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Mosco's Clerking Guide
Mosco's Clerking Guide
MOSCO’S
CLERKING
GUIDE
AUTHORS:
Table of Contents
INTRODUCTION-------------------------------------------------------------------------------------------------------------3
Clerking Format--------------------------------------------------------------------------------------------------------5
Clerking Fever---------------------------------------------------------------------------------------------------------10
Clerking Pain----------------------------------------------------------------------------------------------------------11
CARDIO-RESPIRATORY SYMPTOMS
Clerking Breathlessness/sob--------------------------------------------------------------------------------------12
Clerking Cough--------------------------------------------------------------------------------------------------------17
NEUROLOGICAL SYMPTOMS
Clerking Dementia---------------------------------------------------------------------------------------------------22
Clerking Headache---------------------------------------------------------------------------------------------------24
Clerking Parkinsonism----------------------------------------------------------------------------------------------29
ABDOMINAL SYMPTOMS
Clerking Haematemesis--------------------------------------------------------------------------------------------32
Clerking Constipation-----------------------------------------------------------------------------------------------39
Clerking Jaundice-----------------------------------------------------------------------------------------------------42
URINARY SYMPTOMS
Clerking Pain----------------------------------------------------------------------------------------------------------44
Clerking Haematuria------------------------------------------------------------------------------------------------45
Clerking Difficulty in Urination------------------------------------------------------------------------------------46
Clerking Polyuria-----------------------------------------------------------------------------------------------------47
Clerking Nocturia-----------------------------------------------------------------------------------------------------48
Clerking Frequency of Urination---------------------------------------------------------------------------------48
Clerking Dark Urine--------------------------------------------------------------------------------------------------48
Clerking Urinary incontinence------------------------------------------------------------------------------------51
Clerking Oliguria/anuria--------------------------------------------------------------------------------------------52
ORTHOPAEDICS (MUSCULOSKELETAL SYMPTOMS)
Clerking Pain----------------------------------------------------------------------------------------------------------58
Clerking Swelling-----------------------------------------------------------------------------------------------------60
Clerking Deformity---------------------------------------------------------------------------------------------------61
Clerking Joint stiffness----------------------------------------------------------------------------------------------63
Clerking Inability to use the limb---------------------------------------------------------------------------------63
Clerking Low-back pain---------------------------------------------------------------------------------------------64
Clerking Discharging sinus-----------------------------------------------------------------------------------------66
Clerking Fracture-----------------------------------------------------------------------------------------------------66
Clerking Athritis------------------------------------------------------------------------------------------------------67
Clerking Rheumatoid Athritis-------------------------------------------------------------------------------------67
Clerking Osteoathritis (Denegerative joint disease) --------------------------------------------------------68
Clerking chronic osteomyelitis------------------------------------------------------------------------------------69
ENDOCRINE SYMPTOMS
INTRODUCTION
After our 2MBBS professional exams during our first block lectures as 400L
medical students, I remember having a lengthy but productive discussion with my
friend Harry. We carefully critiqued our journey so far in medical school. During
the discussion, we realized that after spending more than three years in medical
school studying and learning about the human body, something was still amiss.
We understood the human anatomy perfectly; every muscle with its attachment
and nerve supply, every bone and its articulation, every organ, even blood vessels
could be properly delineated by us. How these structures work in tandem with
others, the human physiology and its metabolic pathway were no longer alien to
us. Though we were armed to the teeth with preclinical knowledge and very
excited about meeting patients for the first time in the hospital, we didn’t know
what to expect. How do we know what’s wrong with the patient? How can we
diagnose a patient of a disease? How are doctors able to diagnose & treat
patients effectively? Is there any secret that we haven’t been privy to? Our
bewilderment interlaced with fascination knew no bounds. This was when Oswald
our good friend joined the discussion, interjecting “DOCTORS ARE NOT
MAGICIANS”. He explained that there is a scientific process which doctors utilized
and it all begins with “Clerking the patient”. The rest was history…
Clerking a patient simply means taking a detailed history of the patient. It is the
bedrock of clinical practice and a skill every medical practitioner should possess. It
encompasses the bio-data of the patient, the presenting complaint, the history of
presenting complaint, the past medical and surgical history, the drug and allergy
history, the family and social history and review of systems. What makes this
clerking guide unique is that it focuses more on clerking the history of presenting
complaint while expatiating on other sections of the history. Above all, this
clerking guide teaches you how to think like a doctor not what to think.
The first chapter gives the general overview and format for clerking in UNTH. The
next chapter properly explains the clerking of various symptoms in the different
systems of the body. It is subdivided into the major units we have in UNTH. A
medical student posted to the neurology unit can easily browse to the neurology
section and get acquainted on clerking neurological symptoms.
Finally, this clerking guide is not exhaustive of all the symptoms you’ll see in any
unit you find yourself posted to. It simply shows you the blueprint of clerking
those symptoms that occur commonly in various units and more importantly
teaches you how to think like a doctor. Nothing beats practice, ask your
consultant… the more you clerk patients in clinics and wards, the better you
become.
CHAPTER 1
CLERKING FORMAT
NASOMARTI is the acronym for; Name, Age, Sex, Occupation, Marital status,
Address (place of origin and residence), Religion (state the denomination, if
Christian), Tribe and Informant.
All these parameters are important in your bio-data. You aren’t just asking to
fulfill all righteousness. For the Name and Address, you obviously know why you
need to know. In Medicine, Age isn’t just a number, it really matters. You can’t be
thinking of BPH in a young man of 21 years who presented with some lower
urinary tract symptoms, though this diagnosis is more feasible in an elderly man
of 80 years. Also remember that AD(for adult) is not the age of your patient. Try
as much as possible to indicate the age of your patient in numbers e.g. 33years.
The occupation of your patient also matters. A long time farmer complaining of
low back pain shouldn’t be of much concern as opposed to an accountant.
Occupational asthma is commonly seen in woodworkers, paint sprayers, workers
in the plastic, rubber or electronics industry. About the sex of the patient, a lady
will almost always never be diagnosed of prostatic carcinoma because she doesn’t
have a prostate. Don’t forget to ask for the denomination, if your patient is a
Christian. Some Christian denominations do not permit blood transfusion and
their wishes should be respected. The bio-data will generally help in making your
provisional diagnosis since some diseases are related to the age, sex or
occupation of your patient. The informant should always be the patient except he
is unconscious or unable to speak and in such cases, the relative can substitute as
the informant.
This is where you ask the patient what brought him to the hospital seeking for
expert care. Why did he come to the hospital? The PC should always be in the
patient’s words. Never, use medical terms to characterize the patient’s complaint.
For instance, in a patient that noticed blood when urinating, the PC shouldn’t be
haematuria but “passage of blood in his urine”. Also remember to ask the patient,
the duration of the symptom (for how long has the presenting complaint begun?).
In Medicine, you are not allowed to have more than 3PCs and this should be
arranged chronologically.
This is the section of history taking that shows your consultant or whoever is
listening to your history whether you are actually thinking like a doctor or not.
This is where your clinical knowledge will be assessed. Any medical student can
easily take other sections of the history without much thinking. It is entirely
different when taking the HPC. In the HPC, you must apply your clinical
knowledge to the maximum. When writing your HPC, always analyze any
presenting complaint in this chronological order; the 5Cs
- Complaint
- Course
- Cause
- Complications
- Care
You first characterize the complaint and methodically show how the disease has
progressed (course). Normally, we use FODIPARA as the template though it isn’t
inclusive of every symptom.
Immediately a patient tells you of his PC, there should be some pathologies
already firing through your synapses as the possible cause of the PC . With at least
5 possible causes, you then ask the patient direct questions to rule in or rule out
these causes. The mnemonic TINCAMBED helps you in achieving this goal. If you
are ever at loss as to the questions to ask your patient in “the cause of the HPC”,
remember TINCAMBED.
T--- Trauma
I---- Infectious diseases
N--- Neoplasm/Nutritional disorders
C--- Congenital disorders
A--- Autoimmune disorders
M-- Metabolic disorders
B--- Blood dyscrasias
E--- Endocrine/Environmental disorders
D-- Drugs
You shouldn’t forget to ask for possible “complications” of the PC and how it has
affected the patient’s daily activity. For example, in a diabetic patient that
presents with frequent passage of urine, ask for the micro vascular and macro
vascular complications of DM.
In the final “C” (care), ask the patient what he has been doing or has done to
manage or treat the presenting complaint. This concludes the HPC.
