clerking sheet

1. ©
2013
Tan
Guo
Jeng
All
rights
reserved
HOSPITAL
TENGKU
AMPUAN
RAHIMAH,
KLANG
HOUSE
OFFICER
CLERKING
MANUAL
(beta
1.1
2)

2. ©
2013
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
patient’s
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
doesn’t
mean
that
he
can’t
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.
Tan
Guo
Jeng

3. ©
2013
Tan
Guo
Jeng
All
rights
reserved
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
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

4. ©
2013
Tan
Guo
Jeng
All
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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
high-­‐risk
behaviour
8. quality
of
life
9. activities
of
daily
living:
bathing
dressing
sleep
Presenting
complaints:
1.
Chest
pain
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.
Musculoskeletal
pain:
history
of
heavy
lifting,
unaccustomed
exercise,
reproducible
pain,
muscle
wall
tenderness
on
palpation.
Gastro-­‐oesophageal
reflux
disease:
epigastric
pain,
retrosternal
burning
sensation,
acid-­‐brash,
water-­‐brash,
dryness
of
throat,
wheezing.
Pneumonia:
fever,
cough,
greenish/
yellowish
sputum,
chills,
rigors,
loss
of
appetite,
shortness
of
breath,
peuritic
chest
pain.
Pulmonary
embolism:
sudden
shortness
of
breath,
pleuritic
chest
pain,
haemoptysis,
history
of
cancer,
history
of
DVT,
history

5. ©
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Tan
Guo
Jeng
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immobilization,
history
of
surgery
or
feacture,
tachycardia,
hypoxia,
+/-­‐hypotension.
Dissection
of
the
aorta:
history
Marfan’s
syndrome,
pregnancy,
severe
“tearing”
pain.
Pneumothorax:
pleuritic
chest
pain,
shortness
of
breath.
2.
Abdominal
pain
Intestinal
obstruction:
no
flatus
or
bowel
movement,
vomiting,
unable
to
tolerate
orally,
abdominal
distension.
Pancreatitis:
epigastric
pain
radiating
to
the
back,
relieved
by
bending
forward,
history
of
chronic
alcohol
intake
or
dyslipidaemia,
family
history
of
hyperlipidaemia.
Perforated
ulcer:
severe
epigastric
pain,
history
of
gastric
ulcer,
history
of
gastric
operation,
air
under
diaphragm.
Biliary
colic/
acute
cholecystitis:
right
hypochondrium
pain,
colicky,
radiate
to
the
right
tip
of
scapula,
fever,
jaundice.
Renal
colic/
pyelonephritis:
loin
to
groin
pain,
colicky,
flank
pain,
renal
punch
positive,
fever,
sandy
urine,
passing
stones,
haematuria,
history
of
stones.
Acute
urinary
retention:
unable
to
PU,
distended
bladder,
history
of
Foley’s
catheter,
history
of
urinary
tract
infection.
Acute
myocardial
infarction:
epigastric
pain,
symptoms
of
heart
failure,
radiation
to
left
shoulder
and
jaw,
shortness
of
breath,
nausea,
diaphoresis.
Gastric
cancer:
early
satiety,
loss
of
weight,
loss
of
appetite,
history
of
taking
preserved
foods,
anaemia,
family
history
of
gastric
cancer.
Dengue:
fever,
rash,
myalgia,
arthralgia,
from
dengue
area,
thrombocytopaenia.
3.
Headache
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.
Meningitis:
fever,
altered
behavior,
rash,
neck
stiffness,
photophobia.

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Tan
Guo
Jeng
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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.
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.
Tension
headache:
begins
after
20,
non-­‐throbbing
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.
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.
Sinusitis:
history
of
sinusitis,
rhinorrhea,
pain
on
the
areas
of
sinus,
fever.
Dental
problems:
poor
dental
hygiene,
history
of
caries,
tooth
extraction,
discomfort
on
chewing,
unable
to
open
the
mouth.
Neuralgia:
lightning-­‐like
momentary
along
the
territory
of
the
nerve,
excruciating,
resolve
spontaneously,
triggered
by
stimulation
to
the
trigger
zone,
may
cause
syncope.
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.
Seizures:
abnormal
movements,
tonic-­‐clonic
movements,
post-­‐ictal
drowsiness,
incontinence,
drooling,
up-­‐rolling
of
eyes,
post-­‐ictal
drowsiness,
history
of
epilepsy.
Ocular
disorders:
severe
eye
pain,
decreased
vision,
halo
around
lights,
eye
redness,
nausea
and
vomiting.
Giant
cell
arteritis:
jaw
claudication,
amaurosis
fugax,
aching
and
morning
stiffness
of
the
shoulders.

7. ©
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Tan
Guo
Jeng
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Hypertensive
encephalopathy:
history
of
hypertension,
non-­‐
compliance,
bilateral,
history
of
phaeochromocytoma
associated
with
flushing,
diaphoresis,
palpitations.
Medications:
nitrates,
calcium
channel
blockers,
dipyridamole,
tetracycline,
vitamin
A,
steroids.
4.
Fever
Meningitis:
altered
behavior,
photophobia,
neck
stiffness,
confusion,
rash.
Upper
respiratory
tract
infection:
cough,
sore
throat,
running
nose,
ear
pain.
Sinusitis:
purulent
rhinorrhea,
pain
on
the
areas
of
the
sinus,
ear
fullness,
halitosis,
hyposmia.
Otitis:
ear
pain,
loss
of
hearing,
disequilibrium,
ear
discharge
Pneumonia:
cough,
greenish
or
yellowish
sputum,
chills,
rigors,
pleuritic
chest
pain,
haemoptysis.
Infective
endocarditis:
prolonged
fever,
history
of
intravenous
drug
use,
history
of
valvular
lesions,
positive
blood
cultures,
new
or
changing
murmur,
heart
failure,
arterial
emboli.
Septic
arthritis:
history
of
trauma
or
surgery
near
the
joint,
monoarticular
or
pauciarticular
joint
pain,
swelling
and
redness,
reduction
in
the
range
of
movement.
Urinary
tract
infection:
frequency,
dysuria,
urgency,
suprapubic
pain,
flank
pain,
renal
punch
positive,
chills,
nausea,
vomiting.
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.
Connective
tissue
disease:
arthralgia,
myalgia,
rash,
mononeuritis
(weakness
of
numbness
in
the
distribution
of
one
nerve),
fatigue,
Raynaud’s
phenomenon,
aphthous
ulcers,
alopecia.
Dengue:
myalgia,
arthralgia,
retroorbital
pain,
headache,
bleeding
tendencies,
living
or
working
in
dengue
area,
history
of
fogging,
abdominal
pain,
vomiting,
diarrhea,
thromboytopaenia.

