Standard medicine clerking made easy.pdf

A beautiful step by step approach to mastering clerking

1. FEVER
-When did it start/ how long has it been? (Long duration – ​HIV ​)
-Is it high grade or low grade?
-Is it continuous, remittent or intermittent?
-Is it assoc with chills and rigors?
-Is it worse at night, day or morning or none?
-Is there any assoc convulsion? (Meningitis)
-Is there any relieving factor – Tepid sponging, exposure, fanning or drugs (antipyretics).
-Is there any assoc headache (meningitis)
-Is there any assoc vomiting (meningitis – clerk this)
-Is there any assoc cough (clerk this)
-Is there any associated body weakness.
a.*Longduration(>1month),highgrade,continuous,notworseatanytimeoftheday
>>>>> ​HIV
b.*Longduration(>1month),lowgrade,continuous,assocdrenchingnightsweats,
cough of long duration, productive of sputum which may be bloody >>>>> ​TB
c.*Shortduration,highgrade,continuous,assocchillsandrigor,vomiting,headache,
temporarily relieved by antipyretic >>>>​Meningitis
d.*Shortduration,highgrade,continuous,assocchillsandrigors,coughwhichmaybe
assoc chest pain >>>> ​Pneumonia
e.*Highgrade,intermittent,worseintheevening,assocwithchillsandrigors,weakness,
malaise and body aches, temporarily relieved by antipyretics >>>>> ​Malaria

COUGH
-How long has it been?
-Is it productive of sputum or not?
-What is the color – blood stained or whitish or yellowish?
-What is the consistency – mucoid, very thick, or jelly-like or frothy.
-What is the odour like – fowl smelling or odourless
-How much sputum is produced – copious or small (estimate it)
-Anyeffecttochangeinposturewiththesputumproduction(lungabscess,
bronchiectasis)
-Is it blood stained?
-For how long have you seen the blood?
-Is it fresh blood or altered blood.
-Howoftenisitseeninthesputum–isitwitheverysputumoratimes>>>toestimate
severity and extent of blood loss.

2. -Anyassocbleedormelaena(alteredbloodinstool)–toknowifthebloodisfromthe
upper resp tract or GIT
-Is it worse at night (heart failure) or day.
-Is it paroxysmal (impt in children b/cos of whooping cough) or not.
-Is there assoc vomiting (post tussive vomiting)
-Is it aggravated by anything (Asthma) e.g. pollen, dust or cold
-Is there any relieving factor.
-Any Hx of contact with adult with chronic cough (PTB)
-Is there assoc breathlessness – if so take it up to the presenting complaint and analyze it
-Is there associated orthopnea, fast breathing or PND – to r/o CVS causes
-Is there associated fever( infective causes)
-Is there an associated night sweat (PTB)
-Is there associated weight loss (PTB, HIV)
-Is there associated chest pain (pneumonia)
a.Frothy sputum (LV failure)
b.Thick sputum (asthma)
c.Rusty brown sputum ( pneumonia)
d.Copious mucoid sputum(chronic bronchitis)
e.Copious foul smelling sputum (bronchiectasis, lung abscess)

BREATHLESSNESS (FAST BREATHING)
-How long did it start and for how long now
-Is it worse at rest or on exertion (heart failure)
-Ifworseonexertion,howlongcanptbeabletowalkbeforeitcomes(estimatethe
distancetoknowifitisworseonmild,moderateorsevereexertion)forchildrenthat
suckle,howlongcanptsucklebreastbeforeremovinghismouthtoresti.e.doespttire
easily.
-Has it been progressive since onset (heart failure)
-Is it persistent or intermittent (good and bad days as in asthmatics)
-Any aggravating or relieving factors
-Is it worse eat any time of the day – worse at night mainly in asthmatics
-Canpatientlieflatonbedorwithpillow(ifwithpillow,howmanypillows)orany
preference for posture while sleeping(i.e. check for orthopnea-mainly In heart failure)
-Does patient wake up at night gasping for breath (PND)
-Isthereassociatedweightloss(FTTbecauseofincreasedenergyexpenditurefrom
respiratory effort seen in asthma and emphysema)
-Is there associated body swelling (heart failure)