You are expected to record the relevant history of hospital admissions and
reasons for such. If there is a positive surgical history, state the procedure and
why it was done. Also ask for history of blood transfusion.
In UNTH, it is usually enough to ask for a positive history of HEADS i.e.
Hypertension, Epilepsy, Asthma, Diabetes and Sickle cell disease. It won’t hurt if
you ask for retroviral disease and peptic ulcer disease (PUD).
For example; there is no positive history of HEADS.
6. FAMILY HISTORY
State the position of the patient in the family he was born into, highlighting if he
is from a monogamous or polygamous family with an indication of the ratio of
males to females. Also find out if there’s a familial history of the HEADS in any
member of the patient’s family.
For example; Patient is the 3rd child of a monogamous family of 5 children. There
are four females and one male. The father was known to be diabetic before his
demise 7 years ago. There’s also a history of Hypertension in the patient’s younger
sister.
7. SOCIAL HISTORY
- Ask about Alcohol intake- You have to talk about the frequency, quantity and
possibly brand when significant (calculate the units of alcohol taken per week)
- Ask about tobacco intake, smoking, be it cigarette, indian hemp, marijuana – You
have to know the frequency and quantity when significant(calculate the pack years)
- Depending on what you’re thinking, it’s also good to know how the ventilation
where patient lives in is and the type of water patient takes in.
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Musculo-Skeletal System: Muscle pain, Bone pain, Joint pain, Joint stiffness,
Joint swelling
9. SUMMARY
This should not be more than 3 sentences. For example;
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CHAPTER 2
CLERKING FEVER
Fever is one of the most common presenting features in any doctor’s practice. It is
the hallmark of the body’s response to infection or inflammation. Patients
presenting with fever will often have a glut of associated complaints, many or all
of which may be perceived as the main problem to the patient. It is therefore
prudent to refer to the fever as the main PC. Whenever a patient presents with
fever, you should be seen to have actively asked these questions.
- When did it start/ how long has it been? ( if it has been long , think HIV)
- Is it high grade or low grade?
- Is it continuous, remittent or intermittent?
- Is it associated with chills and rigors?
- Is it worse at night, day or morning or none?
- Is there any associated seizures? (think meningitis)
- Is there any relieving factor e.g exposure, fanning or antipyretic drugs.
- Is there any associated headache? (meningitis)
- Is there any associated vomiting (meningitis – clerk it)
- Is there any associated cough (clerk it)
- Is there any associated body weakness?
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d. Short duration, high grade, continuous, associated chills and rigors, cough
which may be associated with chest pain____think Pneumonia
e. High grade, intermittent, worse in the evening, associated with chills and rigors,
weakness, malaise and body aches, temporarily relieved by antipyretics_____
think Malaria
CLERKING PAIN
Pain just as fever cuts across every system. Always use the mnemonic
SOCRATES to clerk pain! We’ll be using chest pain as an example.
- Site__ where is the pain located (retrosternal chest pain is most likely to be an
angina attack or pericarditis).
- Onset_ when did the pain start and was it gradual or sudden (chest pain due to
pulmonary embolism is sudden in onset).
- Character_ what is the nature of the pain e.g crushing (myocardial infarction),
tearing(aortic dissection), burning(PUD), sharp(pericarditis). Pain could also be
aching, gnawing, stabbing, colicky, waxes and wanes etc
- Radiation__ does it radiate to anywhere (angina pain may radiate into the arms,
throat or jaw).
- Association_ is there any other symptom associated with pain( pain from angina
attacks or PE is usually associated with breathlessness).
- Time course_ does the pain follow any pattern. does it come and go or is it there
all the time. Has it changed since it started.
- Exacerbating/Relieving factor__ Is there anything that aggravated it or makes it
worse such as food or deep breathing. What relieves the pain e.g. eating (duodenal
ulcer), starvation (gastric ulcer), rest (cardiac pain), bending forward (pericardial
pain), belching (GERD), drugs (musculoskeletal pain), antacids (PUD).
- Severity_ how bad is the pain on scale of 1 to 10. Does it interfere with your daily
activity or keeps you awake all night?
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CHAPTER 3
QUESTIONS TO ASK IN DIFFERENT SYSTEMS
There are symptoms specific for different systems of the body and as such there
are specific questions to ask in clerking these symptoms. These questions are
clarified below.
CARDIO-RESPIRATORY SYMPTOMS
Most of the patients, you will meet in cardiology unit or pulmonary unit will
present with similar symptoms. Due to the relationship between the cardiovascular
system and the respiratory system, most cardiac related diseases will inevitably
lead to respiratory symptoms and vice versa. This cannot be overemphasized when
clerking “difficulty in breathing”. It is the commonest presentation in cardiology
and pulmonoloy unit. Though, a common presentation in these units, a cardiologist
sees it differently (yet similarly) from a pulmonologist and uses different
terminologies to characterize “difficulty in breathing”.
For a pulmonologist, the terminology used to characterize “difficulty in breathing”
is “breathlessness” while a cardiologist uses “shortness of breath” (SOB) more
frequently. These terms are different sides of the same coin but they help to give
the student and whoever is reading your history a guide to what to think about
(aetiology).
CLERKING BREATHLESSNESS/SOB
Breathlessness occurs very commonly in pulmonology. When a patient presents
with breathlessness, always think about these aetiologies.
i. Asthma (Commonest pathological cause in clinics)
ii. Pulmonary tuberculosis
iii. Chronic obstructive pulmonary disease (COPD)
iv. Pneumonia (This includes other infective causes)
v. Malignancies
vi. Congestive cardiac failure
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managed as such while other aetiologies simply do not occur commonly (like
ILD & RLD). Remember, common things occur commonly!!!
Characterize “the breathlessness” using the mnemonic “FODIPARA; Ask for the
frequency, onset, duration, intensity, progression, aggravating factors, relieving
factors and associations.
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xii. If there is any relieving factor (some patients you’ll meet in clinic may
have inhalers).
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Ruling out CCF is a little complicated. This is because; you cannot clerk
breathlessness completely in pulmonology without signaling to your consultant
that you had ruled out CCF. Normally, you ask, if the breathlessness is associated
with dry cough, palpitations, PND, orthopnea, body swelling and if it is
progressive since onset, worse at rest or on exertion. Asking the above questions is
more than enough in pulmonology but won’t suffice if you are in cardiology unit.
CCF is the commonest cause of “shortness of breath” in cardiology and as such,
the above symptoms need to be characterized explicitly. You need to probe deep to
determine the cause of C.C.F. Remember that CCF is always secondary to an
aetiology. It is not a standalone diagnosis.
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CLERKING COUGH
Cough, just like breathlessness is a symptom of both the respiratory and
cardiovascular system. In fact, these two symptoms are so intertwined that most of
the pathologies that causes breathlessness will inadvertently lead to cough. To be
concise, when ruling out the cause of cough, you’ll have to rule out those
pathologies that cause breathlessness (check “clerking of breathlessness).
However, there are other pathologies that will cause cough which were not
previously listed. These include but not limited to lung abscess, post-tussive
vomiting, bronchiectasis & chronic bronchitis (COPDs) etc. These are the
pathologies; you’ll need to rule out.
i. Pneumonia
ii. Pulmonary tuberculosis
iii. Asthma
iv. Malignancies
v. Congestive cardiac failure
vi. Chronic obstructive pulmonary disease (e.g bronchiectasis & chronic
bronchitis)
vii. Lung abscess
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As I said earlier, check “the clerking of breathlessness” to see how to rule out the
above pathologies. Although, you need to rule out the above pathologies, there are
other questions, you must ask at first, in order to characterize the cough.
i. How long has the cough been present? (cough lasting less than 3 weeks
can be said to be “acute” while cough lasting more than 8 weeks is a
“chronic cough”.
ii. Is the cough productive of sputum or not (dry cough at night may be an
early symptom of asthma).
iii. If it is productive of sputum, what does the sputum look like especially
the colour and consistency (if the sputum is rusty brown think pneumonia
if it is yellow or green, it is purulent indicating an infective process. If it
is frothy; think CCF. If tenacious, think asthma).
iv. How much sputum is produced? (if it is up to a cupful, think
bronchiectasis, chronic bronchitis produced smaller amounts of sputum
try to estimate it).
v. Is the sputum foul smelling (this is to rule out bronchiectasis, lung
abscess or ay chronic infection of the lungs).
vi. Is the sputum stained with blood (If positive, you must characterize the
blood stained sputum. Is it fresh blood or altered blood? How long have
the patient seen the blood? How often does he see the blood in sputum?
