MOSCO’S GUIDE

MOSCO’S
CLERKING
GUIDE
 MOSCO’S GUIDE

MOSCO’S CLERKING GUIDE

AUTHORS:

UDE SOMADINA GODSFAVOUR (DIST. BIOCHEMISTRY)

OGBU OSWALD CHUKWUEMEKA (DIST. PATHOLOGY AND PHARMACOLOGY)

DIMSON JUSTIN (DIST. ANATOMY, PHYSIOLOGY, BIOCHEMISTRY, PATHOLOGY)

EZE HARRISON CHIMA (DIST. ANATOMY, PATHOLOGY, PHARMACOLOGY,)

AMAECHI FAVOUR-MOSES .O. (MOSCO TOMWEST)

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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
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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

1. BIODATA (NASOMARTI is the standard)

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
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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.

A typical Bio-data; My patient is Dimson Somadina, a 25 year old married lawyer

who hails from Oba Idemili south L.G.A, Anambra state and resides in Trans-ekulu,
Enugu. He is an Igbo Christian of Roman Catholic denomination. The patient is my
informant.

2. PRESENTING COMPLAINT (PC)

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.

A typical presenting complaint; abdominal pain of 3 days duration

3. HISTORY OF PRESENTING COMPLAINT (HPC)

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
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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.

F--- Frequency (how many times does it occur)

O---Onset (was it insidious or sudden in onset)

D---Duration (when did it start? Is it an acute or chronic presentation?)

I----Intensity (grade the intensity of the symptom; mild, moderate, severe.

How bad is it on a scale of 1 to 10?)

P---Progression (what’s the progression of the symptom?

Is it getting better or worse with time?)

A---Aggravating fx (what are the aggravating factors. Does it get worse on

exertion, inhalation of any substance, change in position etc)

R---Relieving fx (what does the patient do/take to relieve these symptom)

A---Associations (are there any other associated symptoms/complaints to

the presenting complaint)

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
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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.

4. PAST MEDICAL AND SURGERY HISTORY

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.
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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.

8. REVIEW OF SYSTEMS (ROS)

- These are some of the questions you can ask but it is not limited to them.

Central Nervous System- Headache, dizziness, Fainting spasms, seizures,

consciousness, forgetfulness.

Respiratory System- Breathlessness, wheezing, chest pain, cough, haemoptysis.

Cardio-Vascular System- Cough, dyspnoea, orthopnea, palpitation, Paroxysmal

Nocturnal Dyspnea, leg swelling.

Gastro-intestinal system- Diarrhea, constipation, abdominal swelling, abdominal

pain, vomiting, jaundice.
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Urogenital system- Flank pain, urethral discharge, haematuria, dysuria, nocturia,

frequency, urgency, hesistancy, incomplete voiding.

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;

I have presented Mr. D.S, a 25 year Petroleum engineer (occupation is important if

it is relating to the presenting complaint) who presented with (presenting complaint
and duration). State positives and negatives (anything symptom that can lead to
diagnosis in the history of Presenting complaint)

CHAPTER 2

QUESTIONS TO ASK IN THESE GENERAL SYMPTOMS

Fever and pain are general symptoms you will encounter in any unit you are in.
These symptoms cuts across every system of the body and will be treated as
general symptoms

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?
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- 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?

Ruling out your differentials

a. Long duration (> 1 month), high grade, continuous, not worse at any time of the
day _____ think HIV
b. Long duration (> 1 month), low grade, continuous, associated drenching night
sweats, cough of long duration, productive of sputum which may be bloody_____
think TB
c. Short duration, high grade, continuous, associated chills and rigor, vomiting,
headache, temporarily relieved by antipyretic_____ think Meningitis
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),
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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.

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” 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).
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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

Other causes of breathlessness like acute pulmonary embolism, acute

myocardial infarction, pneumothorax are medical emergencies and will be
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.

To rule out Asthma, ask the patent these questions;

i. If it is worse at any time of the day (it’s worse at night for asthma
patients).
ii. If it occurs intermittently (asthma patients have good and bad days, so the
breathlessness occurs intermittently).
iii. If it is aggravated by any factor (most asthma patients complains of
exacerbation of symptoms when they inhale dust, smoke, pollen grains,
strong perfumes or comes in contact with animal fur. Others get worst
when expose to cold or occupational exposure).
iv. If there is any history of throat or eye itchiness.(this question is very
important. It helps to rule out any history of atopy. You cannot say you
have successfully clerked an asthma patient without asking this question).
v. If there is an associated wheeze on breathing (a wheeze is an audible
whistling sound usually loudest in expiration. ask the patient, if his
breathing, sounds like he is whistling).
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vi. If there is an associated cough (cough can be an association to

breathlessness or even a presenting complaint in asthma patient).
vii. If the cough is productive of tenacious sputum (this is seen in some
asthma patients, but not always).
viii. If there is any associated chest tightness (this chest tightness is different
from pleuritic pain seen in pneumonia or retrosternal pain seen in angina.
It is called tightness not pain).
ix. If there is a family history of atopy or asthma. (research has shown that
bronchial asthma can be familial and has a genetic predisposition).
x. If there is any weight loss (mild weight loss is usually seen in asthma
patients).
xi. Remember the age of your patient (asthma occurs more in young
patients).
xii. If there is any relieving factor (some patients you’ll meet in clinic may
have inhalers).

To rule out pulmonary tuberculosis, ask your patient

i If there is any history of chronic cough or contact with a person with
chronic cough.
ii If there is any associated haemoptysis (coughing of sputum tinged with
blood is more likely to be PTB).
iii If there is an associated weight loss(ask the patient, how fitted his
clothes are. most patients notice weight loss by how loosely fitted, their
clothes have become).
iv If there is drenching night sweats (this is characteristic of PTB).
v If there is any history of low grade fever.
vi Rule out any history of immune suppression that can reactivate primary
TB (HIV, DM, Cytotoxic drugs, chronic steroid therapy).

