Clerking and General History Taking Flashcards
(24 cards)
How should you begin clerking someone?
Introduce self and grade
Ask for name and DOB
Explain purpose of meeting
What next?
Fill in proforma
Patient details
Time presented
Location
What next?
Presenting complaint(s) Short summary of what the patient has come in with
What next?
History of presenting complaint
Include chronological sequence of each complaint; systems specific review; risk factors; relevant negatives
What next?
Past medical/surgical/mental history
Use a systems review here if patient not forthcoming
JADE TAB MARCH
What next?
Drug history
Allergies and adverse reactions
Include dose/frequency/self-medication/OTC medication/herbal/inhalers/oxygen/nebulisers
What next?
Family history
Any conditions that run in the family
Parents
What next?
Social history
Smoking/alcohol/recreational drugs Living situation Relationship Dependents Support network ADLs Mobility
What next?
Systems review General RS CVS GI CNS MSK GU
What should enquire for general symptoms?
Weight loss Night sweats Fever Rashes Mood
What should enquire for respiratory symptoms?
Cough Sputum Haemoptysis Wheeze Exercise tolerance
What should enquire for cardiovascular symptoms?
Palpitations Chest pain Claudication Breathlessness PND Ankle edema
What should enquire for gastrointestinal symptoms?
Appetite change Vomiting Haematemesis/ melaena Rectal bleeding Bowel habits (any change?) Abdominal pain
What should enquire for CNS symptoms?
Headaches Visual disturbances Syncope Weakness Paraesthesia Fits
What should enquire for locomotor symptoms?
Joint pain
Stiffness
Swelling
What should enquire for genitourinary symptoms?
Haematuria Dysuria Frequency Voiding difficulty PV discharge Date of last menstrual period
What should you ask next?
Ideas
Concerns
Expectations
What should you do next?
General appearance examination
well / ill / moribund
pale / cyanosed / clubbed / jaundiced / lymphadenopathy
What should you do next?
CVS examination
Heart sounds: Capillary refill time (normal<2s) Pulse BP (erect/supine) Jugular venous pressure Oedema Peripheral pulses
What should you do next?
Respiratory examination
Respiratory rate Trachea/position Expansion Percussion notes Breath sounds (wheeze, crepitations, bronchial breathing) Added sounds
What should you do next?
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
What should you do next?
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
What should you do next?
Cranial nerve exam
Peripheral nerve exam
GCS
How do you classify reflexes?
- Absent \+ Reduced \++ Normal \+++ Brisk ± Present with reinforcement
Tone ↓ Reduced N Normal ↑ Increased If increased, state if the tone is spastic or rigid
