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
The majority of the time should be spent in the history of
the presenting complaint. It is often useful to keep a list of
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.
Introduce self, shake hands.
life a bit.
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
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
chest pain, SOB, palpitations.
cough, sputum/blood, wheeze.
weight loss, appetite, bowel habit, distension, blood/mucus,
jaundice, difficulty swallowing.
headache, weakness, faints/fits, numbness or tingling.
dysuria, frequency, hesitancy, dribbling, discharge.
Menarche, last period, ?skipped period,
fever, cold-sweats, rigors, fatigue, weakness
depression, anxiety. rashes, mouth ulcers
Ask relevant questions relating to each
Use the screening questions: MIS J
THREAD . This stands for MI, Stroke, Jaundice, TB, Hypertension,
Rheumatic fever, Epilepsy, Arthritis, Diabetes.
Include allergies, and find out what
"allergic reaction" happened.
Over the counter drugs, contraceptives,
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.
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
"Does illness make it difficult for you
to look after dependents, put a strain on family?"
"Will you require any support when you
"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?"