Is the patient stool altered with blood? All these questions, help to rule
out PTB, malignancies and to be sure if the blood is from cough and its
characteristic pattern in children the upper respiratory tract or GIT).
vii. Is it paroxysmal (remember whooping cough and its characteristic pattern
in children)
He was apparently well until 1/12 ago when he started coughing. This occurred in
tandem with a one-week history of fever, associated with chills, chest pain that gets
worse on inspiration and easy fatigability. The cough was in bouts and productive
of yellowish sputum. The sputum was about half a teaspoon but not foul-smelling.
The cough was aggravated by lying on the right side three weeks later with
associated breathlessness. There is a positive history of weight loss evidenced by
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loose-fitted clothes, though there was no drenching night sweats or contact with a
person with chronic cough. There is a history of eye or throats itching or reaction
to pollen, grass or dust. There is no history of exposure to biomass fumes though
he smoked seldom in the past (30 years ago). He occasionally stays around his
neighbor who smokes often. There was no history of orthopnea, PND, dizziness or
bilateral leg swelling. For the above complaint, he visited a peripheral clinic where
he was given some drugs he could not recall. He wasn’t getting better and was
subsequently referred to UNTH for expert intervention.
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The above symptoms are not exhaustive of the cardio-respiratory system but
they are the major presentations, one will see in practice and every doctor should
know how to clerk them!
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NEUROLOGICAL SYMPTOMS
CLERKING DEMENTIA
It consist of clinical syndromes that manifest as acquired loss of cognitive skills eg
memory, which is of sufficient severity to prevent the person from carrying out
his/her day to day activity and this happens in clear consciousness.
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- The progress (is getting better or not) – Here the ‘course’ will be in the
characterization of the complaint.
Cause
Here you rule out the different types of Dementia
To rule out vascular Dementia
- Ask for history of hypertension, Diabetes mellitus and stroke (if these are
present, is mostly vascular dementia) because it occurs after stroke.
- Smoking, Alcoholism can also lead to Vascular Dementia because they are
predisposing factors for atherosclerosis which can cause Ischemic stroke
To rule out Parkinsonism and Dementia with Lewy body
- Ask for visual hallucinations
- Ask for symptoms of parkinsonism – gait change (shuffling gait or festinant
gait), resting tremor, bradykinesia (difficulty getting up from the bed etc)
To rule out Alzheimer’s dementia
- Ask for family history (though alzheimers can occur spontaneously without
family history)
- Age of the Patient (This is already in the Biodata)
To rule out trauma and Alcohol use
- Ask for any history of trauma to the head. Also, alcohol use can cause
temporary dementia (but the rarely present to the hospital)
Complications
These are the complications resulting from Dementia eg
Depression (patient is usually depressed evidenced by not eating much, not
doing his/her daily activities)
Cannot go to places unaccompanied etc
Care
- The previous care the patient had had concerning the dementia e.g patient
has gone to ------------ peripheral hospital for treatment etc.
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she previously knows. Patient is a hypertensive and has not been compliant with
medications, she also has diabetes. She doesn’t smoke, doesn’t take alcohol. There
is no history of trauma to the head, urinary incontinence, visual hallucinations,
resting tremor.
Due to the above Patient doesn’t eat well again and also doesn’t go out
unaccompanied, she also feels upset when she starts looking for objects she kept
but have forgotten where she kept them. Patient has been taken to a peripheral
hospital where she has been placed on Sertraline, Clopidogrel and Aspirin.
From the above, what is your diagnosis (Which type of dementia) ?
CLERKING HEADACHE
PC
Headache of ----- duration
HxPc
- Complaint
Patient apparently well until ----- months ago when he/she developed a headache
Characterize the headache
- location - unilateral or bilateral
occiput, temporal, frontal, parietal
- severity - in a scale of 10 (with 10 being the worse headache ever)
- nature - throbbing vs non-throbbing, pulsating
- associated symptoms e.g. vomiting, nausea, photophobia, phonophobia
- presence of autonomic symptoms e.g. ptosis
- relieving or exacerbating features
- Headache pattern (Age at onset, frequency)
- Duration of headache episodes
- Family history
- ‘Red flag’ symptoms - fever, neck stiffness, diplopia etc
- Prevents one from doing his/her activities
Here Characterization brings out the cause; so characterization and cause is
overlapping, as you will later see
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Cause;
To rule out Migraine, ask to find out the following
- Frequency : at least 5 attacks
- Duration; Last at least 4-72hrs i.e. 4hrs- 3days untreated
- Unilateral in location
- Pulsating quality/ Throbbing type.
- Moderate or severe pain intensity
- Aggravated by or causes the avoidance of routine physical activities eg
walking, climbing steps etc
- Nausea, vomiting, photophobia, phonophobia
- Migraine may be preceded by an aura ( ask Patient if there is anything that
makes him/her know if she will develop headache before it starts; it can be
visual (e.g. small stars), sensory (e.g. tingling sensation), speech, motor (e.g.
tremor) etc
These mustn’t all be present, to diagnosis Migraine; 3 or more is ok.
To rule Tension type headache, ask to know the following
- Bilateral location
- Pressing or tightening ( Non-pulsating/non-throbbing)
- Mild to moderate intensity
- Not aggravated by routine physical activity
- No nausea or vomiting
- No photophobia, phonophobia etc
To rule out Cluster type headache, ask to rule out the following
- This type is rare and is seasonal i.e. many episodes of headache occurring
during rainy season, dry season etc
Rule out Secondary causes of Headache
- Raised ICP (Intracranial Pressure) can cause headache ( here headache is
worst on waking up from sleep, there is vomiting, nausea)
- Infections e.g. Meningitis ( here there is neck stiffness, photophobia),
sinusitis etc
- Post-traumatic headache
Ask questions to make sure the headache is not secondary to a primary cause
Hx Pc
Patient presented with headache of 8months duration. Patient has lost count of the
number of headaches he had had since then but he estimates that it should be
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around 20 to 25 episodes, each episodes lasts for at least 5hours with the worst one
stretching to almost 13hrs. The headache is said to be unilateral (left temporal
region) and throbbing in nature, the severity of which is rated 6 on a scale of 10
(10 being the most severe headache ever). Headache is aggravated by noise and
light which when patient goes to a quiet dark place to rest relieves a little. There is
no history of nausea and vomiting, no history of trauma, no neck stiffness, no body
weakness etc. This has prevented the patient from doing some of his daily routines
e.g. fetching watch etc. For the above complaint, Patient has come to our facility
for expert management.
From the above what is your likely diagnosis (i.e. type of Headache)?
CLERKING SEIZURES
Occurrence of signs and/or symptoms due to abnormal, excessive or synchronous
neuronal activity in the brain.
PC
Seizure of -------- duration
HxPC;
Complaint
Patient was apparently well until 2 months ago when he started having seizures
Characterize the complaint i.e. seizure here
Generalized seizures:
- Always associated with LOC ( Loss of Consciousness)
- The whole body is involved here (Ask if the whole body was involved)
- There is LOC (was he conscious or not)
- Was there tongue biting
- Was there fecal or urinary maintenance
- Was there associated injury
To rule out partial/local seizures
Here the seizure is limited to one part of the body
- Ask if the seizure started at a part of the body and which part
- Was he conscious or not
(In simple partial seizure - patient is conscious)
(In complex partial seizure – patient is unconscious)
There, you can use Jerking to describe it to your patients
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Example of Hx PC
Patient was apparently well until 12years ago when he started having seizures.
Seizures was said to have started spontaneously and is generalized with loss of
consciousness. Patient has 3 to 4 episodes of seizures in a month and each lasts for
about 10minutes, with the worst reaching up to 15minutes. There is associated
tongue-bitting, feacal incontinence during the episodes. There is no history of
trauma, no numbness, paraesthesia, diplopia, nausea or vomiting (This rule out any
other CNS manifestation that can cause seizures), no history of alcohol use and
brain surgery.
Due to the above, Patients have sustained many injuries such as loss of his 2 left
incisor teeth, dislocation of his shoulder joint and various bruises; this has also
prevented the patient from doing some activities such as cooking due to fear of
having episodes of seizures near fire. Patient has been to a peripheral hospital
where he was given 500mg of sodium valproate and has been during well since
then; however after he changed location, he was referred to this facility to continue
management.
