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INTERNAL MEDICINE CLERKSHIP
History:
1.
2.
3.
4.
5.
Patient Particulars: Date
a. Name, Sex, Address
b. Education level, Occupation
c. Marital Status
d. Known chronic illnesses (for how long) ± medication (regular/irregular) ± clinic attendance
(regular/irregular)
e. If IDS (for how long, baseline CD4 count & current CD4 count, ART regimen?, TMP-SXT
prophylaxis?)
f. Ask for any documentation (e.g. discharge summaries, ANC & CTC card)
g. Ask for any medication that the patient/relative has with them
Introductory Information:
a. Source of Information/Informant (relation to patient)
b. Self-referral from home/referred from hospital (+ reason for referral)
c. When the patient was admitted this time (+ how long ago)
Chief Complaints (C/C):
SOCRATES; Site, Onset, Character, Radiation, Associated factors, Timing
a.
(duration, periodicity, frequency), Exacerbating/alleviating factors,
b.
Severity
History of Presenting Illness (HPI):
a. Amplify complaints
DOPPARA; Duration, Onset, Periodicity, Progression, Associated factors,
b. Complications
Relieving factors, Aggravating factors
c. Risk factors
d. Course of illness
e. Management since admission
Review of Systems (ROS):
a. HEENT; Head, ears, eyes, nose and throat
i. Pain
ii. Bleeding
iii. Discharge
b. Central Nervous System
i. Fever
ii. Loss of consciousness (LOC)/ collapse/ blackouts
iii. Seizures
iv. Headache/ dizziness/ loss of balance
v. Problems in vision/ hearing
vi. Tingling (paraesthesiae)
vii. Spasms/ involuntary movements/ tics
c. Cardiovascular System
i. Awareness of heartbeat (palpitations)
ii. Shortness of breath (dyspnoea, SOB)
iii. Difficulty in breathing on lying flat (orthopnoea)
iv. 'Air-hunger' at night (paroxysmal nocturnal dyspnoea, PND)
v. Lower limb, ankle swelling/ facial puffiness
vi. History of bluish discolouration? (cyanosis)
d. Respiratory System
i. Chest pain
ii. Difficulty in breathing (ask for: rapid breathing?, mouth-breathing?)
iii. Cough ± sputum ± blood-stained sputum (haemoptysis)
e. Gastrointestinal
i. Abdominal pain (site: lower/upper, sides/centrally)
ii. 'Heart-burn' (dyspepsia)
iii. Difficulty swallowing (dysphagia); of solids ± liquids?
iv. Painful swallowing (odynophagia); of solids ± liquids?
v. Nausea ± vomiting: amount, contents: recently-eaten food/blood (fresh/clots/coffeegrounds), nature: projectile/not, meal-related/not
vi. Change in appetite (loss: anorexia)
vii. Weight loss / gain
viii. Bowel pattern and any change; hard-stools (constipation), diarrhoea
ix. Bloody stools; streaks/gross blood, fresh/digested
x. History of yellowish discolouration (jaundice)?
HOODA, Faisal Hasnain
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f.
6.
Genitourinary System
i. Painful urination (dysuria)
ii. Blood in urine/bloody urine (haematuria)
iii. Waking up to urinate at night (nocturia)
iv. Overwhelming desire to urinate (urgency)
v. Change in frequency: ↑/↓
vi. Incontinence; inability to control urination
1. Total incontinence; absolute loss of control of urination, continuous leakage of
urine
2. Stress incontinence; the involuntary leakage of urine from the full bladder
when the intra-abdominal pressure is raised (e.g. coughing/sneezing).
3. Urge incontinence; leakage of urine due to over-activity of detrusor muscle
4. Overflow incontinence; urine leakage secondary to retention of urine
g. Musculoskeletal System: (limbs, back, joints)
i. Weakness
ii. Pain/ stiffness
iii. Swelling
h. Haematopoietic System
i. Easy bruising
ii. Bleeding tendencies (ask how long it takes for bleeding to stop if injured)
Past Medical History (PMHx):
a. Chronic illnesses; Epilepsy, DM, HTN, Cardiac problems, TB, SCD, SLE?