To rule out COPD, ask your patient

i. If there is any history of smoking (almost all case of COPDs occur in
those who have smoked).
ii. If there is any history of exposure to biomass fumes (you can confirm
this, by asking your patient if he cooks with firewood in an enclosed
space).
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iii. If there is associated cough, how long and sputum production.

(bronchiectasis and chronic bronchitis cause the production of sputum in
larger (cupful) and smaller amounts respectively).

To rule out pneumonia (infective causes), ask your patient

i. If there was a previous history of fever (fever almost always indicate an
infection).
ii. If there is associated chest pain (this pain is commonly pleuritic. It is felt
most times at the sides of the chest. It’s sharp, stabbing and made worse
by deep breathing or coughing).
iii. If there is associated cough and productive of sputum (sputum in
pneumonia is mostly rusty brown, though a pseudomonas infection could
color the sputum green).

To rule out malignancies; ask the patient

i. If he smokes or smoked in the past (malignancies of the chest is almost
always associated with smoking).
ii. If there is associated chronic unexplained weight loss (emaciation is a
cardinal complaint of CA patients).
iii. If there is any history of occupational exposure to heavy metals,
hydrocarbons, asbestos, or other carcinogens (asbestosis has been linked
to mesothelioma, a malignant tumour of the mesothelium of the lungs).
iv. If there is any history of chronic cough.
v. If there is associated haemoptysis (in most cases, the patient coughs
frank blood with little sputum).
vi. If there is associated constant chest pain unrelated to breathing (this may
be caused by local invasion of the chest wall by a lung or pleura tumour).

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.
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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.

To check shortness of breath”, ask your patient;

i. Characterize the symptoms using the mnemonic “FODIPARA”
ii. When it started and how has it progressed since onset. (in CCF, SOB will
be progressive since onset).
iii. If it has been persistent.
iv. If it is worst at rest or on exertion.(SOB on exertion is suggestive of
CCF).
v. If worse on exertion, is it on mild or moderate exertion? (this helps you
to characterize the severity. To know if it is on moderate exertion, ask the
patient if he has exacerbated SOB after climbing a small hill or walking a
long distance on level ground. To confirm mild exertion, ask your
patient, if he has SOB after walking a short distance or climbing a flight
of stairs or walks slower than normal on a level ground because of SOB
or has to stop for breath when walking at own pace. SOB at rest or being
too breathless to leave the house or dress/undress is an ominous sign).
vi. If the patient wakes up on sleeping with SOB, gasping for air. (this is to
confirm PND. For severity, ask the patient how soon after on lying down
to sleep, he experiences this SOB. If it occurs hours after lying down to
sleep, then it isn’t still mild. If it occurs immediately after lying down,
then it has upgraded to orthopnea. Ask the patient, the number of times,
he wakes up at night. The more the frequency, the more severe it is).
vii. If he can lie down at all to sleep. (does he need propped up pillows to
sleep? How many, if he does. The more the pillows the more severe it has
become. In advanced disease, the orthopnoeic patient may choose to
sleep, sitting on a chair).
viii. If he gets tired easily especially towards the end of the day.
ix. If he has had any fainting spells or previous history of recurrent dizziness
x. If there is associated cough productive of frothy sputum or haemoptysis
(congestive cardiac failure can also cause haemoptysis).
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xi. If there is associated chest pain. (retrosternal chest pain that radiates to
the jaw/left arm/throat and constrictive in character is suggestive of
myocardial ischaemia).
xii. If there is associated body swelling (most CCF patient will present with
bilateral leg swelling or sacral edema).
xiii. If there is any history of abnormal awareness of the heartbeat(palpitation)
xiv. If there is a history of smoking, alcohol, diabetes or hypertension (Most
CCF in patients is due to diabetes or hypertension).
xv. If there is any history of sore throat (to rule out rheumatic fever).

PC: Recurrent breathlessness of 3 months duration

HPC: He was apparently well until 3 months ago, when he noticed sudden
breathlessness after sweeping his house. It gets worse at night and is aggravated by
cold. It reoccurs whenever he is playing football in an open field.
There was no history of fever, or pleuritic chest pain though the patient complained
of associated chest tightness. There was no history of smoking or exposure to
biomass fumes. There was associated cough that was worse at night and productive
of tenacious sputum. He also complained of eye itchiness on several occasions in
the past. There was no history of chronic cough or contact with a person with
chronic cough; no associated weight loss or drenching night sweats, no
haemoptysis or history of low-grade fever. There was no positive family history of
atopy but he complained of a whistling sound on expiration during breathing.
There was no positive history of orthopnea, PND or body swelling.
On account of these symptoms, he visited a peripheral hospital where he was on
ventolin tablet and was subsequently referred to this hospital for expert
management...What’s your provisional diagnosis???

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
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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
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).
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vii. Is it paroxysmal (remember whooping cough and its characteristic pattern

in children)

Were your thoughts streamlined to any particular provisional diagnosis after

reading this HPC?

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
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.

CLERKING EDEMA (Body swelling)

Body swelling, especially of the lower extremities is a very common presentation
in cardiology. However, body swelling can be a result of a pathology in three
major systems of the body; cardiovascular, renal and GIT (liver specifically). This
is why, when clerking body swelling, you must rule out cardiovascular causes,
renal causes, & GI causes. This is very valid, not only in cardiology, but also in
gastroenterology and nephrology units. General questions to ask your patient who
presented with body swelling include;
i. How and who noticed the body swelling
ii. Where did it start from or what part of the body was first affected (this
helps to rule out which system is most likely affected. If the body
swelling was initially “periorbital”, then you should think of a renal
cause. If the body swelling was first noticed in the abdomen, then you
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should think of a GI cause. If the body swelling was first noticed in the
ankle in an ambulant patient or the sacrum in a recumbent patient, then
cardiac cause should first come to your mind. These sites are not absolute
for the systems but it goes a long way in streamlining your diagnosis)
iii. Was the body swelling rapid or gradual in development (most body
swellings actually begin from the legs, specifically from the ankle
upwards. You must characterize the progression in your clerking, if
present. If it started at the ankle, where has it reached? The midleg, mid
thigh or sacrum?)
iv. If the body swelling started at the lower limbs, was it bilateral or
unilateral? (the commonest cause of unilateral leg swelling is DVT.
Bilateral leg swelling can be due to any of the systems mentioned
earlier).
v. Was the body swelling pitting or non pitting (most body swellings are
actually pitting except for body swellings due to lymphatic obstruction as
seen in elephantiasis or pentazocine abuse which is non-pitting)
vi. At what time of the day is it worse? Is it there all the time or disappears
as the days goes by and later reappears?(in CCF patients, bilateral leg
swelling gets worse in the morning due to gravity, causing pooling of
blood and gets better during the day when there is increased activities
that help in venous return of blood to the heart. Body swelling in renal
disease like nephrotic syndrome is due to reduced oncotic pressure and as
such will persist throughout the day)
vii. Are there any aggravating or relieving factors such as movement, change
in position or rest?