3. -Is there associated squatting with exertion ( TOF)
-Is there associated wheezing (asthma)
-Isthereassociatedbluishdiscolorationofthelips,tongueandpalms(TOF,asthma,
heart failure)
-Is there associated restlessness from hunger and hypoxia as in VSD pt
-Associated chest tightedness (asthma, emphysema)
-Associated orthopnea, PND, body swelling (heart failure)
-Associatedaggravatingfactors,worseatnightorearlymorning,associatedwheezy
breathing, chest tightedness, FTT (asthma)

VOMITING
-Is it projectile or not
-Is it with effort or effortless i.e. any retching
-Whatisthecontentofthevomitus-recentlyingestedfood,bilestained,bloodstained(
if so fresh or altered blood i.e. coffee appearance
-What is the consistency- does it contain mucus
-What is the odor-is it odorless or foul smelling
-Howmanytimeshaspatientvomitedandthenumberoftimespthasvomitedonthe
day you are clerking
-Whatisthevolumeineachepisodeandtotalvolumethathasalreadyvomited-estimate
thevolumeinlitersormlswithcontainersorcupsaroundtochecktheircomplication
like dehydration
-Is there any aggravating or relieving factors
-Is there associated weakness (dehydration)
-Is there associated decreased opening of bowel (constipation)
-Is there associated fever (infective process-gastroenteritis)

DIARRHEA
-Duration (greater than one month – HIV)
-How many times does patient open bowel in a day
-Is it copious or scanty volume (estimate as in vomiting)
-How is the odour –odourless or offensive (infective process)
-What is the color of the stool-pale putty like or porridge like and frothy (steatorrhoea)
-Does it contain blood-infective or may not be
1.Is it fresh or altered blood

4. 2.Is it mixed with the stool or not
3.Does it come immediately with the stool or thought or after passage of the stool
-Does it contain mucus or is it slimy (infective diarrhea)
-Does it contain pus (infective diarrhea)
-Is there associated fever
-Any associated abdominal pain, it there is characterize it
-Is there associated weakness or abdominal distension or tenesmus (amoebic dysentery)
-Is there associated abd pain, fever, mucus, or blood – infective diarrhea(gastroenteritis)

SEIZURE
-Is the patient a known epileptic or is it recurrent
-If a known epileptic is patient compliant with his drugs and check up
-What was patient doing when it started
-Whatpartofthebodyisaffectedorisitthewholebody;diditstartfromonepartand
later affect other parts of the body or became generalized
-Is it tonic or clonic or tonic clonic or atonic
-Does patient have any signs before it occurs (aura)
-How many episodes so far has patient had
-How long does each episode last
-Whenwasthelastepisodeanddescribeitifmanyepisodesbutifonlyoneepisode,
describe it asking further questions such as
1.Is only one side of the body affected (partial seizures)
2.Is there associated loss of consciousness or not
3.Does patient sleep immediately after(post ictal sleep)
4.Is there loss of sphincteric tone
5.Is there associated foaming from the mouth
6.Is there associated loud cry or shout before onset
7.Is there associated up rolling of the eyes and blinking of eyelids
8.Is there associated stertorous breathing
9.Is there associated fumbling of hands, tongue biting or lip smacking
10.Is there associated fall or headache after each episode
11.What time of the day is it more

Rule out other causes of seizures which include
1.Fever (cerebral malaria)

5. 2.Trauma (RTA, fall from a height, fight etc)
3.Complications of DM (DKA, Hypoglycemia)
-Is patient a known diabetic
-Is he compliant with his drugs and check ups
-Symptoms of DKA such as abd pain, altered sensorium, vomiting, signs of dehydration
-Symptoms of hypoglycemia such as anxiety, sweating, tremors, altered sensorium
4.Ispatientaknownhypertensiveandifsoishecompliantwithhisdrugsandcheckups
(r/o hypertensive encephalopathy)
5.Isthereassociateheadacheprecedingtheonset0r/oincreasedICPoraretheresignsof
increased ICP such as headaches, vomiting, altered sensorium, etc
6.Is there any sign of liver failure (ask for hx of jaundice)
7.Any symptoms of renal CRF (r/o uremic encephalopathy)
8.Is patient on any drugs (r/o drug induced seizures)
9.Does patient sleep well

