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Complete guide to clinical examination - Basics of Medicine
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Complete summary and guide to clinical examination with tips to ACE your OSCEs today!
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Comprehensive guide to clinical examination - Basics of medicine
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Complete SystemicGuide to OSCEs –
History + clinical
examination Notes
,History taking
Introduction: Hi, my name is ____ and I am a ____ medical student from ____ University. I am here to
take a full medical history from you. Please be assured that everything you tell me will be kept
confidential between you, me and the treating doctor. Is that alright with you?
Opening Question:
1. What brings you to the GP today?
2. Would like to tell me more about this pain/symptom?
W-Where
W-When
Q-Quality
Q-Quantity
A-Associated Symptoms
A-Aggravating/Alleviating symptoms
B- Beliefs
I-Impact
C-Concerns
E-expectations
Do note that the pneumonic above works with many symptoms, which are often the chief complaint of
the patient. We can still use the pneumonic by tweaking the questions a little. For example: Cough.
1. W- When did you start having this cough?
2. W- Where does it originate? Chest or throat?
3. Q- What type of cough? (Dry/Productive? If sputum present: Colour? Odour? Blood? Amount?
4. Q- How often do you cough? (persistent? Intermittent?)
Systems Review Questions: MSK, Neuro, Cardio, Respiratory, GIT
Involve maybe around 3 Systems Review.
Past Medical History- Any current illnesses?
S- Surgical Hx A- Anaemia/Asthma
H- Hospitalisation B- Hypertension
I- Immunisation C- Hypercholesterolaemia/Cancer
T- Trauma D- Diabetes
C- Childhood illness K- Kidney disease
Family Medical History
Parents: Alive? Age? Well? What conditions?
Siblings
Children
Any genetic diseases known?
D- Doctor prescribed drugs? What? For what condition? For how long? Dose? Quantity per day? Side
Effects? Compliance?
R- Recreational drugs or illicit drugs. Method of administration
U- Over the counter drugs- simple analgesics, anti-inflammatory, rubs, cough syrups, alternative meds
G- Hormone replacement therapy/oral contraceptive pill/Implanon (progesterone rod to stop ovulation)
S- Sensitivity and allergy. To what? What is exact nature of response?
Smoking: How many per day? How long? What type of tobacco? Pack years?
Alcohol: How many standard drinks? How often? CAGE if necessary when you feel patient alcoholic.
Cut Down, Annoyed, Guilty, Eye-opener
Social History- BEDFISH, ESSSENCE
B- BMI E- Education
E- Exercise S- Stress management – How much stress
D- Diet S- Spirituality- Beliefs/ Religion
F- Financial – Financially stable? E- Exercise- How often?
I- Interconnectedness N- Nutrition- diet/fruits and vegetables?
S- Stress/Sleep/Spiritual Housing C- Connectedness- Family/friends/emotional support
Yellow flags: psychological; prevent recovery E- Environment- Occupation/Living
Ask for sleep, night sweats, weight loss, fever?
Conclusion: I have completed taking your full medical history. Is there anything else you would like to tell
me? Otherwise, I will report my findings back to the doctor and we will be back shortly to see you
afterwards. Thank you.
,Systems Review Questions
MSK - PISS WELL DOC
Pain- Are you in any pain right now?
Instability- Do you feel any joint instability?
Stiffness- Do you feel any stiffness in your joints?
Swelling- Have you noticed any swellings lately?
Weakness- Have you experienced any weakness?
Effusion- Any watery swellings that you have noticed?
Loss of function- Have the function of your limb been affected?
Loss of Movement – Have the range of movements of your limb been affected?
Deformity – Have you noticed any deformities?
Other systemic Changes – Have you experienced weight loss, fatigue recently?
Change in sensation – Do you feel any change in your sensation?
Neurology – Some Fellows Dance Very Happily And We Go Visit Nana Downhill
Seizures – Have you had any seizures?
Fits –Have you had any fits? (neurological activity, unconscious, jerking of muscle)
Dizziness – Do you feel dizzy very often?
Vertigo – Have you ever felt that the room is spinning around you? (room spinning, if mins will have
nausea and vomiting, cannot walk independent, needs support. An issue with the vestibular system)
Headache – Have you had a bad headache before?
Anesthesia/Paresthesia – Have you had any tingling or reduced sensation?
Weakness – Have you experienced weakness in your limb?
Gait changes – Do you have any changes to the way you walk?
Visual/sensory changes – Do you have any visual or sensory changes?
Neck stiffness – Do you experience any neck stiffness?
Disturbance of sphincter – Do you have any bladder and bowel control problem?
Loss of consciousness – Have you had head trauma and a loss of consciousness?
Ataxia – Do you have any balancing problems?
Cardiology – PAID COPS are Fatigue
Palpitations – Do you feel that your heart is beating really strongly and rapidly?
Ankle swelling – Do you have any swelling in your ankles/legs?