8. ©
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Guo
Jeng
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Leptospirosis:
history
of
jungle
trekking,
working
in
drains
and
sewers,
exposure
to
rodents,
rigors,
myalgia,
headache,
sore
throat
abdominal
pain,
conjunctival
suffusion,
hepatosplenomegaly,
lymphadenopathy.
Scrub
typhus:
history
of
travel
to
the
jungles
or
estates,
headache,
myalgia,
eschar,
chills,
anorexia.
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
Dengue:
myalgia,
arthralgia,
retro-­‐orbital
pain,
headache,
bleeding
tendencies,
living
or
working
in
dengue
area,
history
of
fogging,
abdominal
pain,
vomiting,
diarrhea,
thrombocytopaenia.
Leptospirosis:
history
of
jungle
trekking,
working
in
drains
and
sewers,
exposure
to
rodents,
rigors,
myalgia,
headache,
sore
throat
abdominal
pain,
conjunctival
suffusion,
hepatosplenomegaly,
lymphadenopathy.
Scrub
typhus:
history
of
travel
to
the
jungles
or
estates,
headache,
myalgia,
eschar,
chills,
anorexia.
Systemic
lupus
erythematosus:
joint
swelling
and
pain,
butterfly
rash,
discoid
rash,
alopecia,
aphthous
ulcers,
HIV:
high-­‐risk
behavior,
lymphadenopathy,
fever
and
rash,
sore
throat,
myalgia,
fatigue,
nausea,
anorexia,
weight
loss,
headache
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.
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.
Meningitis:
altered
behavior,
photophobia,
neck
stiffness,
confusion.
6.
Fever
of
unknown
origin

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Guo
Jeng
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Atypical
infection:
fever,
myalgia,
arthralgia,
headache,
rash,
travel
history,
high-­‐risk
behavior,
lymphadenopathy,
hepatosplenomegaly.
Connective
tissue
disease:
arthralgia,
myalgia,
rash,
mononeuritis
(weakness
of
numbness
in
the
distribution
of
one
nerve),
fatigue,
Raynaud’s
phenomenon,
aphthous
ulcers,
alopecia.
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.
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.
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
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.
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.
Seizure:
abnormal
movements,
post-­‐ictal
drowsiness,
urinary
and
fecal
incontinence,
up-­‐rolling
of
eyeballs,
frothing
in
the
mouth,
post-­‐
ictal
weakness,
history
of
febrile
seizures,
family
history
of
mental
retardation,
sudden
death,
and
epilepsy;
precipitated
by
flashing
lights,
sleep
deprivation,
hunger,
alcohol.
Arrhythmias:
history
of
angina
or
heart
failure,
palpitations,
chest
pain.

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Guo
Jeng
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Stroke:
hemiparesis,
hemiparaesthesia,
slurring
of
speech,
history
of
atrial
fibrillation.
Postural
hypotension:
dizziness
on
changing
of
position
from
lying
to
standing
or
sitting
to
standing,
history
of
diabetes
mellitus
or
Parkinson’s
disease.
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.
Medications:
oral
hypoglycaemics,
beta-­‐blockers,
ACEI,
ARB,
calcium
channel
blockers,
nitrates,
anti-­‐convulsants.
8.
Dizziness
and
vertigo
Cerebellar
stroke:
hemiparesis,
hemiparaesthesia,
slurring
of
speech,
history
of
atrial
fibrillation,
nystagmus,
unsteady
gait,
staccato
speech,
intention
tremors,
past-­‐pointing.
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.
Labyrinthine
dysfunction/
vestibular
nerve:
otalgia,
otorrhoea,
reduction
in
hearing,
tinnitus,
facial
nerve
palsy,
history
of
mastoiditis,
sinusitis,
upper
respiratory
infection.
Seizure:
abnormal
movements,
post-­‐ictal
drowsiness,
urinary
and
fecal
incontinence,
up-­‐rolling
of
eyeballs,
frothing
in
the
mouth,
post-­‐
ictal
weakness,
history
of
febrile
seizures,
family
history
of
mental
retardation,
sudden
death,
and
epilepsy;
precipitated
by
flashing
lights,
sleep
deprivation,
hunger,
alcohol.
Subclavian
steal
syndrome:
history
of
artherosclerosis,
history
of
ischaemic
heart
disease,
history
of
diabetes
mellitus,
history
of
hypertension,
symptoms
precipitated
by
lifting
of
arms.
Carotid
artery
stenosis:
history
of
artherosclerosis,
history
of
Ischaemic
heart
disease,
history
of
diabetes
mellitus,
history
of
hypertension,
symptoms
precipitated
by
head
movements.
Postural
hypotension:
dizziness
on
changing
of
position
from
lying
to
standing
or
sitting
to
standing,
history
of
diabetes
mellitus
or
Parkinson’s
disease.