EDEMA (BODY SWELLING)
-How was It noticed or who noticed it
-Where did it start from or what part of the body was first affected
-Is it rapid or gradual in development
-Isitlocalizedorgeneralizedatonsetorlocalizedandlaterbecamegeneralizedandhow
did it spread
-Is it bilateral or unilateral
-Is it there all the time or disappears as the day goes by and later reappears
-At what time of the day is it worse
-Is it pitting or non pitting
-Is there any aggravating or relieving factor such as change in position, movement or rest
-Is there any associated change in urine volume or color
-Is there any associated urine changes and are the changes gradual or sudden in onset
-Is there any previous hx of sore throat or skin infections
-Any hx of fever to r/o recent malaria attack or malaria infection (glomerulonephritis)
-Any hx of use of herbal medication (toxic nephropathy)
-Any hx of use of medicated soaps containing heavy metals e.g. mercury, lead
-Any associated flank pain (pyelonephritis)
-Any hx of drug ingestion e.g. analgesics, amino glycosides, NSAIDS
-Any hx of anorexia, vomiting and weakness (uremia, heart failure)
-Any associated hx of bee or insect sting or bite (toxic nephropathy)

6. -R/O​hepaticcausesbyaskingforhxofjaundice,anorexiaandsymptomsof
complications of hepatic encephalopathy
-R/O ​CCF ​ by asking for
1.Hx of cough as before
2.Hx of breathlessness as before
3.Symptoms suggestive of hypertensive heart dx

-In established case of ​CRF ​, look out for complications
1.Uremic encephalopathy – asterixis, altered consciousness
2.Gastritis
3.Renal osteodystrophy
4.Anaemia

WEIGHT LOSS
-Whatmakespatientfeelheislosingweight(evidenceofloosenessofpreviouslytight
clothing, belt, rings or bony prominences)
-Any symptoms suggestive of DM (polyuria, polydypsia, polyphagia)
-AnysymptomssuggestiveofHIVinfection(persistentfever,chronicdiarrhea,chronic
cough)
-What is the feeding habit of the patient (does he feed well)
-Any symptoms suggestive of heart disease (cough, breathlessness, PND, orthopnea)
-Anysymptomssuggestiveofmalignancy(cough,swellinginanypartofthebody,signs
of metastasis)
-Anysymptomssuggestiveofmalabsorptionsyndrome(persistentdiarrhea,
steatorrhoea, persistent vomiting)
-Symptomssuggestiveofrespiratorydisease(hxofcough,ptisaknownasthmatic,hx
of night sweats or hemoptysis)
-Symptomssuggestiveofthyrotoxicosis(irritability,prominencesoftheeye,awareness
of heart beat, heat intolerance).

PAIN
-Where is the pain located (point with a finger if possible)
-Does it radiate to any place or not
-Does it interfere with your daily activity or keeps you awake all night
-Does the pain come and go or is it there all the time

7. -Has it changed since it started
-Whatisthenatureofthepain(stabbing,burning,gnawing,colicky,waxesandwanes
etc)
-Is there anything that aggravated it or makes it worse such as food
-Whatrelievesthepaine.g.changeinposition,eating(duodenalulcer),starvation
(gastriculcer),defecationorpassageofflatus(lowerGIpains),rest(cardiacpain),
bendingforward(pericardialpain),belching(gastroesophagealreflux),drugs(
musculoskeletal pain), antacids (GU,DU)

MASS/SWELLING
-When was it noticed and by who
-What made patient notice it
-Has it been increasing in size since noticed
-How rapid is the growth since it was noticed or has it be been gradual
-Is it tender to touch or painful – if painful, characterize it as before
-Is it warm to touch
-What is the consistency – hard, fluctuant or soft
-Is it mobile or attached underlying structures or skin
-Any associated changes in the color of overlying skin
-Any associated swelling in other parts of the body
-Any associated bone pain or weight loss
-Any associated fever
-Other associations will depend on the site of the mass