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CLERKING STROKE
Rapid onset of neurological deficit as a result of a vascular event that lasts for more
than 1hr or leads to death
PC
Weakness in the right part of the body of ---- duration
Can also present as
Deviation of the face to the right/left of ------- duration
Slurring speech of ----- duration
Complaint
Patient was apparently well until --- years ago when he presented/had slurring of
speech/ deviation of the face to the right or left/ weakness in the right part of the
body. Characterize all this.
To rule out ischemic stroke
What time did you notice it.(Ischemic stroke can be thrombotic or embolic.
Thrombotic stroke is usually noticed over the night to early in the morning.
Embolic stroke together with hemorrhagic stroke can occur anytime of the
day; but hemorrhagic stroke normally occurs at the peak of activity).
What where you doing when you noticed it.
What where the activities the day before.
Was the onset sudden or gradual.
Has it worsen or not (Ischemic stroke worsens gradually however ischemic
stroke can resolve while hemorrhagic stroke worsens rapidly in increasing
severity).
Do you feel your heartbeat (palpitations) – This is to rule out Embolic stroke
To rule out hemorrhagic stroke
Ask of
i) Headache
ii) Dizziness
iii) Vomiting
Ask if it got worse rapidly
Course
Already in the characteristic of the complaint
Cause
History of hypertension
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DM
Obesity
Smoking
Sedentary lifestyle
Alcohol
Complications; Change of gait, Depression, Seizures
Care
- Previous care concerning the stroke eg the drugs taken etc
HxPc
Patient was apparently well up until two months ago when he/she developed a right
sided body weakness. This was said to have been noticed in the early hours of the
morning when patient couldn’t come out for her normal early morning routine.
Weakness was sudden in onset with patient unable to move the affected part.
Patient was also noticed to have developed slurring speech and saliva drooling
from the month. There was no history of headache, no dizziness, no loss of
consciousness and no vomiting. Patient is a known diabetic and hypertensive and
has not been compliant with antihypertensive medications. Patient also has a
positive history of smoking and drinking. For the above complaint, patient was
taken to a peripheral hospital where she was managed until she gradually started
walking however with a changed gait and the use of a walking stick.
NB If there is any other complication like memory loss, seizures mention and
briefly clerk them.
CLERKING PARKINSONISM
Parkinsonism is a general term used to define a symptom complex manifested by
bradykinesia (slowness of voluntary movement) with rigidity and / or tremor;
There is also change in gait – shuffling or festinant gait.
PC
- Tremor of the right hand or finger etc (This is most times the PC).
HxPc
Complaint - Patient was apparently well until 4 months ago when he/she started
having tremor at the right hand.
Characterize the tremor
Is it now spreading i.e. becoming generalized.
Is it at rest or doing activities/ movement.
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Course
Ask how it started: whether it started insidiously (gradual in onset) or suddenly.
That is, you want to know the progression.
Cause
To rule out drugs causing tremors eg sympathomimetics and stimulants like
amphetamine.
- Ask if there is confusion, dizziness, occasional seizures.
- Ask also of history of drug use.
To rule out anxiety disorder
- Ask if there is anything that is worrying him of particular significance.
- Ask if he is afraid of any impending disaster/danger.
To rule out cerebellar lesions
- Ask of Intentional tremors: - tremors that start when the person wants to do
something – Ask of this? For this to happen, there might be a history of
trauma ask of it also.
To rule out Essential Tremor
- Ask of tremor starts when the patients wants to do something (ie if Tremor is
postural) such as when holding a glass or cutlery.
- Ask if Anxiety exacerbates the tremor.
If this two are present it is likely essential tremor.
Complications
- Have he stopped his activities because of it.
- Ask how it has affected his life.
Care
- What managements/treatment has he received because of the condition.
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ABDOMINAL SYMPTOMS
CLERKING VOMITING
Differentials to think about include;
1. Gastroenteritis
2. Gastroparesis
3. Oesophageal obstruction
4. Gastric outlet obstruction
5. Intestinal obstruction
6. Cholera
7. Meningitis.
Questions to ask;
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CLERKING HAEMATEMESIS
Differentials diagnosis to think about;
1. Duodenal ulcer
2. Oesophageal varices
3. Erosion of gastric mucosa by drugs such as aspirin and alcoholic gastritis
4. Malignancies of GI tract: - oesophageal, gastric, intestinal etc
5. Bleeding tendencies like hemophilia
6. Chronic renal failure (uremic gastritis)
Question to ask;
- What is the volume of the blood? (Quantify! can it fill a cup?)
- Is it fresh or altered blood?
i. Blood from oesophageal bleeding will appear fresh
ii. Blood that lies in gastric juice from gastritis or gastric CA will appear
altered i.e brownish black like ground coffee
- Is vomiting postprandial or not? (i.e after eating or not?)
- Differentiate haemoptysis (coughing up blood) from haematemesis by
asking if blood is seen on handkerchief during coughing.
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Questions to ask;
-This could be caused by edema of the gastric mucosa as a result of right heart
failure (congestive cardiac failure) So query edema of the extremities, ascites that
will lead to massive abdominal distension.
(i). Clerk it using SOCRATES [i.e. Site, Onset, Character, Radiation, Associated
factors, Time course, Exacerbating/Relieving factors, and Severity.]
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Sever Not Loss of appetite, or usual loss
e, Partl reliev of weight, early fullness
Gastric cancer Epigastric MOSCO’S GUIDE
persist y ed by during meals, even with small
ent meal antaci helpings and
pain - d weakness/tiredness because of
relat anaemia. May also find upper
ed GI bleeding such as
haematemesis or passage of
melena,(dark, tarry, foul-
smelling stools)
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Colonic pain
(causes :infection,
Peri-umbilical or Colick Wor Defae
parasitic
suprapublic y pain se cation
infestation,
Carcinoma, dietary with (left
indiscretion, meal coloni
irritable bowel dx s c
etc.) disord
ers)
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Question to ask;
- When did it start? How frequent has the stooling been? (3times/day)
- Did it occur immediately after meal (contaminated food?)
- Ask for DM symptoms
- Ask for other symptoms of thyrotoxic storm: palpitations, hyperthermia,
tachypnea/breathlessness, pallor, sweating, heat intolerance, irritability, etc.
- Ask if patient has recently treated constipation or recently used antibiotics and is
still on them?
- Did it occur after ingesting milk? (Lactose intolerance)
- What is the colour of the stool?
- Is it mucoid? (Suspect viral or bacterial infection)
- Profuse watery stools assisted with vomiting: Cholera
- How frequent? Chronic diarrhea can be caused by:
*HIV/AIDS, so ask for patients’ retroviral status
*Inadequately treated amoebic or bacillary dysentery
*Inflammatory bowel diseases: ulcerative colitis
*Lactose intolerance
*Intestinal lymphoma.
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CLERKING CONSTIPATION
Questions to ask
a. What is your normal toilet pattern i.e. how often do you defecate?
b. How has it reduced?
c. When did you notice it?
d. Have you been taking enough water?
e. Have you been neglecting the urge to defecate?
f. Any recent change in your diet? Do you take enough of meals containing fibers?
g. Has the patient been abusing laxative?
h. What drugs are you using now or did you use in recent past? (e.g opiods have
the side effects of constipation.This can be also be seen with anticholinergics like
atropine.
i. Patient’s age is important because of senile colon
j. Ask for hypothyroidism
k. Is patient pregnant? Paralytic ileus
l. Query intestinal obstruction? (Any colicky, peri-umbilical or suprapubic pain
asstd with audible bowel sound (borborygmi) any vomiting?)
- Enlarged prostate? Ask for obstructive urinary symptoms: urgency, hesitancy
etc
- Possible tumor of colon: anemia, weight loss, loss of appetite, weakness
m. DM autonomic neuropathy? (Clerk DM symptoms like polyuria, polydipsia,
weight loss, is patient a known diabetic? Any altered sensation over extremities?)
