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When did it start/ how long has it been? (Long duration HIV)
Is it high grade or low grade?
Is it continuous, remittent or intermittent?
Is it assoc with chills and rigors?
Is it worse at night, day or morning or none?
Is there any assoc convulsion? (Meningitis)
Is there any relieving factor Tepid sponging, exposure, fanning or drugs (antipyretics).
Is there any assoc headache (meningitis)
Is there any assoc vomiting (meningitis clerk this)
Is there any assoc cough (clerk this)
Is there any associated body weakness.
* Long duration (> 1 month), high grade, continuous, not worse at any time of the day
>>>>> HIV
* Long duration (> 1 month), low grade, continuous, assoc drenching night sweats,
cough of long duration, productive of sputum which may be bloody >>>>> TB
* Short duration, high grade, continuous, assoc chills and rigor, vomiting, headache,
temporarily relieved by antipyretic >>>>Meningitis
* Short duration, high grade, continuous, assoc chills and rigors, cough which may be
assoc chest pain >>>> Pneumonia
*High grade, intermittent, worse in the evening, assoc with chills and rigors, weakness,
malaise and body aches, temporarily relieved by antipyretics >>>>> Malaria
COUGH
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Any assoc bleed or melaena (altered blood in stool) to know if the blood is from the
upper resp tract or GIT
Is it worse at night (heart failure) or day.
Is it paroxysmal (impt in children b/cos of whooping cough) or not.
Is there assoc vomiting (post tussive vomiting)
Is it aggravated by anything (Asthma) e.g. pollen, dust or cold
Is there any relieving factor.
Any Hx of contact with adult with chronic cough (PTB)
Is there assoc breathlessness if so take it up to the presenting complaint and analyze it
Is there associated orthopnea, fast breathing or PND to r/o CVS causes
Is there associated fever( infective causes)
Is there an associated night sweat (PTB)
Is there associated weight loss (PTB, HIV)
Is there associated chest pain (pneumonia)
Frothy sputum (LV failure)
Thick sputum (asthma)
Rusty brown sputum ( pneumonia)
Copious mucoid sputum(chronic bronchitis)
Copious foul smelling sputum (bronchiectasis, lung abscess)
VOMITING
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Is it projectile or not
Is it with effort or effortless i.e. any retching
What is the content of the vomitus-recently ingested food, bile stained, blood stained (
if so fresh or altered blood i.e. coffee appearance
What is the consistency- does it contain mucus
What is the odor-is it odorless or foul smelling
How many times has patient vomited and the number of times pt has vomited on the
day you are clerking
What is the volume in each episode and total volume that has already vomited-estimate
the volume in liters or mls with containers or cups around to check their complication
like dehydration
Is there any aggravating or relieving factors
Is there associated weakness (dehydration)
Is there associated decreased opening of bowel (constipation)
Is there associated fever (infective process-gastroenteritis)
DIARRHEA
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SEIZURE
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WEIGHT LOSS
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What makes patient feel he is losing weight (evidence of looseness of previously tight
clothing, belt, rings or bony prominences)
Any symptoms suggestive of DM (polyuria, polydypsia, polyphagia)
Any symptoms suggestive of HIV infection ( persistent fever, chronic diarrhea, chronic
cough)
What is the feeding habit of the patient (does he feed well)
Any symptoms suggestive of heart disease (cough, breathlessness, PND, orthopnea)
Any symptoms suggestive of malignancy ( cough, swelling in any part of the body, signs
of metastasis)
Any symptoms suggestive of malabsorption syndrome ( persistent diarrhea,
steatorrhoea, persistent vomiting)
Symptoms suggestive of respiratory disease ( hx of cough , pt is a known asthmatic, hx
of night sweats or hemoptysis)
Symptoms suggestive of thyrotoxicosis (irritability, prominences of the eye, awareness
of heart beat, heat intolerance).