JAUNDICE
-r/ohemolyticcausesbyaskingforhxofSCD,fever,changeinurinecolor,drug
ingestion, blood transfusion, past hx of similar episode in the past
-r/ohepaticcausesbyaskingforhxofbodyitching,lossofappetite,changeinstool
color, abd pain, source of water, family hx of hep A, drug injections, sexual affairs
-hx of neonatal jaundice
-r/o hereditary causes by asking for bone pain, swelling in any part of the body
-hx of contact with patient with yellowness of the eye to r/o hep A virus

8. CVA
ISCHEMIC CVA
-How was the neurological deficit first noticed
-Was it sudden or insidious in onset
-What was the patient doing at time of onset
-Is there associated headaches, seizures or loss of consciousness
-r/oriskfactorsforatherosclerosis–ispatienthypertensive,diabetic,asmoker,an
elderly person, heavy drinker
-is patient a known SCD sufferer
-ispatientaknowncardiacdiseasepatient;ifyesaskforpalpitations,edema,cough,
breathlessness, PND, orthopnea in the past or presently
-is patient on any drugs
-is there associated vomiting (ICH, SAH)
-is there associated collapse (SAH)
-is there associated rapid recovery of symptoms
-Are there associated neurological signs
-Is there any previous hx of TIA
-Any hx of trauma (ICH)
-Sexual hx to r/o STDs

-SymptomssuggestiveofembolicCVA ​–suddenonset,headaches,seizures,lossof
consciousness, rapid recovery

-SymptomssuggestiveofSAH–dramaticonset,pptbyactivity,thunderclapheadaches
wcmaybeoccipitalortemporal,collapseafteractivity,noassociatedneurologicalsigns,
associated neck stiffness, loss of consciousness, vomiting, raised BP

-SymptomssuggestiveofICH–suddenonset,headache,vomiting,lossofconsciousness,
no neck stiffness, may be associated with stress

-SymptomssuggestiveofthromboticCVA–slowdevelopmentofsymptoms,no
headaches,ptatrestorrelaxing,nolossofconsciousnessorassociatedhxofseizures,
presence of risk factors for atherosclerosis

9. HEADACHES
Tension headaches
-Is it associated with stress and worries
-Isitpressingorbandingincharacteroftenfoundatthebackoftheheadfromwhereit
radiates to the neck
-Poorly relieved by analgesia
-Is it less during the early parts of the day and worse as the day goes on
-It is not aggravated by coughing, bending down or straining at stool

Vascular headaches
-Throbbing in character
-Associatedwithinfectionssuchasmalaria,typhoid,epilepticfits,trauma,ingestionof
alcohol, or use of vasodilators
-Typically confined to one side of the head

Headaches due to increased ICP
-Increased respiration occurs in short bursts lasting from a few seconds to a few hours
-Occurs mostly at night or in the early stages of the early morning
-Progressive increase in freq until it may become continuous
-Aggravated by coughing, staining at stool, bending down or sudden change in position
-Vomiting may occur esp. at night or early morning when headache is severe
-Relived by analgesia

Headache due to inflammation esp. meningitis
-Generalizedheadachesworsenedbyheadmovts,coughingorpatientmaybedrowsy
and unconscious

Referred headache
-Headache occurs over the eyes, sinuses, frontal area, maxillary area
-Worseafterreadingandmayoccuroverthefrontalareaandspreadtotheocciputor
vertex
-May be due to dx of the teeth or ear or the mzls of the neck and spine

Migraine headache
-Nonspecificprodromeofmalaise,irritabilityfollowedbyanauraoffocalneurological
signs, a severe hemispherical headache, photophobia and vomiting.
-During the headache phase, patient prefers to be quiet in a dark room and go to sleep

10. DIABETES MELLITUS
Polydypsiapolyuria,polyphagia,weightloss,bodyweakness,boils,ulcers,vulvaitching,symptomsof
peripheral neuropathy e.g. numbness, pain, burning sensation, nephropathy

To assess control if patient is a known diabetic
1.Are you a known diabetic?
2.If so, what drug are you on (oral or insulin)
3.What is the dosage of the drug?
4.Are you compliant with the drugs (check ups)?
5.Any dietary control? If so which ones?