11. ©
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Guo
Jeng
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9.
Weakness
and
paralysis
Stroke:
hemiparesis,
hemiparaesthesia,
slurring
of
speech,
history
of
atrial
fibrillation,
history
of
carotid
bruit.
Transient
ischaemic
attack:
symptoms
of
stroke
lasting
less
than
24
hours
with
full
recovery.
Reversible
ischaemic
neurological
deficit:
symptoms
of
stroke
recovery
more
than
24
hours
but
full
recovery
by
one
week.
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
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.
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,
Lhermitte’s
sign,
asymmetrical
sensory
and
motor
deficit,
wasting;
Subacute
combined
degeneration:
slowly
progressive
weakness,
sensry
ataxia,
paraesthesia,
spasticity,
paraplegia,
incontinence,
macrocytic
anaemia.
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.
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).
Bell’s
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.

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Guo
Jeng
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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.
Periodic
paralysis:
sudden
onset,
respiratory
or
bulbar
muscles
only
mildly
affected,
several
hours,
triggered
by
exercise,
stress
or
high-­‐
carbohydrate
meal
after
few
hours
delay,
proximal
more
than
distal.
10.
Gait
and
balance
disorders
Parkinson’s
Disease:
bradykinesia,
micrographia,
rigidity,
freezing,
anterograde
fall,
stooped
posture,
sialorrhoea,
dysphagia,
asymmetrical,
resting
tremor,
pill-­‐rolling,
festinating
gait,
loss
of
arm
swing,
turning
en-­‐bloc.
Cerebellar
stroke:
ataxia,
nystagmus,
intention
tremor,
past-­‐
pointing,
staccato
speech.
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.
Drug/toxic/metabolic:
alcohol
anti-­‐psychotics,
dopamine
agonists,
steroid,
recreational
drug
use,
vegan
diet,
B12
deficiency.
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’s
syndrome
(electric
shock
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.
Stroke:
hemiparesis,
hemiparaesthesia,
slurring
of
speech,
history
of
atrial
fibrillation.
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.
Stroke:
hemiparesis,
hemiparaesthesia,
slurring
of
speech,
history
of
atrial
fibrillation,
carotid
bruit,
sudden
onset.

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Guo
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Spinal
cord
ischaemia:
sudden
back
pain,
bilateral
flaccid
weakness,
loss
of
pain
and
temperature
sensation.
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.
11.
Numbness,
tingling
and
sensory
loss
Diabetic
neuropathy:
burning
sensation
at
night,
walking
on
cotton,
Charcot’s
joint,
history
of
diabetic
foot
ulcer,
polyuria,
polydipsia,
visual
disturbance,
recurrent
infections.
Medications:
phenytoin,
metronidazole,
pyridoxine,
hydroxychloroquine,
HAART,
amiodarone,
isoniazid,
leflunomide,
vinblastine,
vincristine,
cisplatin,
oxaliplatin.
Gold,
alcohol
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.
Stroke:
hemiparesis,
hemiparaesthesia,
slurring
of
speech,
history
of
atrial
fibrillation,
carotid
bruit,
sudden
onset.
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’s
syndrome
(electric
shock
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.
Radiculopathy:
asymmetrical
involvement
of
a
whole
limb,
worsen
by
coughing,
sneezing
and
straining;
gradual
persistent
progression,
muscle
wasting.
Spinal
cord
lesion:
involvement
of
both
lower
limbs,
sensory
level,
incontinence,
history
of
trauma
or
fall,
could
be
sudden
onset
associated
with
back
pain.

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Guo
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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).
Connective
tissue
disease:
arthralgia,
myalgia,
rash,
mononeuritis
(weakness
of
numbness
in
the
distribution
of
one
nerve),
fatigue,
Raynaud’s
phenomenon,
aphthous
ulcers,
alopecia.
Hypocalcaemia:
peri-­‐oral
numbness,
paraesthesia
of
the
hands
and
feet,
carpopedal
spasm,
Chvostek’s
sign
positive,
Trousseau’s
sign
positive.
Hypothyroidism:
lethargy,
cold
intolerance,
bradycardia,
weight
gain,
dry
and
pale
skin,
tiredness
leg
swelling,
macrocytic
anaemia.
Hereditary
sensorimotor
neuropathy:
foot
deformity,
family
history.
12.
Confusion
and
delirium
Meningitis-­‐
altered
behavior,
photophobia,
neck
stiffness,
confusion
Acute
confusional
state:
elderly
patients
in
sepsis,
post-­‐surgery,
in
pain
or
acute
urinary
retention.
Drugs:
insulin,
oral
hypoglycaemics,
digoxin,
lithium,
opiates,
benzodiazepines,
barbiturates,
anti-­‐cholinergics:
procyclidine,
banzetropine,
amitryptilline,
imipramine,
citalopram,
sertraline,
oxybutynin,
levodopa,
corticosteroids.
Metabolic:
electrolyte
imbalance,
hypothyroidism.
Cerebral
lupus:
arthralgia,
myalgia,
rash,
mononeuritis
(weakness
of
numbness
in
the
distribution
of
one
nerve),
fatigue,
Raynaud’s
phenomenon,
aphthous
ulcers,
alopecia,
history
of
SLE
diagnosis.
Stroke:
hemiparesis,
hemiparaesthesia,
slurring
of
speech,
history
of
atrial
fibrillation.
Endocrinological:
hypoglycaemia,
hyperglycaemia,
change
in
medications,
increased
in
dosages
of
insulin
or
oral
hypoglycaemics
Head
injury:
history
of
alleged
falls,
alleged
assaults,
and
alleged
motor-­‐vehicular
accidents.
Seizure:
abnormal
movements,
post-­‐ictal
drowsiness,
urinary
and
fecal
incontinence,
up-­‐rolling
of
eyeballs,
frothing
in
the
mouth,
post-­‐
ictal
weakness,
history
of
febrile
seizures,
family
history
of
mental