To rule out renal aetiology, ask these questions;

viii. Is there any recent change in urine output (renal failure could present
with oliguria or polyuria depending in the stage during presentation).
ix. Is there any history of flank pain(this helps to rule out pyelonephritis)
x. Is there any history of use of bleaching creams or herbal medication or
insect sting/bite (many individuals may not know it but bleaching creams
and herbal medications are common cause of toxic nephropathy)
xi. Is there any history of haematuria, fever, sore throat or skin infection
(this is to rule out post-streptococcal glomerulonephritis)
 MOSCO’S GUIDE

xii. Is there any recent history of malaria infection (yes, glomerulonephritis

could be a sequelae to malaria attack).
xiii. Any history of use of medicated soaps containing heavy metals like
mercury, lead (this is just for showmanship because most individuals
don’t read the ingredients of medicated soap in Nigeria)
xiv. Any previous history of drug ingestion especially analgesics,
aminoglycosides and NSAIDS (these drugs are notorious for causing
nephropathy as a side effect)
xv. Any symptom, suggestive of complications of chronic kidney disease like
uraemic encephalopathy, bone disease, anemia & electrolyte imbalance?

To rule out hepatic cause, ask for;

xvi. Any history of jaundice, easy anxiety, RUQ abdominal pain, vomiting,
anorexia etc
xvii. Any history of symptoms suggestive of complications of liver failure
(e.g. hepatic encephalopathy).

To rule out cardiac cause (CCF), ask for;

xviii. Any history of cough, dyspnea, PND, orthopnea, palpitations or
retrosternal chest pain.
xix. Any history of sore throat (This is to rule out rheumatic fever and its
complication)
xx. Any history of symptoms suggestive of hypertension and diabetes (These
are the leading cause of CCF).

What do you think is the Provisional diagnosis?

An elderly patient presented with recurrent bilateral leg swelling of 6 months
duration. The leg swelling was pitting and was first noticed by the patient
whenever he wakes up in the morning at the level of ankle joint. It gets better
whenever he goes to work but he complained of the leg swelling reaching his mid-
leg prompting him to seek expert management. There was no history of jaundice,
abdominal pain, anorexia or symptoms suggestive of hepatic encephalopathy.
There was no history of lower flank pan but he complained of change in urine
output, no haematuria, no fever, sore throat or skin infection. Prior to presentation,
 MOSCO’S GUIDE

he complained of not being able to sleep well at night except when he stacks 5
pillows. There is associated breathlessness and cough productive of frothy sputum.
He is known to have diabetes for 10 years and was recently diagnosed of
hypertension 3 months ago. He is not compliant with his medications.
On account of these symptoms, he came to this hospital UNTH for expert care

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!

NEUROLOGICAL SYMPTOMS

The University of Nigeria Teaching Hospital has two units

Unit 1 – Prof. Onwuekwe/Dr.Ekenze
Unit 2 – Dr. Ezeala Adika-Ibe
Common conditions in Neurology
1. Stroke
2. Headache
3. Seizures
4. Dementia
5. Parkinsonism

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.

1. Bio-data – NASOMARTI (Name, Age, Sex, Occupation, Marital Status,

Address, Religion, Tribe, Informant)
2. PC (Presenting Complaint) - Progressive memory loss of ------ (put the
duration here) e.g Progressive memory loss of 2 years duration
3. Hx Pc (History of Presenting Complaint) - Complaint, Course, Cause,
Complication and Care
 MOSCO’S GUIDE

Complaint;
Patient was apparently well until 2 yrs ago when he/she started forgetting
things/events
Characterize the things/pattern of forgetfulness here (using this questions)
- When did it start
- Is it getting better or worse
- Examples of the things he/she forgets
- Does he/she find it difficult to find words or remember names
- Does he/she get loss in familiar places eg on her way to her room
Course;
- Did it start suddenly or insidiously (gradually)
- 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)
 MOSCO’S GUIDE

 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.

Example of Dementia Clerking

Hx Pc
Patient presented with progressive memory loss of 6months duration. This was
said to have started after she had right sided body weakness which caused a change
in her gait. Patient is said to forget things such as names of her daughters, forgets
events repeatedly, the path leading to her room and also gets lost in familiar places
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
 MOSCO’S GUIDE

- 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

Course; was it insidious in onset or Acute. How has it progressed

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
 MOSCO’S GUIDE

- 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
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)
 MOSCO’S GUIDE

- 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
NB A partial seizure can become secondarily generalized;
- So ask if the seizure started from a part and then spread to the whole body.
Course
Ask about the frequency here i.e. How many times in a month does it occur, how
many minutes does each last etc
Causes
Rule out all the possible causes here
- Trauma
- Brain tumor or surgery
- Stroke
- Drugs
- Alcohol withdrawal
- Spontaneously
Complications
Injuries that occurred due to the seizure (Ask about them)
Activities avoid due to the seizure; ask about them
Care
Ask about all the treatment received as regards the seizure

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
 MOSCO’S GUIDE

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.

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.
 MOSCO’S GUIDE

 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
 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.
 MOSCO’S GUIDE

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.
 Does it reduce/stops during motion.
 Is it associated with gait change (shuffling/festinant), loss of smell
(anosmia), reduced frequency of blinking, hypophonic voice (voice getting
smaller),bradykinesia.
 Is there difficulties rising from a chair or getting into or out of bed.
 Is there difficulties rolling over in bed.