b. Previous admissions; number, reason, when
c. History of trauma/surgical intervention; number, reason, when
d. History of blood transfusions; number, reason, when
e. Medication use; what? (drugs, herbal medication), route, duration, compliance
f. Allergies; food/drugs
g. Obs-Gyn History:
i. Age at first period? (menarche: prolonged oestrogen exposure risks endometrial
hyperplasia± Ca)
ii. Last normal menstrual period (LNMP: ask specifically for first day of last menses)
iii. Average duration of menstrual cycle (normal is 21-35 days)
iv. Duration of bleeding in menstrual periods (normal is <7 days)
v. Amount of bleeding in menstrual periods (how many pads/ tampons/ khangas used,
partially-/ fully-soaked) (bleeding >80mls/>3 fully-soaked pads is abnormal)
vi. Any abnormal bleeding between periods? (intermenstrual bleeds)
(menorrhagia: heavy (>80mls) regular periods/ lasting long (>7 days), metrorrhagia:
irregular and frequent uterine bleeding, polymenorrhoea: abnormally frequent <21-day
intervals, oligomenorrhoea: abnormally frequent cycle >35-day intervals)
1. How much?
2. When it occurs?
vii. Contact bleeding (after cleaning-oneself/ intercourse)?
7.
Family Social History (FSHx):
a. Marital status (single/ cohabiting/ married/ separated)
b. Occupation (+partner/spouse)
c. Education level (+partner/spouse)
d. Smoking; how many packs (20 cigarettes)?, duration (years)
e. Alcohol use; quantity, frequency of use
f. Substance use: marijuana (cannabis), cocaine, heroin, opioids?
g. Home; water source (boiled water?), toilets?, insecticide-treated nets?, ventilation?
h. Hereditary familial illnesses; Epilepsy, DM, HTN, SCD, haemophilia, thalassemia, heart problems
i.
Sexual History:
i. Nature of sexual relationship; none/ single partner/ multiple partners
ii. Pain during coitus (dyspareunia; may be due deep pain, and due to endometriosis, PID)
8.
Summary 1:
HOODA, Faisal Hasnain
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Physical Exam
JACCOLYN; Jaundice, Anaemia, Cyanosis, finger Clubbing, Oedema, LYmphadeNopathy
9. General Exam:
a. Consciousness; (alert/ lethargic/ obtunded/ unconscious)
b. Orientation to person, place and time
c. Physique & nutrition (obese/average-build/ wasting/abnormal fat distribution)
d. Febrile/ afebrile (fever?)
e. Dyspnoeic/ not dyspnoeic
f. Anaemia: subconjunctival pallor, tongue, palmar pallor
g. Jaundice: scleral jaundice, earlobes, tongue, nailbed
h. Cyanosis: sublingual frenulum (central), nailbed (peripheral)
i.
Oedema; pitting/non-pitting, location (pedal/ pre-tibial/ sacral/ anasarca)
j.
Superficial lymph node enlargement
i. Site & size
ii. Discrete (solitary) /matted (joined)
iii. Tenderness
iv. Surface, edge, consistency (hard/firm/soft, smooth/nodulated)
v. Mobility (mobile/fixed)
k. Back; normal/kyphosis? (forward bending)/ scoliosis? (lateral bending) /kyphoscoliosis?
10. Vitals;
a. Temperature:
°C
b. Pulse;
i. Rate: beats per minute
ii. Rhythm: regularly regular, regularly irregular, irregularly irregular
iii. Character: good/ fair/ poor volume
iv. Synchronicity; (synchronised/de-synchronised) with (contralateral limb/femoral pulse)
c. Respiratory rate; breaths per minute
d. Blood pressure; mmHg (sitting, standing, MAP =1/3 SBP + 2/3DBP)
e. O2 saturation; % in room air/ x lts of O2
f. BMI: weight (kg)/ height (m)2
11. Systemic Exam:
a. Central Nervous System:
i. Central Nervous System
ii. Higher Centres
1. Mental State
2. Level of Consciousness; AVPU/ GCS
Eye Opening
6
5
4
3
2
1
Spontaneously
To voice
To pain
None
iii.
iv.
Glasgow Coma Scale
Best Verbal
Oriented
Confused speech
Inappropriate response
Incomprehensible sound
None
Alert
Response to voice (lethargic)
Response to pain (obtunded)
Unconscious
Best Motor
Obeys command
Localises to pain
Withdraws from pain
Flexes to pain
Extends to pain
None
Orientation
1. Speech
2. Memory
a. Short-term; name, last meal, date (day) of admission
b. Long-term; first president of the country, birthday of the patient
Cranial Nerves
Cranial Nerve
I (Olfactory)
II (Optic)
III, IV, VI (Oculomotor, Trochlear,
Abducens)
V
(trigeminal)
VII
(facial)
VIII (vestibulocochlear)
IX, X (glossopharyngeal, vagus)
XI
(accessory)
XII
(hypoglossal)
HOODA, Faisal Hasnain
Test
Observe grimacing when a pungent odour is brought under nostril
Test visual fields or Use Snellen chart
Have patient track light/object in an ‘H’ shape track.