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Questions to ask;
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CLERKING JAUNDICE
This is the yellowness of mucous membranes and sclera as a result of accumulation
of bilirubin
Differentials to think about;
1. Prehepatic causes
2. Hepatic causes
3. Post hepatic causes
Questions to ask;
A. Pre-hepatic cause:
i. Hemolytic anemias:
a. Ask for Blood group – Sicke cell, anaemia (SS)
b. Ask for history of incompatible blood transfusion
c. Ask for any previous diagnosis of genetic disorders like ß-thalasemia, G6PD
deficiency, pyruvatekinase deficiency.
d. Is it aggravated by taken fava beans, anti-malarials, sulfonamides,
phenacetin etc.
e. Any coke-coloured urine? (Paroxysmal nocturnal hemoglobluria)
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i. CA head of pancreas
ii. Worms/structures in bile duct lumen
iii. Gallstones (Cholelithiasis)
iv. Cholecystitis
v. Tumors of bile duct lumen (cholangiocarcinoma)
Complications
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URINARY SYMPTOMS
CLERKING PAIN
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CLERKING HAEMATURIA
Questions to ask
a. When did it start?
b. Is it continuous painless (parenchymal renal disease) or intermittent and
associated with renal pain (renal tumour).
c. Is it intermittent and associated with symptoms of cystitis (Bladder tumour
or bacterial cystitis)
d. When does the blood come? Is it before urine with/during urination or after
urination?
i. Before urine/beginning of urine: Lower urinary tract pathology
involving the bladder, urethra –UTI or urethritis, trauma to urethra
due to surgery or catheterization, urethral stones, parasitic infestation.
ii. Midstream: bladder cancer or bladder stones or trauma.
iii. End/terminal: schistosomiasis and neck of bladder pathology which
could be cancer, bladder tuberculosis (ask if patient has low grade
fever, cough, drenching night sweats, weight loss, contact with an
adult who had chronic cough and weakness/easy fatigability.) Or
bladder schistosomiasis.
iv. Total haematuria(throughout): Renal pathology
g. Does it occur even when not passing urine? Consider injury to urethra.
h. Where does patient bathe? River, stream? (schistosomiasis)
Characterize the haematuria
iii. Stones: Is there severe pain in the side and back? Is there pain during
urination?
- Is the urine cloudy or smelly?
- Are there chills, fever, nausea and vomiting?
iv. STIs: Ask for sexual history [Number and gender of partners, safe/unsafe
sexual practices, possible trauma during sexual activity, period between last
activity and development of symptoms.]
- Ask if the partner has any genitourinary symptoms or STI, is from a high risk
country for HIV infection or is an injecting drug user?)
Implies a high urinary flow rate. It is almost always associated with increase in
frequency of micturition and nocturia as well.
2. Osmoticdiuresis:
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*Urea as in chronic renal failure: look for stigmata of Chronic Renal Failure–
Uremic frost, swelling of periorbital area and face, nausea, vomiting, weakness and
bleeding tendencies like epistaxis and bleeding from gut. Fatigue, weightloss,
drowsiness & headaches, Chest pain (uraemic pericarditis)
Altered voiding pattern in which one finds the urge to empty the bladder during the
hours of sleep (for more than 3 to 4times)
Possible causes
*Cystitis from any infection like Schistosomiasis and TB
*Stone or other foreign bodies
*Chemicals around genitals
*Cold weather or anxiety
-Myoglobinuria
Questions to ask;
* To rule out G6PD Deficiency, ask these questions
-Does dark urine appear after use of drugs like sulfonamides and phenacetin? Or
after consumption of fava beans?
-Any aspirin use?
-Any recent use of anti-malarial drugs?
-Any back pain?
-Any abdominal pain?
-Any fatigue?
-Any recent infection? Ask for fever, sores or pain?
-Is it exacerbated by physical stress?
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-Rule out Hepatitis B by asking of any history of blood transfusion, IV drug use,
exposure to sharps like razors, clippers that are not personal. Is the patient sexually
active? What’s the Partner’s gender? (Male homosexuality). Does the partner have
hepatitis? Does the patient have multiple sexual partners.
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This implies involuntary voiding of urine. In extreme cases urgency may lead to
urge incontinence, in which the desire to void cannot be voluntarily inhibited.
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CLERKING OLIGURIA/ANURIA
It is the passage of less than 500ml of urine per day. Anuria is the complete
absence of urine flow.
c. Interstitial nephritis
d. Toxemia of pregnancy: Ask for high blood pressure, edema and foamy urine
in pregnant women at about the 20th week.
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Disease which obstruct urine flow e.g ureteric or bladder outflow obstruction as
caused by:
a.Ureteric stones
b.Stones in the pelvis (ask for flank/ loin pain)
c.Fibrosis and stricture, in bladder or stones due to schistosomiasis.
d.Prostatic enlargement due to benign prostatic hyperplasia or CA prostrate
(for BPH –clerk around obstructive symptoms; for CA Prostate – clerk
around malignancy symptoms like weakness (anemia), weight loss, as
evidenced by prominent zygomatic bone or loose fitting clothes or changing
of belt hole or under wear size etc (asthenia), anorexia (loss of appetite),
bone pain due to metastasis) etc.
e. Urethral structures –
Any previous urethral instrumentation
Any previous surgery at young age (possible posterior urethral valve)
#Any previous UTIs or STIs:
- Any previous painful urination
- Any previous genital discharge
- Any previous frequency of urination or bloody urine
I present Mr Ngwu Godwin, a 51 yr old spare parts dealer at Coal camp Enugu
who hails from abc and lives at xyz. He is married, is a Christian of Roman
Catholic denomination and the patient is the informant.
HPC: Patient was in his apparent state of health until 2 wks ago when he was
resting and noticed he could not hold back urine till he could get to the toilet.
Whereas initially he could sense the urge and rush to a bathroom before voiding,
now he passes urine involuntarily at anytime and anywhere.
There was no associated trauma to the spine from accident or fall. No associated
pain or swelling or restriction of movement in the joints in the back. The patient is
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not known to be diabetic nor does he have abnormal sensations on his hands and
feet. The patient has not had stroke in the past.
There is weakness and weight loss as evidenced by prominent zygomatic bone and
change in belt hole of pg but there is no loss of appetite. There is no cough but
there is bone pain on the left leg.
Table of content/outline
1. Introduction 1.1 - General notes
1.2 - History taking in Orthopedics
2. Common PC in Orthopedics
3. Clerking common PC in Orthopedics
3.1 Clerking pain in Orthopedics
3.2 Clerking Swelling
3.3 Joint stiffness
3.4 Low back pain
3.41 Inability to use the limb/weakness
3.5 Discharging sinus
4. Tying it all up
4.1Fracture
4.2 Arthritis
4.3 Other types arthritis
4.4 Deformities ----- Congenital Vs Acquired
4.5 Chronic Osteomyelitis
5. Diagnostic facts
6. Typical Examples
7. List of provisional diagnosis
8. General knowledge in Orthopedics
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1. Introduction
1.1 General notes
These days, orthopedic injuries seem to be some of the most common issues
that doctors have to deal with. While orthopedic injuries are usually not very
significant causes of mortality, they cause serious morbidity and usually will
adversely affect the quality of life. What then are orthopedic injuries?
These generally involves injuries to the bone, muscle, tendons etc
Orthopedic injuries include a lot more than fractures and cramps thus; orthopedic
injuries include all that affect the musculoskeletal system – as regards movement.
However, the neuronal basis of movement and muscle context lies outside the
scope of orthopedic injury.
1.1 History taking in Orthopedics
Just like every other discipline in medicine, history taking in orthopedics must be
systematic and thorough. Also, certain conventions of history taking must be
observed.
History-taking must always follow:
a. Biodata ---- NASOMARTI (Name, Age, Sex, Occupation, Marital status,
Address, Religion, Tribe, Informant).
The age in biodata is particularly important because of the prevalence of certain
pathologies in certain ages or age range.
Example: The chance of developing osteoarthritis increases with age and most
people over 60 years have some degrees of osteoarthritis with varying degrees.
b. Presenting complaint
Common presenting complaints in orthopedics will be discussed in subsequent
sessions. However, the presenting complaints must be taken in order of descending
Duration: i.e from the earliest to the latest.
Pick presenting complaints that will capture most of the other symptoms as
associations. That way, you reduce the amount of complaints you have to develop,
while still capturing as many important things as possible.
- Patient lost his/her job – cannot brush the teeth - cannot eat well etc
iv. Care = Commonly, students begin to do some form of journalism at
this point just reporting everything the patient told them verbatim.
The good news is that it doesn’t add anything to your mark. Just as much as much
as it doesn’t do you any harm. Learn to make your care as simple as possible, only
getting the very important points. For most trauma patients, you can go on to say
“the patient has been stabilized, the term ‘stabilized’ covers most of the ATLS
protocols. However, you can go on to add very important positives which will add
to the richness of your history.
Example; Patient was managed in a periphery hospital, where a tracheostomy tube
was passed, 3 pints of blood given over 2 days and monitored on urinary catheter.