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Guo
Jeng
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retardation,
sudden
death,
and
epilepsy;
precipitated
by
flashing
lights,
sleep
deprivation,
hunger,
alcohol.
Urinary
tract
infection:
fever,
dysuria,
frequency,
unsatisfactory
voiding,
urgency.
Chest
infection:
fever,
cough,
chills,
rigors,
productive
sputum.
Pulmonary
embolism:
pleuritic
chest,
pain,
shortness
of
breath,
haemoptysis.
Congestive
cardiac
failure:
reduced
effort
tolerance,
NYHA
class,
orthopnoea,
paroxysmal
nocturnal
dyspnea,
bilateral
pedal
oedema,
history
of
acute
coronary
syndrome.
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.
Hepatic
encephalopathy:
jaundice,
abdominal
distension,
history
of
alcohol
abuse,
Wilson’s
disease,
viral
hepatitis,
haematochromatosis
13.
Memory
loss
Stroke-­‐hemiparesis,
hemiparaesthesia,
slurring
of
speech,
history
of
atrial
fibrillation.
Depression-­‐anhedonia,
sleep
disturbances
low
energy,
low
mood,
poor
concentration,
guilt,
suicidal
ideation.
Alzheimer’s
Disease:
anterogade
episodic
memory
loss,
disinhibition,
aggression.
Subdural
haemorrhage:
history
of
trauma,
rapid
decline
of
cognitive
function
over
days
and
weeks,
elderly
persons.
Space-­‐occupying
lesion:
rapid
decline
in
cognition
over
months,
weakness,
sensory
and
visual
disturbances,
headaches,
seizures,
nausea,
vomiting
exacerbated
by
the
change
in
posture.
Normal
pressure
hydrocephalus:
small
steps
with
broad
based
gait
with
loss
of
arm-­‐swing,
urinary
incontinence.
Medications:
anticholinergics,
opiates,
anxiolytics,
antipyschotics,
aluminium
based
phosphate
binders,
recreational
drugs.
Endocrine
causes:
hypothyroidism;
weight
gain,
hoarseness,
lethargy,
cold
intolerance,
Cushing’s
syndrome;
inattention,
weight
gain,
hypertension,
diabetes
mellitus,
muscle
weakness.

16. ©
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Guo
Jeng
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14.
Shortness
of
breath
Congestive
cardiac
failure-­‐reduced
effort
tolerance,
NYHA
class,
orthopnoea,
paroxysmal
nocturnal
dyspnea,
bilateral
pedal
oedema,
history
of
acute
coronary
syndrome.
Silent
myocardial
infarction-­‐
vague
chest
discomfort,
long
history
of
diabetes
mellitus,
palpitations,
reduced
effort
tolerance,
radiation
to
the
left
shoulder
and
jaw,
nausea,
diaphoresis.
Pneumonia-­‐cough,
sputum,
colour
of
sputum,
history
of
taking
antibiotics,
chills
and
rigors.
Gastro-­‐oesophageal
reflux
disease-­‐epigastric
discomfort,
aggravating
and
relieving
factor,
timing
of
food,
retrosternal
burning
sensation,
acid-­‐brash,
water-­‐brash,
bitter
taste.
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.
Muscle
of
respiration
weakness-­‐
history
of
myopathy,
endocrinological
problems,
electrolyte
imbalance,
ascending
weakness
with
areflexia,
loss
of
sensation.
15.
Cough
Community
acquired
pneumonia:
fever,
greenish
or
yellowish
suptum,
chills,
rigors,
shortness
of
breath,
pleuritic
chest
pain,
haemoptysis.
Partially
treated
pneumonia:
history
of
taking
antibiotics.
Hospital
acquired
pneumonia:
history
of
admission
within
the
last
2
months,
antibiotics
taken.
Tuberculosis:
prolonged
cough,
haemoptysis,
loss
of
weight,
loss
of
appetite,
night
fever,
night
sweat,
history
of
tuberculosis
contact.
Bronchial
asthma:
family
history,
childhood
asthma,
allergic
rhinitis,
allergy,
atopic
dermatitis,
use
of
inhalers,
frequency
of
night-­‐time
cough,
frequency
of
nebulisers,
frequency
of
admissions,
history
of
ICU
care,
known
precipitating
factors,
pets,
carpets,
cockroaches.
Congestive
cardiac
failure:
reduced
effort
tolerance,
orthopnoea,
paroxysmal
nocturnal
dyspnea,
pedal
oedema,
history
of
ischaemic
heart
disease.

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Guo
Jeng
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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.
16.
Palpitations
Acute
coronary
syndrome:
central
of
left-­‐sided
chest
discomfort,
heaviness,
shortness
of
breath,
radiation
to
left
arm
and
neck,
diaphoresis,
nausea,
vomiting,
symptoms
of
heart
failure,
exertional
angina.
Congestive
cardiac
failure:
reduced
effort
tolerance,
orthopnoea,
paroxysmal
nocturnal
dyspnea,
pedal
oedema,
history
of
ischaemic
heart
disease.
Thyrotoxicosis:
weight
loss,
diarrhea,
heat
intolerance,
over-­‐dosage
of
L-­‐thyroxine,
agitation,
tremors,
neck
swelling.
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.
Hypoglycaemia:
hunger,
tremors,
irritability,
fasting,
poor
oral
intake,
change
in
insulin
or
oral
hypoglycaemic
dosages.
Phaeochromocytoma:
headache,
dizziness,
flushing,
hypertension.
Medications:
beta
agonist,
theophylline,
levothyroxine,
monoamine
oxidase
inhibitor,
quinidine,
amiodarone,
erythromycin,
azithromycin,
SSRI,
tricyclic,
domperidone,
recreational
drugs,
alcohol,
caffeine.
17.
Dysphagia
Stroke:
hemiparesis,
hemiparaesthesia,
slurring
of
speech,
history
of
atrial
fibrillation.
Parkinson’s
disease:
bradykinesia,
micrographia,
rigidity,
freezing,
anterograde
fall,
stooped
posture,
sialorrhoea,
dysphagia,
asymmetrical,
resting
tremor,
pill-­‐rolling,
festinating
gait,
loss
of
arm
swing,
turning
en-­‐bloc.
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.