Sensation: test sensation by moving soft cotton ball along all three branches
Motor: have the patient clench teeth, chew/swallow food.
Facial, forehead, nasolabial fold symmetry, blinking, squinting eyes, raising eyebrows against
resistance when closed, grimacing, smiling, blowing-out cheeks
Whisper a word/command behind the patient’s back and have them repeat it
Have the patient say ‘ah’. Observe movement of uvula, soft palate. Test gag reflex
The patient shrugs their shoulders, and turns their face to the other side while resistance is
applied against the movement
Ask the patient to stick out their tongue all the way. Note any wasting, fasciculation, tremors
of tongue
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v.
b.
Meningeal Signs
1. Neck stiffness: passively but gently flex the patient’s neck to see if they can
touch the chest without pain.
2. Kernig's sign: With the patient supine on the bed passively extend the patient’s
knee on either side when the hip is fully flexed and look for patient spasm.
3. Brudzinski's sign: forced flexion of the neck elicits a reflex flexion of the hips
vi. Motor/Reflexes;
1. Bulk: (normal/wasted)
2. Tone: (normal/increased/decreased/rigid/spastic)
3. Power: (grade 0 - 5)
a. Upper limbs
b. Lower limbs
4. Superficial Reflexes: (present/absent)
c. Pupillary Light Reflex; (CN II, III) observe direct and consensual
constriction of pupils as light is shone into eye(s).
d. Occulocephalic Reflex; (CN III, VI, VIII) movement of the eyes in an
opposite direction to head movement.
e. Corneal Reflex; (CN V, VII) blinking of eyes on contact with cotton
f. Gag Reflex; (CN IX, X) gag/choking induced as tongue is depressed
using tongue spatula.
g. Apnoea Reflex; for a ventilated patient, switching-off ventilator
evokes a gasping response.
h. Abdominal Reflex; stroke abdomen gently from flanks → inward.
Observe the contraction of the abdominal muscles resulting in
deviation of umbilicus towards the area stimulated.
i.
Cremasteric Reflex; stroke the upper inner part of the thigh. Testicle
moves upward
j.
Anal Reflex; reflexive contraction of the external anal sphincter upon
stroking of the skin around the anus
k. Babinski Reflex; scratch the outer edge of the sole of the foot with a
stick from the heel to the toe, and watch for flexion of the toes
(down-going/up-going/equivocal)
5. Deep Tendon Reflexes (DTRs); (grade 0-4. Normal: grade 2+)
a. Biceps (C5, C6)
b. Brachioradialis (C5, C6)
c. Triceps (C6, C7)
d. Finger (C8)
e. Adductor (L2, L3)
f. Knee (L3, L4)
g. Ankle (S1)
6. Sensory System;
a. Pin-prick
b. Temperature
c. Light touch
d. Vibration sense
e. Joint position sense
f. 2-point discrimination
7. Co-ordination, Gait & Balance;
a. Co-ordination:
i.
Finger-to-nose
ii.
Rapid alternating movement (RAM)s of the hand
iii.
Heel-shin test
b. Gait
c. Balance/Stance
Cardiovascular System; (inverted J)
i. Hand/palm;
1. Warmth of extremities
2. Cyanosis: (check nail-bed, circumorally, tongue)
3. Digital (finger/toe) clubbing
4. Capillary refill (<3 secs)
HOODA, Faisal Hasnain
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5.