For optimum management of patient, he/she was referred to this hospital.
Aside: remember to introduce your PC properly and also add the mode via which
the patient presented to the hospital.
E.g. The patient is a known hypertensive who presented via the Accident and
emergency with a two days history of ……… or
The patient was apparently normal before now and presented through the
MOP/SOP, with a 3 weeks history of ………
Others
Past medical history of any or even similar problems
Past surgical history – steroids can cause a vascular necrosis or problems in wound
healing.
Phenytoin Dupuytren’s contractive
Social history level of care and nutrition in children (with effects on nutrient and
nutrient deficiencies).
Occupational history/Work practices
Smoking impairs bone healing after fractures
Menstrual History (in females):
a. Menarche – scoliosis/Age at menarche considered a reliable prognostic
factor for idiopathic scoliosis)
b. Menopause – Osteoporosis
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COMMON PC IN ORTHOPEDIC
a. Pain
Inability to use hands
b. Difficulty using limb
Inability to walk
c. stiffness of Joints
d. Swelling
e. Weakness
f. Discharging sinus
g. Deformity
h. Compartment syndromes
i. Low back pain
j. Dislocation of joints
k. Stress fractures
CLERKING PAIN
Pain remains a very common presentation in orthopedic clinics. Most other
symptoms seen in Orthopedics are also associated with pain. Thus, clerking pain in
Orthopedics goes hand in hand with the associated symptoms.
The complaint is the pain, and you must be seen working through cause, course,
complication and care.
Ask the following while clerking pain OPQRST
A. Onset: Was it sudden/insidious, what triggered the pain, what was the patient
doing when it started? Etc
B. Progression: Is the pain constant? Is it worsening overtime? Any
improvement? Or does it come on and off?
Neoplasia - Will give you constant pain
Eg Osteoblastoma - Lameness and enlargement of the bone, often hard and
warm to touch.
Trauma – Pain increases up to 4-6 hours and then decreases
Acute Inflammation – Sudden increase, then subsides
Chronic Inflammation – Remissions and exacerbations of disease.
New origin pain in painless disease - Malignant change, Pathological fractures
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C. Quality
- Aching --- Chronic arthritis (like heaviness)
- Stabbing – Ruptured tendon
- Burning - Neuralgia
- Throbbing - Abscess (like pulsating)
D. Radiation/Referred
- Shoulder pain from heart or diaphragm
- Arm pain from neck
- Leg pain from back (Sciatica)
- Back pain from kidney, aortic aneurysm, Duodenal ulcer
- Pain may ridicule to adjacent sites
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You should make sure each of the term used, clearly represents what the patient
feels.
H. Time and Duration
- Remember to also bring this up earlier in your PC
CLERKING SWELLING
In clerking swelling, it is important you describe the shape of the swelling and the
site and size in relation to known anatomical land mark
E.g. there is an oval swelling on the anterior aspect about 4.3cm from the medial
malleolus, measuring about 5cm x 3cm x 1cm (Remember to talk about the shape
in 3D – Length, Width & Height).
- Measuring from known anatomical sites help to provide objective ways of
assessing the progression of the swelling. i.e is it increasing or decreasing
- Swelling (tumor) being a cardinal sign with accompany most process
eliciting inflammation in the body including but not limited to trauma may
be causing fractures), infective processes (of both soft tissues and underlying
bone). Also limb benign and malignant neoplasms can also be associated
with swelling.
Certain regions are associated with specific swelling:
1. Greater toe isolated swelling – Gouty arthritis
2. Swelling about the size of pea to Golf balls close to a joint in maybe the
hand/Wrist – Ganglion cyst.
3. Swelling around metaphyseal regions of long bones – Osteochondroma
4. Foot – can be from fracture/Trauma or synovial sarcoma
In clerking swelling also remember to get information about the following as they
may suggest or cancel out certain pathologies:
1. Onset – When did you first notice this swelling and how:
- Rapid swelling – Hematoma (maybe following closed fracture),
Hemarthrosis (bleeding into a joint)
- Slow swelling – Inflammation , tumour, infection
2. Associated pain and/or tenderness
- Painful swellings – Acute inflammation, infection, Malignancy
- Painless swelling – Benign growth, low grade malignancy
3. Progression – How has this swelling progressed over the days from the time
patience noticed it to the time of clerking?
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CLERKING DEFORMITY
Deformity remains a common presenting complaint in musculo-skeletal system.
According to Taber’s medical dictionary, Deformity is simply the alteration in or
distortion of the natural form of a part, organ or the entire body.
Deformities in orthopedics include (but not limited to) swellings and abnormal
movement of limbs, shortening of limbs, abnormal positioning of joints and limbs,
abnormal curvature of the spine. Etc. usually, it will result in impaired ability to
use affected parts. Deformity can be acquired or congenital and attempts should be
made by the student to differentiate between the two types. (Ask about presence or
otherwise at birth).
- If present after a traumatic injury, deformity usually implies the presence of
bone fracture, bone dislocation or both. It may be due to extensive swelling,
extravasation of blood, or rupture of muscles and severe contracture or scar
tissues.
Congenital deformities
Patients with these types of deformities presenting to UNTH for management will
commonly be in the younger age range. And will not usually appear in your regular
clinic clerking. However, it is important we mention some common congenital
deformities:
- Limb deficiencies – congenital limb amputations & deficiency.
Upper limbs most commonly affected
- Longitudinal deficiencies – Complete or partial absence of radius, fibula or
tibia
e.g. radial ray deficiency, hypoplasia of the fibula
These defects are seen in syndromes like Holt –Oram syndrome, thrombocytopenia
absent radius - TAR Syndromes, fanconi anaemia and sometimes part of
VACTERAL Syndrome – You should ask about other abnormities making up
the syndrome.
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In this case, while doing the H-PC, It is important to establish or rule out history of
previous fractures in affected limb and possible visit to the traditional bone setters
(TBs).
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Also, using various parameters, try to establish that this inability is not from
nervous origin (As in cord compressions and other forms of peripheral
neuropathy).
Ask about previous history of abnormal sensations on affected limb and transient
loss of motor function.
Sometimes, limb weakness also presents in a similar fashion and attempt should be
made to narrow down the cause of the weakness to few pathologies.
Generalized body weakness could be due to anaemia, starvations or generally
poor metabolic status.
(So, ask the patient about fainting and blood transfusions in the past)
Partial stroke (hemorrhagic & ischemic) can present as inability to use
specific limbs. Ask about hypertensive stautus to rule out hemorrhage HTN,
Previous history of ischemic stroke etc.
Ask about confusions, difficulty in speaking or abnormal facial symmetry to either
implicate or rule out stroke.
Myaesthenia Gravis can cause proximal myopathies. And present as
difficulty using the limb which usually worsen with activity.
Spinal cord (Tumor and Metastasis) can cause paraplegia, Quadriplegia or
in mild cases, paresis, depending on level and extent of involvement.
Locking = sudden inability to complete a particular movement can also be present
Causes:
loose bodies
- Torn meniscus
CLERKING FRACTURE
This simply refers to a break in the continuity of a bone. May be complete or
incomplete (Greenstick fractures).
Some of the symptoms and associations of fracture are:
1. Localized pain to that limb/body part
2. Swelling: Edema or even hematoma formation at fracture site causes the
area to be bigger than contralateral side.
3. Angulation: Affected area is bent at an unusual angle.
4. Abnormal movement in at least 2 planes: In fractures, you can at least
demonstrate/elicit abnormal movement of limb segments in 2 planes.
5. The patient is unable to put/bear weight on affected area.
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CLERKING ATHRITIS
This is simply the inflammation of joints
Some features associated with arthritis include:
1. Pain: Pain may be intermittent, sharp, associated with activity. It may be
present at the joint involved or/and at the lower back.
2. Swelling: There’s usually an associated swelling of the involved joints
3. Joint stiffness with tenderness and reduced range of motion/locking
4. Difficulty in using affected limbs or muscle weakness
5. There may be general fatigue or malaise
6. Skin redness over the affected area, flare, or stiff neck
7. Deformities.
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- Commonly affects the bigger joints of the body viz: knee, hip, neck,
shoulders, hands, spine (causing low back pain).
- Development is sometimes correlated to a history of previous bone injury or
trauma. Also with obesity---especially osteoarthritis of the weight bearing
joints (knees and hips).
