blurring of vision, blurring of vision
when bending down, projectile vomiting, altered
behavior, reduced cognition.
e. Head injury: history of alleged assault, history
alleged motor vehicular accident, birth trauma,
cerebral palsy.
f. Alcohol withdrawal: units of alcohol
consumed in a week, attempts to stop: when
and for how long, type of alcohol consumed, last
drink
g. Drug withdrawal: barbiturates,
benzodiazepines.
h. Drug overdose: lithium, neuroleptics,
imipramine, recreational drugs, ciprofloxacin,
imipenem, flumazenil.
i. Non-compliance: reason for non-compliance,
side-effects of the drug, patients ideas about
the drugs and illness, TDM, regularity of followup.
35.
Leg swelling
a. 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.
b. Congestive cardiac failure: history of
ischaemic heart disease, diabetes mellitus,
hypertension, dyslipidaemia, reduced effort
tolerance, NYHA class, orthopnoea, paroxysmal
nocturnal dyspnea.
35
c. Renal failure: history of traditional

medications, NSAID abuse, connective tissue
disease, nausea, vomiting, metallic taste, itch.
d. Chronic liver disease: history of viral
hepatitis, alcohol abuse, Wilsons disease,
haematochromatosis, abdominal distension,
leuconychia, jaundice, gynaecomastia, bruising,
spider naevi.
e. Nephrotic syndrome: frothy urine, facial
puffiness on waking up, recurrent infection, risk
of deep vein thrombosis.
f. Cellulitis: fever, leg swelling and redness,
tenderness on palpation, history of insect bite or
other wounds.
g. Drugs: calcium channel blockers.
36
Reference:
1. UpToDate, Wolters Kluwer Health
2. Clinical Medicine for the MRCP PACES, vol. 2: historytaking, communications and ethics, Gautam Mehta et
al. Oxford Specialty Training.
3. Davidsons Principles and Practice of Medicine, 21 st
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.
37

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The Art Of Clerking

Tan Guo Jeng

House Officer Clerking Manual

Use the mnemonic D2FMC3 which stands for duration,

5. Asthma: duration, medication, follow-up, frequency of

see next section

Drugs: traditional and herbal medications, current

medications, compliance and reactions

orthopnoea, paroxysmal nocturnal dyspnoea,

f. Acute urinary retention: unable to PU,

few minutes to 2 hours, usually same side,

a. Meningitis: altered behavior, photophobia,

l. Leptospirosis: history of jungle trekking,

history of drugs such as allopurinol,

a. Atypical infection: fever, myalgia, arthralgia,

a. Vasovagal/ neurocardiogenic: prodromal

b. Cardiovascular structural disorders:

c. Labyrinthine dysfunction/ vestibular nerve:

sensation on the flexion of the neck), fatigue,

carbohydrate meal after few hours delay,

Gait and balance disorders

a. Parkinsons Disease: bradykinesia,

i. Spinal cord ischaemia: sudden back pain,

Numbness, tingling and sensory loss

a. Diabetic neuropathy: burning sensation at

f. Radiculopathy: asymmetrical involvement of a

Confusion and delirium

a. Meningitis- altered behavior, photophobia,

d. Metabolic: electrolyte imbalance,

a. Stroke-hemiparesis, hemiparaesthesia, slurring

a. Congestive cardiac failure-reduced effort

d. Gastro-oesophageal reflux diseaseepigastric discomfort, aggravating and relieving

a. Community acquired pneumonia: fever,

a. Acute coronary syndrome: central of leftsided chest discomfort, heaviness, shortness of

a. Stroke: hemiparesis, hemiparaesthesia,

c. Myasthenia gravis: fluctuating muscle

l. Structural cause: Plummer-Vinson syndrome;

Nausea and vomiting

a. Uremia: history of NSAID abuse, history of

tolerance, orthopnoea, paroxysmal nocturnal

a. Gastroenteritis: diarrhea frequency,

h. Carcinoid syndrome: episodic flushing

a. Obstruction: no flatus, no bowel movement,

a. Malignancy: how much weight in how much

a. Hepatitis: fever, jaundice, tattoos, shared

chlorpromazine, carbamazepine, oestrogens,

j. Malignancy: loss of weight, loss of appetite,

a. Chronic liver disease: history of viral

f. Pancreatitis: acute, severe epigastric pain,

Azoteamia and urinary abnormalities

a. Nephrotic syndrome: pedal oedema, ascites,

a. Nutritional deficiency: reduced effort

e. Blood loss: haematemesis, haematochezia,

a. Smoking: number of years and pack, quit for

a. Drugs: warfarin, enoxaparin, anti-platelets,

d. Dengue: myalgia, arthralgia, retro-orbital pain,

a. Deep vein thrombosis: history of cancer,

e. Drugs: oral contraceptive, hormone

a. Lymphoma: reduced effort tolerance, pica,

Wheezing and shortness of breath

a. Bronchial asthma: family history, childhood