PAIN
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Does it interfere with your daily activity or keeps you awake all night
Does the pain come and go or is it there all the time
Has it changed since it started
What is the nature of the pain (stabbing, burning, gnawing, colicky, waxes and wanes
etc)
Is there anything that aggravated it or makes it worse such as food
What relieves the pain e.g. change in position, eating (duodenal ulcer), starvation
(gastric ulcer), defecation or passage of flatus (lower GI pains), rest (cardiac pain),
bending forward (pericardial pain), belching (gastro esophageal reflux), drugs (
musculoskeletal pain), antacids (GU,DU)
MASS/SWELLING
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JAUNDICE
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r/o hemolytic causes by asking for hx of SCD, fever, change in urine color, drug
ingestion, blood transfusion, past hx of similar episode in the past
r/o hepatic causes by asking for hx of body itching, loss of appetite, change in stool
color, abd pain, source of water, family hx of hep A, drug injections, sexual affairs
hx of neonatal jaundice
r/o hereditary causes by asking for bone pain, swelling in any part of the body
hx of contact with patient with yellowness of the eye to r/o hep A virus
CVA
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ISCHEMIC CVA
How was the neurological deficit first noticed
Was it sudden or insidious in onset
What was the patient doing at time of onset
Is there associated headaches, seizures or loss of consciousness
r/o risk factors for atherosclerosis is patient hypertensive, diabetic, a smoker, an
elderly person, heavy drinker
is patient a known SCD sufferer
is patient a known cardiac disease patient; if yes ask for palpitations, edema, cough,
breathlessness, PND, orthopnea in the past or presently
is patient on any drugs
is there associated vomiting (ICH, SAH)
is there associated collapse (SAH)
is there associated rapid recovery of symptoms
Are there associated neurological signs
Is there any previous hx of TIA
Any hx of trauma (ICH)
Sexual hx to r/o STDs
HEADACHES
Tension headaches
- Is it associated with stress and worries
- Is it pressing or banding in character often found at the back of the head from where it
radiates to the neck
- Poorly relieved by analgesia
- Is it less during the early parts of the day and worse as the day goes on
- It is not aggravated by coughing, bending down or straining at stool
Vascular headaches
- Throbbing in character
- Associated with infections such as malaria, typhoid, epileptic fits, trauma, ingestion of
alcohol, or use of vasodilators
- Typically confined to one side of the head
Headaches due to increased ICP
- Increased respiration occurs in short bursts lasting from a few seconds to a few hours
- Occurs mostly at night or in the early stages of the early morning
- Progressive increase in freq until it may become continuous
- Aggravated by coughing, staining at stool, bending down or sudden change in position
- Vomiting may occur esp. at night or early morning when headache is severe
- Relived by analgesia
Headache due to inflammation esp. meningitis
- Generalized headaches worsened by head movts, coughing or patient may be drowsy
and unconscious
Referred headache
- Headache occurs over the eyes, sinuses, frontal area, maxillary area
- Worse after reading and may occur over the frontal area and spread to the occiput or
vertex
- May be due to dx of the teeth or ear or the mzls of the neck and spine
Migraine headache
- Non specific prodrome of malaise, irritability followed by an aura of focal neurological
signs, a severe hemispherical headache, photophobia and vomiting.
- During the headache phase, patient prefers to be quiet in a dark room and go to sleep
DIABETES MELLITUS
Polydypsia polyuria, polyphagia, weight loss, body weakness, boils, ulcers, vulva itching, symptoms of
peripheral neuropathy e.g. numbness, pain, burning sensation, nephropathy
Any blurring of vision (DM retinopathy) or double vision (CN 4 and 6).
Any decrease in frequency or volume of urine ( nephropathy) or ankle swelling?
Any numbness or burning or painful sensation on the limbs.
Any feeling of walking on pebbles, cotton wool or slipping off of shoes without knowing?
Any ulcer in any part of the body?
Any boils or body itching/vulval itching or furuncles?
Any difficulty in swallowing (due to oesophageal atony)?
Any feeling of abdominal fullness (easy satiety)?
Any vomiting, constipation or diarrhea (nocturnal diarrhea)?