Intermittent claudication – Do you feel pain in your calves when you walk? How far?
Dyspnoea – Do you experience any shortness of breath?
Chest pain – Do you experience any chest pain? Does it radiate?
Orthopnoea – How many pillows do you use to sleep well? Has it always been the same?
Paroxysmal nocturnal dyspnoea – Do you have SOB when sleeping?
Syncope – Have you ever fainted suddenly/ blackouts?
Fatigue – Do you feel consistently tired?
Respiratory- CC-DEF-HHS-NSW
Cough- Do you have a cough?
Chest Pain- Do you have chest pain? (If so, what is it like? Is it made worse by breathing?)
Dyspnoea- Do you have any shortness of breath/ feel breathless
Epistaxis- Do you ever have nose bleeds?
Fever- Do you experience any fever/ malaise/myalgia(muscle pain)?
Haemoptysis- Do you ever cough up blood?
Hoarseness- Do you ever get a hoarse voice?
Stridor- Do you ever have a stridor? (Difficulty to inhale)
Night sweats- Do you experience any night sweats?
Sinusitis- Do you ever suffer from facial pain?
Wheezing- Do you have a wheeze? (Difficulty to exhale most of the time)
Post nasal drip- Do you feel mucus at the back your nose/throat?
, Gastroenterology- ABCDEFGHI-NOPR
Appetite- How has your appetite been lately?
Bowel movement- Have you noticed any change in your bowel habit?
Changes in skin- Have you noticed any change in the colour of your skin, eyes, urine and/or bowels?
Dysphagia/Odynophagia- Do you ever have difficulty swallowing? Any painful swallowing?
Esophageal reflux- Do you get the feeling of acid at the back of your chest, throat or neck? Is it worse on
lying down or after particular foods? (GORD/Heartburn)
Fever- Have you had any fevers recently?
Gain/Loss of weight- Have you noticed any weight change recently?
Hematemesis- Have you ever vomit blood before?
Itch- Do you have any itch? (Caused by bilirubin)
Nauseous/Vomitting- Have you felt nauseous? Have you vomited?
Overseas travel- Have you been on any recent overseas trip?
Pain- Do you feel any abdominal/tummy pain? (When, mode of onset. Where, radiation, type of pain?)
Rectal bleeding- Do you have any rectal bleeding. What colour is it? Fresh, mixed or dark.
Renal
Pain- Do you have any pain in your flanks/loins/suprapubic?
• Onset, when, where, radiation, severity, type, frequency, aggravating/alleviating factors,
associated symptoms
Micturition- Do you have any difficulty urinating?
• Enuresis: Do you have incontinence/problem holding in your urine at night?
• Hesitancy: Do you have difficulty staring to urinate?
• Pis en due: Do you have the desire to urinate despite having just done so?
• Dribbling: Do you have any dribbling of urine after you finish urinating?
• Reduced stream: Do you urinate with a slower and slower stream?
• Straining: Do you have to force and strain when you urinate?
• Urgency: Do you have the urgent need to go toilet consistently?
Pain on micturition (dysuria)- Do you have pain when you pass urine?
Alteration of urine- Do you notice any changes/frequency to the amount of urine?
• Polyuria: >2 litres/day (diabetes)
• Oliguria: 400-500ml/day
• Anuria: no urine (complete renal failure)
Alteration of urine appearance- Do you see any unusual changes to your pee?
• Do you see any colour changes? Cloudy? Dark? Dilute?
• Do you notice that your urine is frothy
• Is there a bad smell to your urine?
• Is there blood in your urine?
Urethral Discharge- Do you have any discharge coming out from your urinary tract?
Fever- Have you had a fever recently
Pulmonary oedema- Do you have any difficulty breathing?
Itch: Do you suffer from any itch?
Fatigue: Have you felt consistently tired recently?
Hiccups: Do you have persistent hiccups very often?
Fish Breath: Has anyone told you that your breath smells fishy?
Breast
Any changes to your breasts?
• Any Lumps: cysts/abscess/fibroadenomas (breast mice)/cancer/ blocked milk ducts (mastitis)
and hence lead to systemic infections e.g fever / redness
• Any pain: Where? How bad is it? Does it move anywhere? Suddenly or increasing.
a. one side or bilateral? Bilateral= systemic while unilateral= localized.
b. Bilateral: pregnancy, menstrual cycles, contraceptive pills
• Discharge: bloody may be cancer, milky fluid in non-pregnant: pro-lactinomas (pituitary
adenoma) and this may cause amenorrhoea
Weight loss: Have you experienced any severe weight loss recently?
Night sweats: Have you had any night sweats recently?
Bone pain (metastasis)
Nipple rashes: Have you had any rashes or discolouration of your nipples?
Fatigue: Have you been tired all the time?
Skin dimpling: Have you noticed anything unusual about the skin of your breast?
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