- Slow progression, occurring several years or decades over which patient
becomes less and less active, and susceptible to morbidies relating to
decreases physical activity
- Joint pain worsened by activity and relieved by rest. Pain tends to worsen
throughout the day, but stiffness tends to improve.
- Antalgic gait may be present especially if weight bearing joints are involved.
(Ask patient if he/she is limping)
- Bony enlargements of joint
- Crepitus
- Cool effusions
- Absence of hot, red inflammation commonly seen in
inflammatory/crystalline arthritis
- Remember; older age (>40 years) and female sex are independent risk
factors in osteoarthritis and should be highlighted in your history.
Deformities: Especially in Osteoarthritis of the hands
Herbeden’s nodules: Swollen, bony DIP Joint
Bouchard’s nodes: Bony bumps on the PIP Joint (swollen)
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Diagnostic facts
Some things occur together, suggesting some other things:
1. Present at birth or otherwise Congenital/Hereditary vs Acquired
2. Fever, Chills, Rigors, Night cries Infective processes
3. Nutritional/socioeconomic standardMetabolic/Nutrient deficiency
As in Osteomalacia/Rickets
4. Other evidences of hormonal imbalance - Renal osteodystrophy &
anaemia
5. Seasonal variation/Cyclical changes
- Inflammatory signs - morning stiffness (>30 minutes)
*Pain improves with use of affected part
6. History of Road traffic accident, fall trauma Remember to add ATLs
(Advanced Trauma life-saving protocol) When evaluating trauma patients.
7. Degenerative process
- Advancing age - pain improved by rest and worsening by use of
affected part/ at the end of the day.
8. Bone metastasis
o Constant bone pain (as in multiple myeloma), Night cries (in children)
o Low grade fever, night sweats, anorexia, fatigue
9. No obvious causes ===>Idiopathic.
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Example 1:
PC; Presented 4 hours ago with a history of right ankle wound and pain.
HPC: He was a passenger in a motorcycle moving at moderate speed along a
tarred road at Omega and was on helmet when the motorcycle had a head on
collision with a car at moderate speed from the opposite direction. He fell of the
bike and was dragged a little distance.
He sustained a deep wound on the distal 1/3 of the leg and ankle and upper fist,
exposing the leg bones. Associated profuse bleeding and severe pain of the leg,
inability to bear weight. He was able to move the toes
There was no loss of consciousness, no headaches, no bleeding from craniofacial
orifices, no seizure, no neck pain, no chest pain, no hemoptysis.
He was rushed to UNTH via a tricycle to the Accident and emergency unit where
he was stabilized. He was seen by the orthopedic surgery unit. Requested CTU to
review in view of suspected vascular injury.
- Had (L) inguinal herniorrhaphy
- Nil HTN, DM, Asthma, SCD
1. Open tibia/fibular fracture with extensive tissue loss of Right leg.
2. Vascular compromise. (Gustillo and Anderson type 111B)
IMPORTANT positives supporting provisional diagnosis
1. RTA (High impact force)
2. Deep wound on distal 1/3 of leg exposing the bones
3. Severe pain on leg
4. Inability to bear weight on the leg
Important –negatives/Rules out:
- Could move the toes (ruled out foot drop from nervous compromise)
- No loss of consciousness, no headaches, no craniofacial orifice bleeding, no
seizure, - Ruled out CNS involvement
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Example 2
PC; Shortening of left lower limb x12 yrs
Protrusion of bone of from left thigh x 6 months
HPC:
Patients’ problem date back to 12 years ago when she developed a febrile illness at
age of 11yrs. No history of trauma to the leg area. There was associated swelling of
the left thigh with pains and limping. Patient was treated by both Orthodox and
traditional healers before she was taken to IMSUTH Orlu where she had a surgical
operation (couldn’t get the details).
Subsequently, she had POP applied with crutches for immobilization. However,
the surgical wound broke down with exudation of serous fluid from the medial
aspect of the lower thigh. There was also shortening of the affected limb with
progressive stiffness of the (L) knee. She stopped using crutches one year after the
surgical procedure, but has continued to limp.6 months ago, she noticed protrusion
of a pieces of bone from the sinus which has continued to increase in size.
Patient revisited IMSUTH for further treatment after several years of absconding
from treatment due to financial difficulty but was dissatisfied with the treatment
she received there and then decide to come here.
PM Hx - Nil
FH (Nothing significant)
Chronic Osteomyelitis of Left Femur.
Important positives supporting provisional diagnosis
1. Followed febrile illness and associated swelling and pain.
2. Surgical procedure to affected region
3. Chronic discharging sinus ( 12yrs)
4. Deformity (Limping and shortening of limb)
5. Recently, protruding deformed bones from knee region
6. Knee stiffness
Important negatives
- No high impact of trauma to the region (rule out fracture)
- No history of chronic bone pain (Rule out pathological fracture)
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ENDOCRINE SYMPTOMS
1. Introduction
1.1 Endocrine Organs
2. Presenting complaints in Endocrinology
3. Clerking around common PC in Endo
4. Tying it all up
5. Typical examples of clerking in Endocrinology
6. Conclusion
Introduction
The Endocrine system deals with the chemical (as against electrical) regulation of
body function.
Endocrine disorders are important causes of morbidity and mortality in the world
today with diabetes and hypertension being the most frequently occurring.
History taking in endocrinology thus involves accessing for certain risk factors in
the biodata and using the same to clerk around the presenting complaints so as to
establish possible presence or otherwise of pathologies by asking about their
specific distinguishing associated symptoms. Because of the non-specific nature of
endocrine symptoms, the role of investigations in arriving at a particular diagnosis
can never be over emphasized.
Endocrine Organs
In our day to day practice, disorders of the hormones of the following organs
constitute the vast majority of the endocrine diseases.
a. Hypothalamus/ pituitary
b. Thyroid
c. Parathyroid
d. Adrenals
e. Pancreatic islet cells
f. Gonads etc
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--Diabetes Insipidus (both the cranial & Nephrogenic types) can cause
impairment in the renal concentrating power – due to decreased levels or
actions of antidiuretic hormone (ADH)
--Sometimes increased fluid intake can cause apparent polydipsia and
polyuria. This may be very excessive in extreme cases (Psychogenic
polydipsia)
B. Muscle Weakness
Before you proceed with this presentation, rule out that it is not due to neurological
disease, Symptomatic muscle weakness in this case can be due to thyrotoxicosis,
curling’s syndrome and vitamin D. deficiency.
In all these conditions, the metabolic myopathy will cause some form of
symmetrical proximal weakness, mainly involving the shoulder and hip girdle
musculature and associated with muscle wasting.
Major presentation is difficulty in climbing stairs, boarding a bus, or rising from a
sitting position.
Proximal myopathy of vitamin D deficiency – painful
Spinal root or plexus disease can have similar presentations.
D. Weight loss
Feature of reduced food intake or increased metabolic rate. However, there are
conditions where an interplay of both reduces the body weight e.g cachexia of
malignancy. Hyperthyroidism is usually associated with effortless/unintentional
weight loss and increased appetite.
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E. Cold intolerance
The patient feels abnormally cold, out of proportion to that experienced by others.
Usually a feature of hypothyroidism. It is important you distinguish this from
Raynaud’s phenomenon which is a localized vasomotor symptom associated with
cold extremities.
F. Heat Intolerance
Patient feels unnecessary hot and at other times, feels comfortable at temperatures
too cold for others. It is quite specific for thyroid over activity as the increased
metabolic rate of thyrotoxicosis is usually associated with heat intolerance.
G. Increased Sweating
Hyperhidrosis (excessive sweating) may be a constitutional abnormality
characterized by onset in childhood or adolescent and sometimes by a family
history.
However, a recent increase in sweat secretion may be an early sign of thyroid over
activity. Paroxysmal sweating is seen commonly in anxious state.
- Gustatory hyperhidrosis (intermittent sweating after meals) usually occur in
patients with autonomic dysfunction.
- Increased catecholamine secretion from a pheochromocytoma of the adrenal
medulla is a rare cause of hyperhidrosis.
- Growth hormone excess (Acromegaly) can cause increased sweating via the
hypertrophy of the sweat glands.
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I.Tremor
Fine rapid resting tremor: cardinal features of thryrotoxicosis. This must be
distinguished from coarser and more irregular tremor of anxiety which is usually
associated with a cool peripheral skin temperature, in contrast to the warm skin of
the thyrotoxic patient.
Tremor due to neurological disease is greater in amplitude, slower in rate and may
be present at rest (Parkinson’s disease) or movement (cerebellar tremor).