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
 MOSCO’S GUIDE

- 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.

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.
 MOSCO’S GUIDE

Questions to ask;

- When did it start?

- How frequent is it?
- Is it projectile or non- projectile (due to raised intracranial pressure or
metabolic disturbance/intestinal obstruction– vomiting is usually painless
and not assisted with eating).
- What is the content?
a. In oesophageal obstruction (dysphagia), the vomitus contains food just
recently eaten.
b. In gastric outlet obstruction, the vomitus is copious, brownish and acidic.
c. In intestinal obstruction, the vomitus is bitter due to content of bile or it
could be faeculent.
d. Large bowel obstruction is less common & vomitus is faeculent.
e. Is there associated headache, neck stiffness and pain, nausea, photophobia-
meningitis.
f. Is the patient pregnant?
g. Is the patient on any drugs (most drugs like digoxin and morphine cause
vomiting as side effect).
h. Does the patient have left parasternal chest pain that is aggravated by
exertion and radiates to the left neck, jaw, shoulder and back? (Angina due
to myocardial infarction normally present this way).
i. Does the patient have heart failure? (Ask for any swelling on the body,
orthopnea or PND).
j. If it is associated with any feeling of indigestion, ask if abdomen is swollen,
if patient is a known diabetic?
k. Does the vomitus contain blood?(Note if it is merely blood-stained
(oesophageal or buccal bruises) or if the entire vomitus is blood think
oesophageal CA).

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
 MOSCO’S GUIDE

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.

PC: Nausea and vomiting, passage of watery stool of 3 days duration.

HPC: Patient was in her apparent state of health until 2 days ago when she felt
nauseous and started vomiting immediately after eating a meal purchased from a
roadside food vendor. The vomitus contains recently eaten food and is not copious.
There is no associated fever, headache, neck stiffness or altered consciousness.
There is no bloating or feeling of fullness, no belching or passing of flatus. There is
peri-umbilcal colicky pain; there is also associated passage of watery stool of 3
days duration and feeling of weakness. On account of these symptoms she visited a
peripheral hospital for expert care.
Ddx: Gastroenteritis

CLERKING ABDOMINAL DISTENSION

Questions to ask;

i. When did you first notice it?

ii. Was it sudden or gradual in onset?
iii. How has it progressed? Is it much bigger now than at first notice?
iv. For how long has it persisted?
v. Is it associated with reduced frequency of defecation? (constipation)
vi. Are there audible abdominal sounds? (Flatus/gas)? Is it associated nausea,
belching or passing of gas?
 MOSCO’S GUIDE

(Indigestion or passing of gas? (Indigestion perhaps due to lactose intolerance).

vii. Ascertain patient is not pregnant
viii. Could be fluid in the bowels?
Rule out ascites by asking for edema in the extremities and in the sacrum. Any
right upper quadrant pain?

CLERKING EASY SATIETY

-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.

-Other causes Gastric caracinoma, cirrhosis of liver, previous partial gastrectomy

(stomach size reduces).

CLERKING ABDOMINAL PAIN

(i). Clerk it using SOCRATES [i.e. Site, Onset, Character, Radiation, Associated
factors, Time course, Exacerbating/Relieving factors, and Severity.]

Differentials: are in the table below;

 MOSCO’S GUIDE

Disease Site Character Radiation Aggravating Relieving Association

factors factors
1.Peptic ulcer Epigastric Burning or Radiates Meal-related Relieved Wakes the patient
disease gnawing to the (2 hrs after by from sleep
(Duodenal/Gastric pain. back meal) also antacid
ulcer or gastritis) Sometimes, alcohol;
dull. spicy foods,
cassava or
plantain–
containing
foods
2.Hepatic congestion Right Vague, To tip of
hypochondrium dull, shoulder
dragging sometimes
pain due to especially
stretching when
of liver there is an
capsule abscess in
the dome
of the
liver
3. Billiary system (ie Right upper Colicky To the Worse with Sweating, passage
gallstone in cystic or quadrant pain back . consumption of dark urine, fever
bile duct); (waxes and of fluid or & sometimes
cholecystitis Right wanes; To the oily foods jaundice
hypochondrium hooks and shoulder;
 MOSCO’S GUIDE

Ureteric stones Left and right releases maybe

(Urolithiasis) lumbar regions severe, referred to Sweating, nausea,
(loins) constant the groin restlessness
colicky and
pain too genitalia.
(renal
colic)
- Sudden in
onset
&severe
Enteritis Colicky Passage of
pain Often gas/flatus,
Excess air in the Epigastric and improves
bowel e.g due to periumbilical Colicky following Nausea, abd.
indigestion areas: Also in abdominal prolonged disteriion/ belding
(dyspepsia) right and left pain passage and flatulence
upper abd of flatus (passage of gas)
quadrants and
belching
 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)

Pancreatic e.g. High epigastric Agoni Ra Felt Reliev Accompanied by vomiting.

Acute pancreatitis zing dia imm ed by
pain tes ediat sitting
to ely forwar
the after d
bac eatin
k g
 MOSCO’S GUIDE

Small bowel Peri-umblical area. Colick Could be accompanied by

obstruction y pain audible abdominal
rumbling(borborygmi)
In intestinal
The pain is severe,
strangulation
persistent and
associated with Asstd with painful ineffective
vomiting of faeculent straining(tenesmus)
material.

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)

Peritonitis/peritone Diffuse/generalizedifl Conti Mov Difficulty standing erect

al pain ocalizedasinpainofap nuous eme
penditis,maybefeltaro nt
undumbilicusorreferr
edtoMcBurneypointi
nrightiliacfossa
 MOSCO’S GUIDE

CLERKING WATERY STOOLING (Diarrhea)

Differentials to think about:

1. Gastroenteritis, amoebic or bacillary dysentery, typhoid fever, food

poisoning
2. HIV/AIDS(chronic)
3. food poisoning
4. Laxative abuse or prolonged antibiotic treatment
5. Diabetes mellitus
6. Malabsorption syndrome, Lactose intolerance
7. Thyrotoxicosis etc.