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Guo
Jeng
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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
distrubances,
internuclear
ophthalmoplegia,
numbness,
Lhermitte
syndrome
(electric
shock
sensation
on
the
flexion
of
the
neck),
fatigue,
Uthoff
phenomenon
(worsening
of
symptoms
of
exposure
to
heat
and
increased
temperature),
oligoclonal
band
on
CSF,
bowel,
bladder
dysfunction.
Oesophagitis:
odynophagia,
epigastric
discomfort,
retrosternal
burning
sensation,
worse
on
lying
down,
acid-­‐brash,
water-­‐brash,
bitter
taste
in
the
mouth.
Diffuse
oesophageal
spasm:
heart
burn,
dysphagia,
chest
pain,
regurgitation.
Achalasia:
dysphagia
for
liquid
and
solid,
difficulty
belching,
abdominal
distension,
weight
loss,
regurgitation
especially
on
recumbency,
retrosternal
burning
sensation,
heartburn,
Systemic
sclerosis:
sclerodactyly,
digital
ulcers,
cutis
calcinosis,
telangiectasia,
Raynaud’s
phenomenon,
reflux,
oesophagitis,
interstitial
lung
disease:
dyspnea,
unproductive
cough;
pulmonary
hypertension,
bird-­‐like
facies.
Sjogren
syndrome:
eye
dryness,
irritation,
grittiness,
mouth
dryness
leading
to
difficulty
swallowing,
salivary
gland
enlargement.
Drugs:
doxycycline,
bisphosphonate,
NSAIDS,
ferrous
sulphate,
nitrates,
calcium
antagonist,
alcohol.
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.
Structural
cause:
Plummer-­‐Vinson
syndrome;
pharyngeal
web,
anaemia,
diverticula,
oesophageal
web
or
ring
18.
Nausea
and
vomiting
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.
Food
poisoning:
history
of
taking
outside
food,
other
people
with
similar
symptoms
having
taken
similar
food,
poor
hygiene.

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Guo
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Adrenal
insufficiency:
hypotension,
anorexia,
nausea,
vomiting,
abdominal
pain,
weakness,
fatigue,
lethargy,
confusion,
hypoglycaemia,
history
of
tuberculosis,
traditional
medicaitions,
septic
shock,
hyponatraemia,
hyperkalaemia.
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.
Acute
gastroenteritis:
diarrhea
frequency,
consistency,
colour
of
stools,
mucus,
blood,
vomiting
frequency,
content,
dietary
history,
travel
history,
contact
with
people
with
similar
symptoms.
Dengue:
myalgia,
arthralgia,
retro-­‐orbital
pain,
headache,
bleeding
tendencies,
living
or
working
in
dengue
area,
history
of
fogging,
abdominal
pain,
vomiting,
diarrhea,
thrombocytopaenia.
Pancreatitis:
acute,
severe
epigastric
pain,
radiating
to
the
back
relieved
by
bending
forward,
nausea,
vomiting,
hypotension.
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
tolerance,
orthopnoea,
paroxysmal
nocturnal
dyspnea.
ENT
problem:
otalgia,
otorrhoea,
tinnitus,
loss
or
reduction
in
hearing,
imbalance,
dizziness.
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
Gastroenteritis:
diarrhea
frequency,
consistency,
colour
of
stools,
mucus,
blood,
vomiting
frequency,
content,
dietary
history,
travel
history,
contact
with
people
with
similar
symptoms.
Dengue:
myalgia,
arthralgia,
retroorbital
pain,
headache,
bleeding
tendencies,
living
or
working
in
dengue
area,
history
of
fogging,
abdominal
pain,
vomiting,
diarrhea,
thrombocytopaenia.
Laxative
use:
wanting
to
lose
weight,
history
of
depression,
anorexia,
bulimia.

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2013
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Guo
Jeng
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Malabsorption:
steatorrhoea
(pale,
greasy,
voluminous,
foul-­‐smelling
stools),
abdominal
distension,
flatulence,
borborygmi,
iron
deficiency
anaemia,
osteopaenia,
weight
loss
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.
Malignancy:
loss
of
weight,
loss
of
appetite,
altered
bowel
habit,
blood
or
mucus
in
stools,
early
satiety,
dysphagia,
anaemia,
mass,
nausea,
vomiting,
tenesmus,
haematochezia.
Hyperthyroidism:
weight
loss,
heat
intolerance,
diarrhea,
palpitations,
sweating,
neck
swelling,
constipation
alternating
with
diarrhoea
(spurious
diarrhea).
Carcinoid
syndrome:
episodic
flushing
associated
with
hypotension
and
tachycardia,
venous
telangiectasia,
diarrhea,
bronchospasm,
cardiac
lesions.
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.
Medications:
antibiotics,
ACEI,
digoxin,
SSRI,
statins,
proton
pump
inhibitors
especially
lansoprazole,
laxative,
magnesium-­‐based
medications.
20.
Constipation
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.
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.
Hypercalcaemia:
depression,
constipation,
anorexia,
nausea,
polyuria,
nephrolithiasis,
bone
pain,
muscle
weakness,
Drugs:
opiates,
iron,
anti-­‐cholinergic,
tricyclics
anti-­‐depressant,
calcium
antagonists.

