CLINICAL HISTORY AND DIFFERENTIAL DIAGNOSIS AT YOUR FINGERTIPS

By Rao Maaz Bin Shakir

This book is written to give history-taking a methodical approach and to lay a strong
foundation to reach differential diagnoses. Aim of this book is to allow medical students,
interns and trainee doctors to prepare for PLAB, USMLE and MRCS (PART B) examinations
and to let junior doctors to apply history taking skills to day-to-day clinical practice. This book
is written in succinct language and format for easy memorization.

• Language: English
• Publisher: Lulu.com
• Release date: Jun 1, 2023
• ISBN: 9781447662228

Book preview

DEDICATION

This book is dedicated to my parents, my loving wife  and my teachers.

PREFACE

It is indeed an arduous and time-consuming process to obtain a meaningful clinical history that guides towards a number of possible diagnoses before carrying out physical examination. Hence, this book is written to give history-taking a methodical approach and to lay a strong foundation to reach differential diagnoses. Aim of this book is to allow medical students, interns and trainee doctors to prepare for PLAB, USMLE and MRCS (PART B) examinations and to let junior doctors to apply history taking skills to day-to-day clinical practice. This book is written in succint language and format for easy memorization.

I hope this book fulfills its use as a resourceful tool in the ocean of knowledge.

Best Regards

Rao Maaz Bin Shakir

MBBS, MRCS (Ed)

[e-mail]

INDEX

Abdominal distension

Acute confusion

Acute diarrhea

Acute red eye

Anal pain

Anuria/Oliguria

Backache

Breast lump

Breast pain

Chest pain

Chronic diarrhea

Coma/Loss of consciousness

Cough

Difficulty passing urine

Dysphagia

Epistaxis/Nosebleed

Erectile dysfunction/Impotence

Fatigue

Goitre

Groin mass

Headache

Hearing loss

Heartburn

Hematemesis

Hematochezia

Hematuria

Hemoptysis

Insomnia

Jaundice

Joint pain

Leg pain

Leg swelling

Lymphadenopathy

Male breast enlargement/Gynecomastia

Nausea and vomiting

Nipple discharge

Numbness

Palpitations

Pain epigastrium/right hypochondrium

Pain right iliac fossa

Painful shoulder

Parotid swelling

Polyuria

RIF mass

Scrotal swelling

Seizures

Shortness of breath

Syncope

Testicular pain

Tremor

Urinary incontinence

Vaginal discharge

Vertigo/dizziness

Weakness of both lower limbs

Weakness of one half of body

Weight gain

Weight loss

HISTORY TAKING

INTRODUCTION

-self and role (Hello, I am Dr Maaz, surgical SHO on call, working for Mr...)

WASH HANDS

CONFIRM PATIENT NAME AND DOB

RAPPORT

(Could you tell your name and DOB, please)

-ask open question (How can I help you today?)

PRESENTING COMPLAINT

HISTORY OF PRESENTING COMPLAINT

  -QUESTIONS ABOUT ANY SYMPTOM

      DOC IF PAPARS

Duration

Onset

Character

Intensity

Frequency

Progression

Associated symptoms

Previous episodes

Aggravating factors

Relieving factors

Special time of occurence

  -QUESTIONS ABOUT ANY PAIN SYMPTOM

        SR DOC IF PAPARS

Site

Radiation

Duration

Onset

Character

Intensity

Frequency

Progression

Associated symptoms

Previous episodes

Aggravating factors

Relieving factors

Special time of occurence

SYSTEMIC REVIEW (G CRAUN MESH P)

G eneral

C ardiovascular

R espiratory

A limentary (GIT)

U rinary

N eurological

M usculoskeletal

E ndocrine

S kin

H ematological

P sychiatric

G-loss of appetite

   -weight loss

   -fever

   -night sweats

   -sleep

C-chest pain

     -shortness of breath on exertion

     -orthopnea

     -PND

     -ankle swelling

       -syncope/faints/blackout

       -dizziness

       -palpitations

         -limb pain

         -walking distance

         -colour changes in hands and feet

R-chest pain

  -SOB

      -cough

      -sputum

      -hemoptysis

         -hoarseness

         -wheezing

         -exercise intolerance

             -snorring

             -sneezing

A-difficulty with swallowing

   -jaundice

       -nausea

       -vomiting

       -diarrhea

       -constipation

          -blood in vomitus

          -black coloured stools

          -bleeding per rectum

             -regurgitation

             -flatulence

             -heartburn

                -abdominal pain

                -abdominal distension

                -bowel habit

                    -fecal incontinence

                    -tenesmus

U-loin pain

   -burning micturition

   -blood in urine

       -frequency of micturition

       -urgency

       -nocturia

       -poor stream

       -hesitancy

       -dribbling

          -polyuria

          -thirst

          -urinary incontinence

  -impotence

      -date of menarche or menopause

      -frequency

      -duration and quantity of menstruation

         -vaginal discharge

         -painful intercourse

         -painful menstruation

         -prolapse

            -breast pain

            -lump

            -nipple discharge

N-change of behaviour

   -memory loss

   -tremor

       -loss of consciousness

       -fits

       -headaches

       -dizziness

       -double vision

           -muscle weakness

           -sensory disturbances

           -changes in smell

           -vision

           -hearing

           -speech

           -tinnitus

           -ataxia

M-pain in muscles or joints

   -swelling of joints

   -limitation of joint movements

   -morning stiffness

         -locking

         -weakness

         -disturbances of gait

H-bleeding

   -bruises

   -painful unilateral calf swelling

PAST MEDICAL AND SURGICAL HISTORY 2

-any medical condition/previous illnesses/operations/accidents

-MJTHREADS (Myocardial infarction/Jaundice/Tuberculosis/Hypertension/Rheumatoid arthritis/Epilepsy/Asthma/Diabetes mellitus/Stroke)

(PSTF)

PERSONAL HISTORY 6

-any habits

-smoking (no. per day) pack years

   20 cigarettes/day for 1 year = 1 pack year

-alcohol (units/week) for male limit 21 units/week and for female limit 14units/week

-recreational drugs/IV drugs/tattoos

-mobility and exercise tolerance

-activities of daily living

    -wash

    -dress

    -go downstairs

    -cook breakfast

    -clean up