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.

- Is it blood stained? Possible parasitic infestation (amoebic dysentery)

- Ascertain if stool is stained with blood or mixed with blood.
- If mixed with blood–lower GI bleeding, amoebic infestation etc.
 MOSCO’S GUIDE

If the stool is bloody; you should be thinking of causes of GI bleed.

- Differentials for lower GI Bleed: colon cancer, rectal cancer, bleeding disorder,
hemorrhoids, anal fissure etc.
- Differentials for upper GI Bleed: The stool is dark, tarry, foul-smelling and
sticky (Melena). This is due to altered blood(by Hcl) coming from an upper GI
bleeding. Causes include ruptured oesophageal varices from portal hypertension,
oesophageal cancer, peptic ulcer disease (perforated), bleeding disorders like
hemophilia or vWD, medications like NSAIDS, uremic gastritis in kidney failure,
parasitic infestation etc.
-If fresh blood comes from an upper GI bleed, it is indicative of a massive bleed.

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 anticholinergic 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
 MOSCO’S GUIDE

m. DM autonomic neuropathy? (Clerk DM symptoms like polyuria, polydipsia,

weight loss, is patient a known diabetic? Any altered sensation over extremities?)
n. Had typhoid recently?
o. Have painful lesions of the anus? Like tears, ulcers, hemorrhoids? (Because
patient will be afraid to defecate.
p. Any neurological disorder? Rule out:
1. Parkinson’s disease: Age of patient (Old), Resting tremors? Muscle rigidity?
Slow movement?
2. Cerebral palsy
3. Hirschsprung’s disease – usually congenital
4. Chagas disease

CLERKING DIFFICULTY IN SWALLOWING

Differentials to think about;
1. Malignancy
2. Trauma

Questions to ask;

- When did you notice it?

- How long has it lasted?
- When you first notice the difficulty, was it with solid first, then progressed to
liquids? (oesophageal or upper gastric carcinoma). Was there associated weight
loss? Weakness? Loss of appetite? (cancer generally)
- A benign lesion will follow same pattern but less rapidly.
- Any corrosive burns due to ingestion of toxic chemical?
- Neurogenic dysphagia will present with greater difficulty swallowing liquids than
solids sometimes asstd with aspiration and coughing – oesophageal spasm/
corkscrew oesophagus
- Odynophagia (which is painful swallowing in the oropharynx and oesophagus).
May be due to infection of oesophageal mucosa by candida infection seen in the
immunocompromised state in HIV.
 MOSCO’S GUIDE

CLERKING WEIGHT LOSS

In an era, where most individuals are trying to lose weight, a patient may present to
a doctor because he is losing weight. This presentation, though it might counter
intuitive actually signify that something is wrong with the patient and should never
be taken lightly. Clerk your patient by asking these questions:
i. What makes the patient feel, he is losing weight? (is it evidenced by
looseness of previously fitted clothes, belt or ring? Are his bony
prominences including facial bones very visible?)
ii. What is the feeling habit of the patient (does, he feed well, is he a
vegetarian or on a special diet? Chronic malnutrition will inevitably lead
to weight loss).
iii. Is there any symptom suggestive of HIV infection (persistent fever,
chronic diarrhea, chronic cough etc)
iv. Is there any symptom suggestive of diabetes (Polyuria, Polydipsia,
polyphagia)
v. Is there any symptom suggestive of malabsorption syndrome (persistent
diarrhea, steatorrhea, persistent vomiting).
vi. Is there any symptom suggestive of respiratory disease (is he a known
asthmatic? Any history of persistent cough, drenching night sweats or
haemoptysis).
vii. Is there any symptom suggestive of malignancy (chronically ill looking,
chronic cough, swelling in any part of the body, signs of metastasis)
viii. Is there any symptoms suggestive of heart disease (cough, dyspnea, PND,
orthopnea)
ix. Is there any history suggestive of thyrotoxicosis (irritability, prominences
of the eye, awareness of heart beat, heat intolerance etc)

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
 MOSCO’S GUIDE

Questions to ask;

- Was there history of yellowness of eyes? Past Hepatitis infection

* Deep yellow with pruritus (itching):Obstructive jaundice
* Yellowish with greenish tinge. Hepatic obstruction
- Was there any agonizing high epigastric pain that radiates to the back and is
felt after eating? (CA head of pancreas)
- If associated with Hepatitis, any right upper quadrant pain, fever, weight loss
- Hepatitis/Jaundice could be pre-hepatic, hepatic, post-hepatic.

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)

B. Hepatic cause: Hepatitis:-

i. Hepatitis A: Ask if patient has diarrhea, vomiting, after eating food
cooked on the roadside or poor toilet hygiene.
ii. Hepatitis B:
 Any hx of blood transfusion
 Any IV drug use
 Exposure to sharps like razors, clippers that are not personal
 Ask for occupation: People at risk are. Heath care workers
(medical doctors & medical students, nurses & student nurses,
medical lab scientist etc),commercial sex workers, long-distance
long drivers, uniformed men etc.
 Ask for local practices that predisposes to HBV like:
 Tattooing/scarification/ear piercing
 Condom use
 Unbound wounds and sores as in sports
 MOSCO’S GUIDE

C. Post-hepatic causes: Obstructive jaundice due to:

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

- Any hx of neonatal jaundice

- Any bleeding disorders
- Any confusions, memory loss, somnolence, seizures (hepatic
encephalopathy)
- Any distended peri-umblical veins
- Any ascites
- Any bleeding from oesophagus i.e haematemesis, bleeding per rectum etc.