CCF
PC: dyspnoea, breathlessness, fatigue, orthopnoea, PND, cough, hemoptysis, effort intolerance,
ankle edema.
HPC
- is there any hx of palpitations or headaches (htn)
- is patient a known hypertensive, if so, is he compliant with his drugs and clinics
- Any hx of chest pain, if so, characterize it (r/o angina, MI, pericarditis)
- Any hx of body weakness or difficulty/shortness of breath (r/o anaemia)
- Any hx of sore throat in the past (r/o rheumatic heart dx)
- Any hx of significant alcohol ingestion (r/o alcoholic heart dx)
- Any hx of smoking (r/o atherosclerosis and its complications)
- Any hx suggestive of DM (polyuria, polyphagia, polydypsia) to r/o atherosclerosis
- Any hx of heat intolerance, irritability, weight loss, prominence of the eye balls (r/o
thyrotoxicosis)
Summary of conditions to rule out in heart failure
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Hypertension
Angina pectoris
Myocardial infarction
Pericarditis
Anaemia
Rheumatic heart disease
Alcoholic heart dx
Atherosclerosis
Thyrotoxicosis
PULMONARY TUBERCULOSIS
PC: fever (low grade), cough, weight loss, haemoptysis (>1 month)
HPC
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Explore the fever and cough as above (r/o chronic bronchitis, asthma, bronchiectasis,
lung abscess)
Explore the weight loss as above to r/o DM, HIV, heart dx, malignancy, malabsorption
syndrome, respiratory dx, thyrotoxicosis and good nutrition.
Rule out immunosuppresion that can reactivate primary TB ( HIV, DM, Cytotoxic drugs,
long term steroid therapy)
If there is associated night sweats r/o other causes of night sweats e.g. lymphomas by
asking for hx of pruritus
Any hx of contact with someone with chronic cough or if patient lives in an overcrowded
environment
If pt presents with hemoptysis, ask where pt came from to r/o paragonomiasis
If associated with drenching night sweats r/o lymphoma by asking for hx of body itching,
swelling in the neck
PARKINSONISM
PC: tremor, rigidity, hypokinesia, other vague symptoms such as aches, pains, tiredness.
HPC
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Expressionless face
Stell wags sign
Glabella tap (meryesons sign)
Festinant gait
Kaysor-fleisschers
Corneal arcus
HIV
PC: fever, cough, weight loss
Counseling in HIV
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Any dilated peripheral veins on the the leg (r/o venous ulcers)
Any hx of fever, cough, night sweats or contact with person with chronic cough (r/o TB
ulcers)
Any hx of trauma (r/o traumatic ulcers)
Any hx of polyuria, polyphagia, polydypsia and weight loss (r/o DM)
If patient is a known diabetic, what drugs is he on and how compliant is he to therapy
Any hx of calf muscle pains intermittent claudication- to r/o arterial ulcers
Is patient a known smoker, hypertensive, or diabetic(r/o atherosclerosis)
Any hx of prolonged immobility ( r/o pressure ulcers)
Any hx of weight loss, swelling in any part of the body, bone pains (r/o malignancy)
Any hx of loss of sensation around the leg (r/o neuropathic ulcers)
Is patient a known sickler (r/o sickle ulcers)
Any hx of STD in the past with ulcers in other parts of the body (r/o syphilitic ulcers)
Differentials of ulcers
Guinea worm, varicose veins, trauma, DM, TB, atherosclerosis, pressure ulcers, malignancy,
leprosy, sickle cell anaemia, STDs (syphilis), Multiple myeloma
EXAMINATION
General
Musculoskeletal System: Ulcer examination
Other systems (digestive, CVS, respiratory)
Investigations
Wound swab, Mantoux test, FBC, ESR, urinalysis, VDRL, FBS, CXR, genotype, lipid profile, SEUCr,
HIV screening
NEPHROTIC SYNDROME
PC: anuria, oliguria, edema, body swelling, uremic symptoms
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