To make a diagnosis or to rule out DM as a differential
6.Do you have an increased rate of eating without a corresponding increase in weight.
7.Any history of weight loss as evidenced by what?
8.Any increase in thirst/drinking much fluid?
9.Any increase in frequency of urination or volume of urine?
10.Do you stay long in cold environment?
11.Any history of trauma to the head- to rule out diabetes insipidus?
12.Any history of abdominal surgery in the past? R/o pancreatic damage.

To rule out DM complications
13.Any blurring of vision (DM retinopathy) or double vision (CN 4 and 6).
14.Any decrease in frequency or volume of urine ( nephropathy) or ankle swelling?
15.Any numbness or burning or painful sensation on the limbs.
16.Any feeling of walking on pebbles, cotton wool or slipping off of shoes without knowing?
17.Any ulcer in any part of the body?
18.Any boils or body itching/vulval itching or furuncles?
19.Any difficulty in swallowing (due to oesophageal atony)?
20.Any feeling of abdominal fullness (easy satiety)?
21.Any vomiting, constipation or diarrhea (nocturnal diarrhea)?
22.Any erectile dysfunction in male?
23.Anyfacialswellingwhileeating(gustatorysweating)ordrenchingnightsweating?(last5assess
autonomic neuropathy 16 and 17 immunosuppression. They are all complications.)

CCF

11. PC:dyspnoea,breathlessness,fatigue,orthopnoea,PND,cough,hemoptysis,effortintolerance,
ankle edema.
HPC
-is there any hx of palpitations or headaches (htn)
-is patient a known hypertensive, if so, is he compliant with his drugs and clinics
-Any hx of chest pain, if so, characterize it (r/o angina, MI, pericarditis)
-Any hx of body weakness or difficulty/shortness of breath (r/o anaemia)
-Any hx of sore throat in the past (r/o rheumatic heart dx)
-Any hx of significant alcohol ingestion (r/o alcoholic heart dx)
-Any hx of smoking (r/o atherosclerosis and its complications)
-Any hx suggestive of DM (polyuria, polyphagia, polydypsia) to r/o atherosclerosis
-Anyhxofheatintolerance,irritability,weightloss,prominenceoftheeyeballs(r/o
thyrotoxicosis)
Summary of conditions to rule out in heart failure
1.Hypertension
2.Angina pectoris
3.Myocardial infarction
4.Pericarditis
5.Anaemia
6.Rheumatic heart disease
7.Alcoholic heart dx
8.Atherosclerosis
9.Thyrotoxicosis

PULMONARY TUBERCULOSIS
PC: fever (low grade), cough, weight loss, haemoptysis (>1 month)
HPC
-Explorethefeverandcoughasabove(r/ochronicbronchitis,asthma,bronchiectasis,
lung abscess)
-Exploretheweightlossasabovetor/oDM,HIV,heartdx,malignancy,malabsorption
syndrome, respiratory dx, thyrotoxicosis and good nutrition.
-RuleoutimmunosuppresionthatcanreactivateprimaryTB(HIV,DM,Cytotoxicdrugs,
long term steroid therapy)
-Ifthereisassociatednightsweatsr/oothercausesofnightsweatse.g.lymphomasby
asking for hx of pruritus

12. -Anyhxofcontactwithsomeonewithchroniccoughorifpatientlivesinanovercrowded
environment
-If pt presents with hemoptysis, ask where pt came from to r/o paragonomiasis
-Ifassociatedwithdrenchingnightsweatsr/olymphomabyaskingforhxofbodyitching,
swelling in the neck