URINARY SYMPTOMS

CLERKING PAIN

Differentials to think about:

1. Acute or chronic pyelonephritis

2. kidney cancer
3. polycystic kidney disease
4. cystitis
5. Acute bladder outflow obstruction,
6. Urethritis etc.
a. Renal pain is felt in the flank or loin.
b. Pain due to ureteric obstruction (e.g from a stone or a cancer etc);
discomfort may radiate to the iliac fossa, the testicle or the labia,
depending on the level of obstruction.
 MOSCO’S GUIDE

c. Pain due to polycystic kidney diseases presents as chronic, flank, pain

worsened by cyst infection and haemorrhage.
d. Acute bladder outflow obstruction: present with severe suprapubic pain.
e. Pain of cystitis or urethritis: pain in suprapubic and perineal region
accompanied by dysuria, frequency or weak streaming (painful, frequent
urination of small volumes expelled slowly by straining and despite a
severe sense of urgency, usually with the residual feeling of incomplete
emptying).If pain is associated with severe perineal or rectal discomfort
in men, prostatitis is suggested.
f. Pain from the kidneys, if it results from acute infection or abscess: may
cause diaphragmatic pain due to tracking of pus upwards to diaphragm,
or in the retroperitoneal space to the psoas muscle, leading to pain when
the muscle is stretched on passive hip extension.
g. Kidney tumour: cause a dull persistent flank pain.
h. Pelvic pain in women may point to pathology of uterus , ovaries or
fallopian tubes.

CLERKING HAEMATURIA

This is the passage of blood in urine, whether macroscopic red cells or

microscopic (only seen with aid of microscope).

Differentials to think about;

Blunt trauma to the kidneys, ureter and urethra, acute tubular necrosis,
glomerulonephritis, hemolytic Uremic syndrome, IgA nephropathy, renal
tumors, cystitis e.g due to Schistosomiasis, bladder tumors/trauma, Prostatitis,
Bladder tuberculosis etc.

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).
 MOSCO’S GUIDE

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

e. For how long has it been?

-Short period: UTI (Urethritis)
-Longer period: Malignancy and coagulation disorders (hemophilia etc)
f. How frequent does it occur?
i. One episode: Renal stone etc
ii. Constant: coagulations disorders, malignancy, schistosomiasis
g. Does it occur even when not passing urine? Consider injury to urethra.
h. Where does patient bathe? River, stream? (schistosomiasis)
Characterize the haematuria

1. Is it frank blood or urine mixed with blood or altered?

2. Patient passing clots?
3. Quantify the bleeding: How much
i. Any recent event like recent throat infection– glomerulonephritis (will
have microscopic hematuria and associated proteinuria on testing)
j. What drugs are you using?
- Anti-coagulant drugs would worsen bleeding disorders
- Cyclophosphamide, an anti-cancer drug, causes drug-induced/hemorrhagic
cystitis- haematuria.
k. Any passage of fleshy substances in urine (necroturia)? Rule out Bladder
cancer (CA):- Any hx of weight loss, bone pain, easy fatigability.
 MOSCO’S GUIDE

CLERKING DIFFICULTY IN URINATION

Differentials to think about;

a. Urinary tract infection:

Is there associated “burning” or “scalding” pain when urine is coming
out? Is there discharge?
b. Neoplasia of bladder and urethra in
- Is there any swelling in any part of the body?
- Is there weakness, severe weight loss[as evidenced by change in belt hole of
patients trousers or change in size of underwear or change in patients weight
as measured by him/her, or prominent zygomatic bone] and loss of appetite?

C. Blockage/ Obstruction of urinary tract due to;

i. Structures: Any history of traumatic urethral catheterization or urethral

lumen wound? Does stream improve with time? Any urethral discharge
in part?
ii. Benign prostatic hyperplasia: Male sex? Age above 40? Is there
frequency, nocturia, urgency, hesitancy, poor stream, straining, terminal
dribbling, feeling of incomplete voiding etc? (voiding, storage symptoms
of BPH).
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.]

- Is there purulent or whitish genital discharge? Are there boils or warts in

genitals? Is there itchiness? Is the discharge foul-smelling?

- 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?)
 MOSCO’S GUIDE

- Is there associated frequency in urination, testicular pain or pain during

intercourse (in women)

- What is the duration of symptoms and at what time is it worse?

- In women: a menstrual and basic obstetric history, including contraception should

also be taken, to ascertain risk of pregnancy.

- Is there presence of anogenital ulceration(or sores)?

CLERKING POLYURIA

Implies a high urinary flow rate. It is almost always associated with increase in
frequency of micturition and nocturia as well.

Differentials to think about;

1. Excessive water intake (psychogenic polydipsia or beer drinking or you just

drank a lot because you love water Lol.)

2. Osmoticdiuresis:

*Glucose as in diabetes mellitus (take full history of DM: refer to Endocrinology

section)

*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)

*Sodium chloride: Ask for diuretic use

*Diabetes Insipidus: Ask for previous head trauma or injury to head.

*Hypercalcemia, hypokalemia, chronic pyelonephritis, treatment(relief) of

obstructive uropathy can also cause Polyuria.

Polyuria is often accompanied by symptoms of dehydration like postural dizziness,

muscle cramps etc.
 MOSCO’S GUIDE

CLERKING NOCTURIA

Altered voiding pattern in which one finds the urge to empty the bladder during the
hours of sleep ( for more than 3 to 4times)

Causes are related to causes of polyuria: Also, reduction in functional capacity of

bladder can also cause it.

CLERKING FREQUENCY OF URINATION

It usually follows polyuria, a reduction in functional capacity of the bladder.

Frequency just like nocturia is an irritative lower urinary tract symptom.

Possible causes
*Cystitis from any infection like Schistosomiasis and TB
*Stone or other foreign bodies
*Chemicals around genitals
*Cold weather or anxiety

CLERKING DARK URINE

Differentials to think about:
-G6PD deficiency
-Glomerulonephritis
-Alkaptonuria
-Acute hepatitis
-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?
 MOSCO’S GUIDE

-Any fatigue?
-Any recent infection? Ask for fever, sores or pain?
-Is it exacerbated by physical stress?