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2013
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Guo
Jeng
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Pelvic
floor
dysfunction:
depression,
anxiety,
history
of
sexual
abuse,
difficulty
passing
soft
and
hard
stools,
difficult
to
relax,
use
finger
to
help
pass
stools.
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.
21.
Weight
loss
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.
Chronic
infection:
history
of
travel,
high-­‐risk
behaviour
Hyperthyroidism:
weight
loss,
heat
intolerance,
diarrhea,
palpitations,
sweating,
neck
swelling
Diabetes
mellitus:
polyuria,
polydipsia,
thirst,
recurrent
infection,
slow
healing
wounds,
history
of
diabetic
foot
ulcer,
non-­‐compliance.
Malabsorption:
steatorrhoea
(pale,
greasy,
voluminous,
foul-­‐smelling
stools),
abdominal
distension,
flatulence,
borborygmi,
iron
deficiency
anaemia,
osteopaenia.
Tuberculosis:
prolonged
unproductive
cough,
haemoptysis,
loss
of
weight,
loss
of
appetite,
night
fever,
night
sweat.
Medications:
SSRI,
levodopa,
metformin,
theophylline,
digoxin;
indirectly:
anticholinergic,
diuretic,
bisphosphonate,
NSAID,
theophylline
antibiotics,
iron,
azathioprine,
metronidazole,
HAART,
cocaine,
amphetamine.
Neurological
diseases:
different
causes
of
dysphagia;
muscle
weakness,
choking
on
swallowing,
muscle
wasting
and
atrophy,
tremors.
22.
Jaundice
Hepatitis:
fever,
jaundice,
tattoos,
shared
needles,
medical
and
dental
treatment
abroad,
history
of
transfusion,
family
history,
sexual
history,
high-­‐risk
behaviours.
Drugs:
rifampicin,
isoniazid,
pyrazinamide,
nitrofuratoin,
phenytoin,
valproate,
paracetamol,
diclofenac,
methyldopa,
statins,

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Guo
Jeng
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amiodarone,
halothane,
methotrexate,
amiodarone,
erythromycin,penicillins,
chlorpromazine,
carbamazepine,
oestrogens,
steroid,
sulphonylureas,
allopurinol.
Cholangitis/cholecystitis:
fever,
history
of
biliary
stones,
jaundice,
right
hypochondrium
pain
radiating
to
the
tip
of
the
scapular,
Murphy’s
sign
positive.
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.
Choledocholithiasis:
dyslipidaemia,
biliary
colic,
right
hypochondrium
pain
radiating
to
the
tip
of
scapula,
nausea.
Alcohol:
how
long,
number
of
units
a
week,
type
of
alcohol,
attempts
at
quitting,
last
drink.
Budd-­‐Chiari
syndrome:
usually
middle-­‐aged
women,
associated
with
myeloproliferative
disorders,
sudden-­‐onset
ascites,
hepatomegaly
and
abdominal
pain,
variceal
bleed,
portal
hypertension,
cirrhosis.
Hereditary:
Wilson’s
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.
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.
Malignancy:
loss
of
weight,
loss
of
appetite,
onset
weeks
to
months,
abdominal
distension,
family
history
of
cancer,
abdominal
pain
Haemolysis:
pica,
reduced
effort
tolerance,
palpitations,
fever,
splenomegaly,
history
of
sickle
cell
disease,
haemaglobinopathy.
Disorders
of
bile
transport:
family
history
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

23. ©
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Guo
Jeng
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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
Chronic
liver
disease:
history
of
viral
hepatitis,
alcohol
abuse,
Wilson’s
disease,
haemachromatosis,
jaundice,
loss
of
appetite,
leuconychia,
parotid
swelling,
easy
bruising,
spider
naevi,
hepatomegaly,
splenomegaly,
asterixis,
fluid
thrill,
shifting
dullness.
Neoplasm:
loss
of
weight,
loss
of
appetite,
blood
and
mucus
in
stools,
post-­‐menopausal
bleeding,
intestinal
obstruction,
haematuria,
constipation,
spurious
diarrhea,
intermenstrual
bleed,
anaemia.
Tuberculous
peritonitis:
abdominal
pain
and
distension,
loss
of
weight,
loss
appetite,
history
of
tuberculosis,
night
fever,
night
sweat.
Congestive
cardiac
failure:
reduced
effort
tolerance,
orthopnoea,
paroxysmal
nocturnal
dyspnea,
pedal
oedema,
history
of
ischaemic
heart
disease.
Renal
failure:
nausea,
vomiting,
itch,
pedal
oedema,
history
of
NSAID,
traditional
medications,
diabetes
mellitus,
hypertension
and
connective
tissue
disease,
proteinuria.
Pancreatitis:
acute,
severe
epigastric
pain,
radiating
to
the
back
relieved
by
bending
forward,
nausea,
vomiting,
hypotension.
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
Nephrotic
syndrome:
pedal
oedema,
ascites,
dyslipidaeamia,
frothy
urine,
facial
puffiness.
Post-­‐streptococcal
glomerulonephritis
and
chronic
GN:
recent
sore
throat,
fever,
rash,
cola
coloured
urine,
frothy
urine,
pedal
oedema
Drug-­‐induced
or
herbal
nephropathy:
history
of
frequent
NSAID,
history
of
taking
traditional
medications
and
herbs,
supplements,
‘jamus’.

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2013
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Guo
Jeng
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Diabetic
nephropathy:
duration
of
diabetes,
control,
compliance,
frothy
urine,
frequency,
polyuria,
polydipsia,
recurrent
infections.
Hypertensive
nephropathy:
duration
of
hypertension,
control
and
compliance.
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
Nutritional
deficiency:
reduced
effort
tolerance,
palpitations,
pallor,
pica,
poor
dietary,
exclusive
vegetarian
diet,
malnourishment.
Hypothyroidism:
macrocytic
anaemia,
constipation,
weight
gain,
lethargy,
slow
speech,
cool,
pale,
dry
skin,
cold
intolerance.
Hemoglobinopathy:
family
history,
recurrent
transfusions,
splenomegaly.
Menorrhagia:
menarche,
start
of
each
cycle,
regularity,
duration
of
cycle,
number
of
pads
a
day,
overflow,
clots,
dysmenorrhea.
Blood
loss:
haematemesis,
haematochezia,
blood
mixed
in
stools,
history
of
NSAID
and
steroid
use.
Marrow
infiltration:
history
of
malignancy,
symptoms
of
anaemia,
recurrent
infections,
easy
bruising,
difficulty
in
stopping
bleeding,
bone
pain.
Haematological
malignancy:
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.
26.
Polycythaemia
Smoking:
number
of
years
and
pack,
quit
for
how
long.
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.
High
altitude:
place
of
birth,
work
and
training.