PARKINSONISM
PC: tremor, rigidity, hypokinesia, other vague symptoms such as aches, pains, tiredness.
HPC
-Find out if patient has tremors at rest or intention
-Where did the tremors start (for parkinsonism, it starts at the fingers, foot, lips)
-Is tremor of pill rolling type
-Does the tremor disappear during sleep
-Is there associated muscle rigidity
-If yes, where did the rigidity start (usually at the wrist for parkinsonism)
-Is there any difficulty in movement
-Ifyes,howdiditprogress(forparkinsonism,thereispovertyofmovt,thendifficultyin
walkingtonowalkingatallthentoinabilitytogetupfrombedtoinabilitytoeventurn
in bed
-If pt is walking, does he swing his arm
-Any associated difficulty in swallowing, slow chewing or drooling of saliva
-Any associated difficulty with speech (dysarthria)
-If patient is literate, any change in hand writing (micrographia)
-Any change in patients walking steps (shuffling gait)
-Any hx of fever (r/o viral infections and encephalitis lethargica)
-Any hx of trauma (r/o punch drunk syndrome)
-Is pt hypertensive, diabetic or a smoker (r/o atherosclerosis)
-What is pt occupation (r/o poisons as a cause e.g. Wilson’s disease)
-Any hx of confusion, seizures, psychiatric symptoms (r/o SOL )
-Any hx of STD in the past (r/o syphilis)
-Any hx of heat intolerance, wgt loss (thyrotoxicosis)
Remember the following signs
-Expressionless face
-Stell wag’s sign

13. -Glabella tap (meryeson’s sign)
-Festinant gait
-Kaysor-fleisschers
-Corneal arcus

HIV
PC: fever, cough, weight loss
Counseling in HIV
-Fear and stigmata associated with the dx
-Adequate dietary intake
-Proper health care in case of any illness
-Regular exercise
-Avoid alcohol, smoking, hard drugs, narcotics etc
-Patient should not receive any live vaccines
-Partner notification
-Use of condoms and other forms of protection
-Treat any concurrent infection appropriately
-Psychological support

CHRONIC LEG ULCER
-Where is the site of the ulcer
-How did it start or how was it noticed
-Has it been increasing in size and shape
-Is there associated pain (r/o any inflammatory process)
-Any difficulty in movement of the joints around the ulcer(to assess severity)
-Any associated discharge, if so, characterize it (color, volume, blood stained)
-Any itching at site of ulcer (to r/o guinea worm)
-………
-………
-Any dilated peripheral veins on the the leg (r/o venous ulcers)
-Anyhxoffever,cough,nightsweatsorcontactwithpersonwithchroniccough(r/oTB
ulcers)

14. -Any hx of trauma (r/o traumatic ulcers)
-Any hx of polyuria, polyphagia, polydypsia and weight loss (r/o DM)
-If patient is a known diabetic, what drugs is he on and how compliant is he to therapy
-Any hx of calf muscle pains –intermittent claudication- to r/o arterial ulcers
-Is patient a known smoker, hypertensive, or diabetic(r/o atherosclerosis)
-Any hx of prolonged immobility ( r/o pressure ulcers)
-Any hx of weight loss, swelling in any part of the body, bone pains (r/o malignancy)
-Any hx of loss of sensation around the leg (r/o neuropathic ulcers)
-Is patient a known sickler (r/o sickle ulcers)
-Any hx of STD in the past with ulcers in other parts of the body (r/o syphilitic ulcers)

Differentials of ulcers
Guineaworm,varicoseveins,trauma,DM,TB,atherosclerosis,pressureulcers,malignancy,
leprosy, sickle cell anaemia, STDs (syphilis), Multiple myeloma

EXAMINATION
General
Musculoskeletal System: Ulcer examination
Other systems (digestive, CVS, respiratory)
Investigations
Woundswab,Mantouxtest,FBC,ESR,urinalysis,VDRL,FBS,CXR,genotype,lipidprofile,SEUCr,
HIV screening

NEPHROTIC SYNDROME
PC: anuria, oliguria, edema, body swelling, uremic symptoms
-Explore the body swelling as above
-How long ago was it noticed ( >3months CRF, <3months ARF)
-Any signs and symptoms of anaemia
-Is patient a known hypertensive or diabetic (nephropathy)

15. -Any hx of strenuous exercise, trauma or beating (r/o myoglobinuria)
-Is pt a known HIV patient
-Any hx of drug ingestion or herbal drug use
-Isthereanychangeinconsciousness,alteredsensoriumsuchasalteredsleeppattern,
memory impairment, coma etc
-Any hx of nausea, vomiting or anorexia
-Any hx of chest pain (uraemic pericarditis)
-Any hx epigastric pain (uraemic gastritis)
-Any hx of body itching
-Any hx of numbness, pain, burning sensation on the limbs (peripheral neuropathy)
-Any hx of generalized body weakness