J. Postural unsteadiness
Dizziness or a sensation of faintness on standing should prompt measurement of
lying and standing blood pressure.
Postural hypotension occurs with reduced blood volume. In the absence of obvious
bleeding of GIT, fluid loss, Adrenal insufficiency should be considered.
Postural hypotension is frequently due to autonomic neuropathy, especially in DM.
- Also a common side effect of any drug treatment for essential HTN (Elicit
this from drug history).
K. Visual disturbance
Decreased visual acuity may be due to space occupying lesions compressing the
optic nerve.
- Bitemporal hemianopia (bilateral loss of part or all of the temporal fields of
visions), often asymmetrical or incongruous is a major feature of suprasellar
extension of pituitary adenomas, compressing the optic chiasm but may occur in
that location.
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L. Fasting symptoms
Tachycardia, sweating and tremor occurring intermittently, especially when fasting
are suggestive of hypoglycemia.
These resemble those associated with the increased sympathetic drive found in
states of fear or with excess secretion of Norepinephrine as in
phaeochromocytoma.
-Symptoms may progress to decreased consciousness in severe hypoglycaemia
(Neuroglycopenia) –It is a serious emergency enough to impair brain function.
Causes of spontaneous or fasting hypoglycaemia:
1. Autonomous insulin production due to an insulinoma.
2. Glucocorticoid deficiency (± thyroxine and growth hormone failure eg Primary
adrenal failure or hypopituitarism.
3. Inappropriate insulin or excessive sulphonyl urea drug administration in a
diabetic patient.
N. Nausea
Rare symptom of Endocrine disease.
Feature of adrenal insufficiency in which it is typically maximal in the morning
and may be associated with vomiting.
- Similar symptoms seen in severe hypercalcaemia.
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O. Dysphagia
Difficulty in swallowing may be a presenting feature of multinodular thyroid
enlargement with retrosternal extension.
Smaller goitre only rarely result in dysphagia.
Severe hyperthyroidism with generalized weakness may be associated with a
reversible myopathy of the pharyngeal musculature and consequent dysphagia.
Q. Impotence
Reduced erectile potency could be as a result of:
Atherosclerosis – Reduced blood flow to the penis
Autonomic Neuropathy complicating DM – Neural dysfunction
Hypopituitarism and primary testicular failure – Testosterone deficiency
Hyperprolactinaemia
Drug therapy (As in some antihypertensives)
Psychological factors Principal cause
Questions around these for any patient presenting with impotence.
R. Gynaecomastia
This refers to a smooth, firm, mobile, often tender disc of breast tissue under the
areola in the male. This should not be confused with the soft, fatty enlargement
often seen in obesity.
- Mild Gynaecomastia (usually unilateral or asymmetrical (frequently occurs
as a temporary phenomenon in normal puberty; and may persist for several
years or sometimes, indefinitely.
Cause
- Excess estrogen stimulation
- Reduction in circulating levels of androgens
- Antagonism of androgen action
- Androgen insensitivity
S. Amenorrhoea:
Absence of menstrual periods (menses).Most common cause of primary
amenorrhea Physiological delay of puberty.
T. Galactorrhoea
Inappropriate lactation (which is usually bilateral) can be caused by:
1. prolactin secreting tumours of the pituitary gland
2. Idiopatehic galactorrhea, in which there is an apparent increased sensitivity to
normal levels of serum prolactin.
3. Hyperprolactinaemia due to hypothyroidism
4. Hyperprolactinaemia due to lactotroph disinhibiting lesions of the
hypothalamopituitory region.
Tying it all up
Something’s occur together and serve as pointers to certain pathologies.
However, you don’t need all these to be present to suspect or even diagnose a
disease. Here’s some pathologies and common associations (You should be seen
actively trying to implicate or rule out some of these symptoms.
Diabetes Mellitus
- Excessive thirst (Polydipsia)
- Polyuria
- Unexplained weight loss or gain
- Nausea and vomiting
- Excessive hunger (polyphagia)
Clerk around the complications of diabetes:
- Vision changes/blurring vision: DM retinopathy
- Calf/leg pain(claudication): peripheral vascular dx
- Proteinuria and other renal defects (Glycosuria, Polyuria): DM Nephropathy
- Pin and needles, leg numbness, abnormal sensations: Peripheral neuropathy
- HTN and other cardiac abnormalities: Coronary artery disease
- Stroke and other cerebrovascular accidents
- Diabetic foot ulcers
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- Heat intolerance
- Irregular heart rate
- Irritability and mood changes
- Rapid heart rate(Tachycardia)
- Thick or red skin on the skins
- Tremors
- Unexplained weight loss
Prolactinoma (Hyperprolactinemia)
-Erectile dysfunction
-Infertility
-Loss of libido
-Missed menstrual periods
-Unexplained milk production (Common in females)
Note on Obesity
Obesity is a disorder involving excessive body fat that increases the risk of health
problems.
It often results from taking in more calories than are burned by exercise. It is
described in terms of the body mass index (BMI) of the person.
( )
Body mass index (BMI) =
^ ( )
2
(Kg/m )
Example 1
PC
Blurring of vision - 6/12
HPC
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The patient was referred from the ophthalmology unit on account of raised blood
glucose level (FBG =238mg/dl) which was discovered 4 days prior to presentation.
The blurred vision is recurrent in a way with periods of improvement in between..
The blurred vision started suddenly and there was no history of trauma to the head
or exposure of the eye to any physical or chemical agent
The eye is itchy and sometimes secretes tears just on looking at anything for a long
time. However it has worsened over the months and the patient complained that
she can’t even study her bible again
There’s history of recurrent one-sided throbbing headaches. There has been no
form of peripheral care for the blurring vision +ve Polyphagia, +ve polyuria (and
nocturia) – Wakes about 2 to 3 times in a night to urinate. Equivocal for
polydipsia. No associated pain during urination, but there is weight loss as
evidenced by loose fitting clothing. There is also associated abdominal discomfort
on eating recently, but no associated abdominal pain. Presence associated
peripheral tingling sensations and sometimes numbness on the limbs.
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Important positives
1. Elevated fasting blood glucose levels (>126mg/dl)
2. Blurry vision
3. Caesarian section
4. Paresthesia (tingling sensation/Numbness
5. Polyuria and
6. Polydipsia
DM with complications (Respiratory, Peripheral neuropathy, Autonomic
neuropathy)
Example 2
PC; Left foot ulcer-
HPC: The patient was apparently in her normal state of health until about 3
months ago when she started noticing pain on her second toe of the left foot. Pain
was mild and insidious in onset, with a boil like lump at the same location. It was
non-radiating.
Pain was aggravated, and lump became tender and soft after patient took some
unprescribed antibiotic medication (can’t remember their names) the lump
eventually became purulent.
There was no history of trauma to that toe. No previous needle prick to the area or
any surgical procedure. –No chronic cough or contact with someone with chronic
cough. The pain wasn’t associated with any loss of function to the limb. No
associated fever. No history of joint stiffness or joint pain. However, patient is a
known diabetic of about 5 years duration compliant with her metformin
medication. She has paresthesia on the lower limbs. No previous CVA. She doesn’t
feel pain on the calf muscles on walking long distances. Positive weight loss
evidenced by loose fitting clothes. There’s currently no chest pain or any
associated CVS abnormalities but patient has blurring vision. For the above
symptoms, patients presented to a peripheral hospital where the lesion was
examined and subsequently incised and later the 2nd toe was computed. Due to
poor wound healing and crises around the initial point of management, patient
presented to UNTH for expert management. The patient has been on admission for
about 27 days, during which the 3rd, 4th and 1st toes became gangrenous and were
amputated. The wound site is currently being managed and dressed daily with
honey and KY-Jelly.
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Past medical/surgical Hx
Ho Eo Ao D+ So
Have been admitted previously on issues of blood glucose control. No previous
surgeries, but patient has received 1 pint of blood in this hospital.
Gynaecology Hx
Had all her 4 childbirth via a spontaneous and Vertex delivery.
No complication ever during delivery
Have since reached menopause (>15 years ago)
Family History
2nd child in a family of 4….Monogamous setting
No history of HEADS among 1st degree relatives
Social History
Patient is married in a monogamous setting. Gave birth to 4 children 2 boys and
2girls. Lives in a well-ventilated apartment. Source of drinking water is from the
stream. Used to be a social drinker. Doesn’t take tobacco in any form.
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