* To rule out Alkaptonuria, ask these questions

-Does urine turn black on exposure to air? Has it been there since birth?
-Any joint pain in the spine, hips and knees? Does this pain restrict daily living and
ability to work?
-Any restriction of movement of the ribs such that breathing is difficult?
-Any hearing loss
-Any loin pain with pain during urination? (Kidney stones)

*To rule out Glomerulonephritis, ask these questions

-Any recent infection with fever, sore throat?
-Foaming urine due to proteinuria?
-Does patient have high blood pressure?
-Any allergic skin reactions (hepsis) or joint pain?
-Any difficulty breathing or haemoptysis etc (Good pasture syndrome) etc.

*To rule out Acute hepatitis, ask these questions

-Is the patient easily fatigued?
-Is stool pale?
-Are there flu-like symptoms:-fever or body aches, loss of appetite, headache, dry
cough, sore throat or running or stuffy nose?
-Is there yellowness of eyes and/or mucous membranes?
-Any right upper quadrant abdominal pain?
-Unexplained weight loss?
-Rule out hepatitis A by asking if patient had diarrhea, vomiting

-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.
 MOSCO’S GUIDE

- Occupation? Health care workers, Commercial see workers, Laboratory

workers, medical students, nurses etc.
- Ask for certain local practices that can predispose one to HBV
a. Tattooing/scarification/ ear-piercing
b. Condom use
c. Unbound wound and sores (in sports)
- Any hx of neonatal jaundice
- Any bleeding disorders?
- Any confusion, memory loss, somnolence, seizures,(hepatic encephalopathy)
- Any ascites? Bleeding from the oesophagus i.e haematemesis, bleeding from
anus.
- Any distended superficial abd veins?

*Myoglobinuria: Is the presence of muscle pigments (like myoglobulin) in

large quantities in the urine.
- Can be caused by severe crush injuries e.g due to Road traffic accident, or from
bite of certain species of sea-snakes (rhabdomyolysis).
- Can also be caused by infections like coxsackie virus, malaria, hepes virus,
influenza virus, HIV and salmonella.
- Drugs like: alcohol, sedative-hypnotics, cocaine, methadone, antilipemic drugs.
- Ask for any predisposing genetic disorders diagnosed previously.

CLERKING URINARY INCONTINENCE

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.

Differentials to think about;

1. Spinal cord disease

- Ask for any trauma to spinal cord
- Ask for metastasis to spine? Any swelling in any part of the body? Any bone
pain, anorexia, weight loss, weakness?
 MOSCO’S GUIDE

- Could commonly be a prostatic carcinoma in males; so ask for symptoms of

obstruction – hesitancy, poor stream, straining, terminal dribbling, feeling of
incomplete voiding.
ii. Damage to nerve controlling bladder from disease like DM (DM
neuropathy), Multiple sclerosis or Parkinson’s disease (age, resting tremors,
slow movement, shuffling gait, muscle rigidity etc).
iii. In women, it can be related to pregnancy, multiple childbirth [stress
incontinence which is easily triggered by laughing, coughing or strenuous
exercise (increase abdominal pressure)] and menopause as these events can
damage the muscles and nerves involved in urination. Can also be seen in
women who have vesico-vaginal fistula, pelvic organ prolapsed (bladder,
rectum or uterus shifts into vagina).
iv. Urinary tract infection: ask for fever, genital discharge, pain/discomfort
during urination etc, vaginal infection or irritation.
v. Do you have constipation? Ask about number of bowel movement a
week; if there is deviation from normal pattern?
- Is there difficulty passing stools?
- Are stools often lumping or hard?
- Do you have feeling of being blocked or of not having fully emptied your
bowels?
- Ask about excessive use of laxatives
- Ask about diet? Enough fruits and vegetables and high fibre diet.
- Ask about exercise.
vi. Disease such as arthritis may make it difficult to get to the bathroom in
time.

CLERKING OLIGURIA/ANURIA

It is the passage of less than 500ml of urine per day. Anuria is the complete
absence of urine flow.

Causes/Differentials to think about;

1. Physiological: in reduced intake of water.

2. Pathological:
i. Pre-renal: due to renal hypo perfusion
 MOSCO’S GUIDE

ii. Renal: Intrinsic renal disease

iii. Post-renal: obstruction (mechanical) at any level, from the collecting
system in the kidney to the urethra.
i. Pre- renal causes:
- Any hemorrhage? Bleeding disorders, Recent RTA, menorrhagia in women,
etc.
- Severe burns
- Any dehydration due to reduced water intake?
- Any sepsis from recent infection
- Drugs like ACE inhibitors and NSAIDs that reduce blood supply to kidney

ii. Renal causes.

a. To rule out Acute glomerulonephritis.

ii. Ask for any recent sore throat, fever

iii. Any foamy urine?
iv. Any high blood pressure
v. Any swelling in face, hands or feet etc.

b. Vasculitis (ask for history of haemorrhage)

c. Interstitial nephritis

d. Toxemia of pregnancy: Ask for high blood pressure, edema and foamy urine
in pregnant women at about the 20th week.

iii. Post-renal causes:

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
 MOSCO’S GUIDE

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

An example of clerking urinary tract symptoms

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.

PC: Urinary incontinence of 2 wks duration.

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
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.

He had hesitancy, poor stream, terminal dribbling and feeling of incomplete

voiding a month prior to development of incontinence. On account of these
symptoms he visited some peripheral hospitals for expert management.

Ddx: urinary incontinence secondary to CAP

 MOSCO’S GUIDE

ORTHOPAEDICS (MUSCULOSKELETAL SYMPTOMS)

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

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.
 MOSCO’S GUIDE

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.

Also, occupational history should be taken seriously in orthopedic history as some

occupations poses special treats on some certain joints while others put patients at
increased risk for trauma. e.g Typists and clerical staffs who constantly use the
fingers are at risk of arthritis of the metacarpophalangeal, distal and proximal
interphalangeal joints. Farming (Hip joint). Marathon runners (Ankle and tarsal
bone injuries).Also Golfer’s/Tennis elbow have strong occupational basis.
-A good occupational history will also form a basis for counseling the patients.

Sex: Some diseases are more common in certain sexes.

