General Clerking History
This is an art that everybody develops. For exam purposes
time is the major
problem. If one hour is allocated for a long case, you should aim to be
finishing the history in under 25 minutes to allow enough time for the
examination.
The majority of the time should be spent in the history of
the presenting complaint. It is often useful to keep a list of
3
differential diagnoses
in mind and to jott them down on
the paper. Ask
specific questions (including risk factors) about these diagnoses in
order to support or rule them out.
The Routine
Preliminary
Introduce self, shake hands.
PC
Explore their
life a bit.
HPC
-
Open questions "What problem brought you
in to hospital?";
-
Address each point in detail. Find out
what treatment has been given. Ask questions relevant to the diffential
diagnosis. If patient hints at social/psychological issues then address
this in detail. Ask “how is this affecting your life?”
-
Pain: SOCRATES, related to
movement/eating/vomiting/bowel movements
Systems Review
This should be delivered as a battery of
questions all at once, so that only real symptoms are picked up (the
tendency to say yes to all of the questions by some patients can waste
time).
-
CVS:
chest pain, SOB, palpitations.
-
Respiratory:
cough, sputum/blood, wheeze.
-
GI:
weight loss, appetite, bowel habit, distension, blood/mucus,
jaundice, difficulty swallowing.
-
CNS:
headache, weakness, faints/fits, numbness or tingling.
-
Urinary:
dysuria, frequency, hesitancy, dribbling, discharge.
-
Gynaecological:
Menarche, last period, ?skipped period,
painful/bloody, menopause.
-
Systemic:
fever, cold-sweats, rigors, fatigue, weakness
-
Psychatric:
depression, anxiety. rashes, mouth ulcers
-
Musculoskeletal:
pain, stiffness
PMH
-
Ask relevant questions relating to each
condition.
-
Use the screening questions: MIS J
THREAD . This stands for MI, Stroke, Jaundice, TB, Hypertension,
Rheumatic fever, Epilepsy, Arthritis, Diabetes.
DH
-
Include allergies, and find out what
"allergic reaction" happened.
-
Over the counter drugs, contraceptives,
recreational drugs.
FH
-
List of immediate family
-
Remember to ask specifically for
conditions relating to the differential diagnosis. this is also about
the emotional support that they have.
SH
-
Pack years, alcohol units ( "what did
you drink in your heyday" may be a useful question).
-
Activities of daily living,
accomodation, partner, carers.
-
"Does illness prevent you from doing
things?"
-
"Does illness make it difficult for you
to look after dependents, put a strain on family?"
-
"Will you require any support when you
return home?"
Review
-
"I would like to check that I have
understood you correctly" Summarise what you have learnt and give a
list of problems.
-
"Is there anything else that is worrying
you or that you would like to ask?"