Signs of Infective endocarditis; (dermal infarcts, Janeway lesions: painless
haemorrhagic cutaneous lesions on the palms and soles, Osler's nodes: painful
subcutaneous lesions in the distal fingers, Roth's spots: on the retina)
6. Arterial Pulses
a. Radial
b. Brachial
c. Carotid
d. Femoral
e. Popliteal
f. Pedal (dorsalis pedis)
g. Middle malleolar
7. Pulse:
a. Rate: bpm
a. Rhythm: regularly regular/ regularly irregular/irregularly irregular
b. Character: good/fair/poor volume
c. Synchronicity: with contralateral limb
ii. Arm; blood pressure
iii. Neck;
1. Jugular Venous Pressure: (normally <4cm)
2. Hepatojugular reflux
iv. Precordium;
1. Inspection
a. Precordial bulging (protrusion of the chest around heart)
b. Precordial hyperactivity
c. Traditional marks/surgical scars
2. Palpation
a. Thrills (palpable murmurs in all 4 areas of auscultation)
b. Heaves (indicative of chamber enlargement: Apical/ Rt parasternal/
Lt parasternal)
c. Apex beat (5th ICS along Lt MCL)
3. Auscultation: (4 areas of auscultation. apex area: mitral area, lower left
All ← physicians ←
sternal edge: tricuspid area, upper left sternal edge: pulmonary area, upper
take ← money
right sternal edge: aortic area)
a. Heart Sounds
i. S1, S2 ± Extra heart sounds (gallop rhythm: S3/S4)
ii. Murmurs
1. Loudness; grade (1-6)
2. Quality; pitch (low/medium/high)
3. Location; best hear(aortic/ pulmonary/
tricuspid/ mitral) area
4. Timing; (systolic/diastolic/ continuous)
5. Radiation
v. Other areas (report only if necessary)
1. Lungs; bibasilar crackles (≡pulmonary oedema)
2. Liver; enlarged, tender, hepatojugular reflux (≡hepatic congestion)
3. Oedema; pitting/non-pitting (periorbital, lower limb)
c. Respiratory System;
i. On inspection;
1. Respiration Pattern:
a. Rate (breaths per minute, dyspnoeic)
b. Rhythm (regular/ irregular)
2. Respiratory distress; nasal flaring, mouth-breathing, use of accessory muscles
of respiration, head-nodding
3. Skin; scars/lesions/lumps
4. Spine; normal/kyphosis/scoliosis
5. Ribcage: normal/barrel-shaped/ pigeon-chest /sunken-chest
6. Movement
a. Expansion
b. Symmetrical movement:
c. Intercostal recessions? lower chest wall in-drawing?
ii. On palpation;
1. Lymph node enlargement:
2. Swelling/tenderness
HOODA, Faisal Hasnain
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3. Position of trachea: deviated/centrally-located
4. Asymmetry during chest expansion
5. Tactile vocal fremitus: reduced/normal/increased
iii. On percussion;
1. Resonance; reduced/normal/increased
iv. On auscultation;
1. Breath sounds
a. Intensity; normal/ loud/ diminished
b. Quality; vesicular/ bronchial/ bronchovesicular
c. Added breath sounds; wheezes, crackles, stridor, pleural rub
2. Vocal resonance; increased/ normal/ reduced
d. Per Abdomen;
i. On inspection
1. Shape; scaphoid/ flat/distended: generalized/local, symmetric/asymmetric
2. Umbilicus: inverted/everted
3. Movement of abdominal wall; diminished, aortic pulsation, peristalsis
4. Skin; (surgical scars, traditional marks, stretch marks/shininess, superficial
veins)
5. Dilated superficial abdominal veins; (caput medusae)
ii. On palpation
1. Superficial: tenderness?
2. Deep: tenderness?, organomegaly?
a. Left kidney
b. Spleen; (palpable, span below costal margin)
c. Right kidney
d. Liver;
i. Span
ii. Surface; soft/firm/hard, regular/irregular, tender/nontender, nodular/smooth
e. Gallbladder (murphy’s sign?)
f. Urinary bladder
g. Aorta
h. Rectus abdominis muscle
i.
Abdominal mass(es)
iii. Site, size & shape
iv. Surface, edge, consistency: hard/soft, irregular/regular,
nodular/smooth, round, tender/non-tender
v. Mobility
vi. Pulsation
j.
Guarding / rebound tenderness
iii. On percussion; tympanic note/dullness
1. Liver; span
2. Spleen; span
3. Urinary Bladder
4. Other masses
5. Ascites; chest-knee position dullness/ shifting dullness/ fluid thrill
iv. On auscultation;
1. Bowel sounds
2. Vascular bruits
12. Summary 2:
13. Provisional Diagnosis & Differentials:
a.
Rule out
14. Investigations:
15. Management:
a. Pharmacologic
b. Non-pharmacologic
16. Prognosis:
17. Follow-up & Other Remarks:
HOODA, Faisal Hasnain