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History Taking
Taking notes and presenting
General Clerking
Psychiatric
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Suicide risk
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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

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).
  1. CVS: chest pain, SOB, palpitations.
  2. Respiratory: cough, sputum/blood, wheeze.
  3. GI: weight loss, appetite, bowel habit, distension, blood/mucus, jaundice, difficulty swallowing.
  4. CNS: headache, weakness, faints/fits, numbness or tingling.
  5. Urinary: dysuria, frequency, hesitancy, dribbling, discharge.
  6. Gynaecological: Menarche, last period, ?skipped period, painful/bloody, menopause.
  7. Systemic: fever, cold-sweats, rigors, fatigue, weakness 
  8. Psychatric: depression, anxiety. rashes, mouth ulcers
  9. Musculoskeletal: pain, stiffness

PMH

DH

FH

SH

Review

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