25. ©
2013
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Guo
Jeng
All
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Cyanotic
heart
disease:
history
of
congenital
heart
disease,
cardiac
surgery
history,
valvular
disorder.
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
Drugs:
warfarin,
enoxaparin,
anti-­‐platelets,
NSAIDs.
Platelet
defects:
family
history.
Uraemia:
nausea,
vomiting,
itch,
pedal
oedema,
orthopnoea,
paroxysmal
nocturnal
dyspnea,
metallic
taste.
Dengue:
myalgia,
arthralgia,
retro-­‐orbital
pain,
headache,
bleeding
tendencies,
living
or
working
in
dengue
area,
history
of
fogging,
abdominal
pain,
vomiting,
diarrhea,
thrombocytopaenia.
Marrow
infiltration:
history
of
malignancy,
symptoms
of
anaemia,
bone
pain,
recurrent
infections,
petechial
rash,
bruising.
Haematological
malignancy:
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.
28.
Thrombosis
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.
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.
Essential
thrombocythaemia:
headache,
light-­‐headedness,
syncope,
atypical
chest
pain,
amaurosis
fugax,
erythromelagia
(burning

26. ©
2013
Tan
Guo
Jeng
All
rights
reserved
sensation
of
the
hands
and
feet
with
erythema,
thrombosis
(stroke,
myocardial
infarction,
pulmonary
embolism)
and
haemorrhage.
Acquired
thrombophilia:
family
history,
recent
starting
of
warfarin,
malignancy,
hyperviscosity,
myeproliferative
disorders,
nephrotic
syndrome.
Drugs:
oral
contraceptive,
hormone
replacement
therapy,
bevacizumab,
tamoxifen.
29.
Splenomegaly
Lymphoma:
reduced
effort
tolerance,
pica,
easy
bruising,
frequent
infections,
paleness,
lymphadenopathy,
hepatosplenomegaly,
loss
of
weight,
loss
of
appetite,
night
fever,
night
sweat.
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.
Connective
tissue
disease:
arthralgia,
myalgia,
rash,
mononeuritis
(weakness
of
numbness
in
the
distribution
of
one
nerve),
fatigue,
Raynaud’s
phenomenon,
aphthous
ulcers,
alopecia.
Chronic
liver
disease:
history
of
alcohol
abuse,
Wilson’s
disease,
haematochromatosis,
leuconychia,
loss
of
axillary
hair,
abdominal
distension,
parotid
enlargement,
jaundice,
spider
naevi,
bruising.
Thalassaemia:
recurrent
transfusion,
family
history,
anaemia,
splenectomy.
30.
Wheezing
and
shortness
of
breath
Bronchial
asthma:
family
history,
childhood
asthma,
allergic
rhinitis,
allergy,
atopic
dermatitis,
use
of
inhalers,
frequency
of
night-­‐time
cough,
frequency
of
nebulisers,
frequency
of
admissions,
history
of
ICU
care,
known
precipitating
factors,
pets,
carpets,
cockroaches.
Chronic
obstructive
airway
disease:
smoking
history,
number
of
pack
years,
treatment,
stopped
smoking
when
and
for
how
long.
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.
Congestive
cardiac
failure:
reduced
effort
tolerance,
orthopnoea,
paroxysmal
nocturnal
dyspnea,
pedal
oedema,
history
of
ischaemic
heart
disease.

27. ©
2013
Tan
Guo
Jeng
All
rights
reserved
Post-­‐infectious
bronchospasm:
history
of
severe
pneumonia,
history
of
tuberculosis.
Allergic
broncho-­‐pulmonary
aspergillosis:
history
of
exposure
to
fungal,
work
in
dark
dusty
places,
haemoptysis.
Gastro-­‐oesophageal
reflux
disease:
epigastric
pain,
retrosternal
burning
sensation,
acid-­‐brash,
water-­‐brash,
dryness
of
throat,
wheezing.
31.
Haemoptysis
Neoplasm:
loss
of
weight,
loss
of
appetitie,
cough,
history
of
smoking,
dilated
veins,
hoarseness
of
voice,
ptosis
and
reduced
sweating
on
one
side.
Bronchiectasis:
cough,
copious
mucopurulent
sputum
production,
dyspnea,
rhinosinusitus,
history
of
severe
pneumonia,
pertussis,
tuberculosis,
cystic
fibrosis.
Pneumonia:
fever,
chills
and
rigors,
greenish
or
yellowish
sputum.
Tuberculosis:
night
fever,
night
sweat,
prolonged
unproductive
cough,
loss
of
weight,
loss
of
appetite.
Vasculitic
disorders:
rash,
fever,
epistaxis,
loss
of
appetite,
loss
of
weight,
muscle
weakness,
numbness
in
the
territory
of
one
nerve
(mononeuritis),
joint
pain,
petechial.
Leptospirosis:
fever,
jaundice,
history
of
exposure
to
rats,
history
of
travel,
history
of
going
to
waterfalls,
sewers,
drains,
thrombocytopaenias
with
leukocytosis
and
raised
creatinine
kinase.
Pulmonary
embolism:
shortness
of
breath,
pleuritic
chest
pain,
palpitations,
risk
factors
for
DVT
or
has
DVT,
tachypnoea,
tachycardia,
D-­‐dimer
is
raised
32.
Tremor
Parkinson’s
disease:
bradykinesia,
micrographia,
rigidity,
freezing,
anterograde
fall,
stooped
posture,
sialorrhoea,
dysphagia,
asymmetrical,
resting
tremor,
pill-­‐rolling,
festinating
gait,
loss
of
arm
swing,
turning
en-­‐bloc.
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.

28. ©
2013
Tan
Guo
Jeng
All
rights
reserved
Multisystem
atrophy:
akinetic
rigidity,
cerebellar
ataxia,
postural
instability,
jerky
postural
and
action
tremor,
pyramidal
signs,
presyncope,
syncope,
frequency,
hesitancy,
incontinence,
constipation,
impotence,
sialorrhoea,
nystagmus.
Progressive
supranuclear
palsy:
stiff
broad-­‐based
gait,
lurching,
fall
backwards,
vertical
gaze
impairment,
rigidity
more
apparent
in
axial
muscles,
bradykinesia,
micrographia,
freezing,
stuttering,
palilalia,
emotional
lability.
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.
Cerebellar
syndrome:
ataxia,
nystagmus,
intention
tremor,
past-­‐
pointing,
staccato
speech.
Hyperthyroidism:
weight
loss,
heat
intolerance,
diarrhea,
palpitations,
sweating,
neck
swelling.
Phaeochromocytoma:
palpitations,
headache,
sweating,
dizziness,
hypertension.
Wilson’s
disease:
drooling,
dysphagia,
dystonia,
psychosis,
depression,
history
of
hepatitis.
Medications:
metoclopramide,
prochlorperazine,
chlorpromazine,
haloperidol,
phenytoin,
valproate,
lithium,
salbultamol,
salmeterol,
tricyclics,
levothyroxine.
33.
Haematuria
Glomerulpnephritis:
cola-­‐coloured
urine,
hypertension,
impaired
renal
function,
symptoms
of
uraemia;
nausea,
vomiting,
itch,
loss
of
appetite,
metallic
taste.
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,
Raynaud’s
phenomenon,
easy
bruising.
Connective
tissue
disease:
arthralgia,
myalgia,
rash,
mononeuritis
(weakness
of
numbness
in
the
distribution
of
one
nerve),
fatigue,
Raynaud’s
phenomenon,
aphthous
ulcers,
alopecia.
Malignancy:
loss
of
weight,
loss
of
appetite,
history
of
prostate
cancer,
renal
cell
carcinoma,
frequency,
nocturia,
unsatisfactory

29. ©
2013
Tan
Guo
Jeng
All
rights
reserved
voiding,
urgency,
strangury,
incontinence,
poor
stream,
hesitancy,
lower
back
pain.
Infection:
urgency,
dysuria,
frequency,
fever.
Renal
calculi:
sandy
urine,
loin
to
groin
pain,
history
of
gout,
passage
of
stones,
dysuria.
Drugs:
cyclophosphamide,
warfarin.
Radiotherapy
34.
Seizure
Epilepsy:
abnormal
movements,
post-­‐ictal
drowsiness,
urinary
and
fecal
incontinence,
up-­‐rolling
of
eyeballs,
frothing
in
the
mouth,
post-­‐
ictal
weakness,
history
of
febrile
seizures,
family
history
of
mental
retardation,
sudden
death,
and
epilepsy.
Meningitis:
fever,
neck
stiffness,
altered
behavior,
photophobia,
rash.
Stroke:
hemiparesis,
hemiparaethesia,
slurring
of
speech,
history
of
atrial
fibrialltion.
Space-­‐occupying
lesion:
early
morning
headache,
blurring
of
vision,
blurring
of
vision
when
bending
down,
projectile
vomiting,
altered
behavior,
reduced
cognition.
Head
injury:
history
of
alleged
assault,
history
alleged
motor
vehicular
accident,
birth
trauma,
cerebral
palsy.
Alcohol
withdrawal:
units
of
alcohol
consumed
in
a
week,
attempts
to
stop:
when
and
for
how
long,
type
of
alcohol
consumed,
last
drink
Drug
withdrawal:
barbiturates,
benzodiazepines.
Drug
overdose:
lithium,
neuroleptics,
imipramine,
recreational
drugs,
ciprofloxacin,
imipenem,
flumazenil.
Non-­‐compliance:
reason
for
non-­‐compliance,
side-­‐effects
of
the
drug,
patients’
ideas
about
the
drugs
and
illness,
TDM,
regularity
of
follow-­‐up.
35.
Leg
swelling
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.

30. ©
2013
Tan
Guo
Jeng
All
rights
reserved
Congestive
cardiac
failure:
history
of
ischaemic
heart
disease,
diabetes
mellitus,
hypertension,
dyslipidaemia,
reduced
effort
tolerance,
NYHA
class,
orthopnoea,
paroxysmal
nocturnal
dyspnea.
Renal
failure:
history
of
traditional
medications,
NSAID
abuse,
connective
tissue
disease,
nausea,
vomiting,
metallic
taste,
itch.
Chronic
liver
disease:
history
of
viral
hepatitis,
alcohol
abuse,
Wilson’s
disease,
haematochromatosis,
abdominal
distension,
leuconychia,
jaundice,
gynaecomastia,
bruising,
spider
naevi.
Nephrotic
syndrome:
frothy
urine,
facial
puffiness
on
waking
up,
recurrent
infection,
risk
of
deep
vein
thrombosis.
Cellulitis:
fever,
leg
swelling
and
redness,
tenderness
on
palpation,
history
of
insect
bite
or
other
wounds.
Drugs:
calcium
channel
blockers.
Reference:
1. UpToDate,
Wolters
Kluwer
Health
2. Clinical
Medicine
for
the
MRCP
PACES,
vol.
2:
history-­‐taking,
communications
and
ethics,
Gautam
Mehta
et
al.
Oxford
Specialty
Training.
3. Davidson’s
Principles
and
Practice
of
Medicine,
21st
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.