Example: Osteoarthritis is commoner in females with F:M ration of 3:1
Also remember to add the hand dominance while introducing the patient (right
handed male)
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.
 MOSCO’S GUIDE

c. History of presenting complaints: The 5cs

This carries the bulk of the marks; and most of the work should be done at this
point. At the end of the H.PC, our mind should be already tying up the pathological
process ongoing.
Complaint: You should discuss each of the presenting complaint thus:
Complaint Cause Course Complications Care
i. Cause – A common mistake commonly made by students at this point is
assuming trauma or something else they’ve been told by the patient
caused the problem. The effect is that they end up not exploring other
possible causes of the problem.
At this point, you should be seen to actively try to ask around other things that can
cause similar presentations at least, rule out 3 other possible causes by asking
questions that either implicate or completely excuse them.
E.g. A fracture is usually caused by very strong forces. However, patient may
present with a history of trauma (say not so heavy force on the limb) which can be
from many causes including multiple myeloma, you will miss out the diagnosis by
assuming that the trauma (blow) caused the fracture.
On the other hand, a simple question such as history of lower back pain or previous
bone pain will either suggest or completely excuse this pathology.
ii. Course  Here, you should talk about how the disease has progressed
over time from when patient first noticed it to the point of history taking.
Important things to look out for: signs of improvement, worsening, is it
always there, does it come and go? Etc
iii. Complications  How has this pathology affected the patient’s quality
of life? Talk about everything even the least of them.
Examples: Patient is not able to rise from the bed/sitting position because of the
pathology. Or patient couldn’t go to school/work because of this.
- 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
 MOSCO’S GUIDE

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

COMMON PC IN ORTHOPEDIC

a. Pain
Inability to use hands
b. Difficulty using limb
Inability to walk
c. stiffness of Joints
 MOSCO’S GUIDE

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

C. Quality
- Aching --- Chronic arthritis (like heaviness)
- Stabbing – Ruptured tendon
- Burning - Neuralgia
 MOSCO’S GUIDE

- 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

E. Relieving and aggravating factors

- Direct questions --- What makes you feel more pain? What do you do to
help with the pain?
- Indirect questions –What happens on joint movement, walking, standing,
assuming certain body postures and on exercise
- Related to any food intake: Example eating food high in purines will cause
more precipitations & worsen govt.
- Relieve with analgesics, fomentation or other means
Fomentation is the therapeutic application of water or moisture, basically to
relieve the pain and stiffness.
F. Site  Remember you must have said this while introducing your
presenting complaint.
Eg Pain in the lateral aspect of the thigh of 3/7 duration
For greater visual picture, go on to describe the site in relation to standard
anatomical landmarks.
G. Severity – Use the pain scale to generally get an idea of the pain
 Mild: Pain not so strong, easily ignored
 Moderate: Can’t be ignored, interferes while function and needs attention
from time to time.
 Severe: Present most times, demanding constant attention or treatment
 Excruciating: Totally incapacitating.
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
 MOSCO’S GUIDE

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?
- Constant or gradually increasing in size – Neoplastic process
- With associated remission/resolving –inflammatory
- Hardens in months – Myositis ossificans
4. Swellings following fractures could be due to the displacement of the bone’s
involved, and the associated inflammatory process.
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Also, it could be due to callus formation over time in a healing fracture.

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.
VACTERL = (Vertebral anomalies, anal atresia, cardiac malformations,
tracheoesophageal fistula, renal anomalies, Limb anomalies)
- Polydactyl (More than normal fingers and syndactyl (Webbing or fusion
of fingers may also be a presentation).
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- Kyphosis: This is an increased front to back curvature of the upper spine.

Can be congenital or caused by poor pore in childhood, such as slouching,
leaning back in chairs and carrying heavy school bags etc.
Make sure you ask around all these
- Lordosis: This is the curving inward of the lower back. It becomes a
deformity when it is excessive and at that point is also called swayback.
Can be inherited, or caused by conditions like arthritis, muscular dystrophy
and dwarfism. Ask around these two.
- Scoliosis: A sideways/lateral curvature of the spine. Usually occurs
following the growths spurt arising just before puberty.
1. Genu Varum (Bow or leg): abnormal outward curvature of legs at knee
2. Genu valgum (knock knee): Abnormal inward angling of the knee which touch
each other when the two legs are straightened out.
3. .Abnormal leg positioning
All the above can be congenital in origin or also acquired due to nutrient
deficiency in early childhood (Rickets) or even infections and trauma interfering
with normal bone growth and development.
While clerking a congenital abnormality, note that it could be a part of a syndrome.
So ask around other possible presentations for that syndrome.
- Ask about the mother’s antenatal history and folic acid/calcium intake
before and during pregnancy.
- Also ask about the child’s milestone history (if still very young)

Normal Development History for Children

Age (Months) Milestone
1–2 Holds up chin
6–8 sits alone
8 – 10 stands with support
10 – 12 Walks with support
14 Walks without support
24 Ascends stairs one foot at a time
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CLERKING JOINT STIFFNESS

This refers to the feeling that the motion of a joint is limited or difficult where the
feeling is not caused by weakness or reluctance to move the joint due to pain.
Some people with stiffness are capable of moving the joint through its full
range of motion, but this movement can require force.
Joint stiffness can present as:
- Early stages: Due to muscle spasms
- Late stages: Due to adhesions and fibrosis within/around joint
*Ankylosis is the pathological fusion of a joint (bones in a joint), causing
abnormal stiffening and immobility.
Possible causes of Joint stiffness
Intra – articular cause:
a. Arthritis: Rheumatoid arthritis vs Osteoarthritis
b. TB
c. Septic arthritis
d. Viral arthritis
- Present of past infection/sepsis can implicate septic arthritis. Further
investigations may be needed to distinguish the various forms.

Extra articular causes

- Myositis
- Arthrogryposis Multiplex congenita
- Burn contracture
- Scleroderma and other such diseases

CLERKING INABILITY TO USE THE LIMB

Commonly, the presentation to orthopedic clinic is due to inability to use the limb.
Patient present commonly with inability to walk or even use the upper limb as the
case may be.

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 LOW-BACK PAIN

Most commonly, mechanical issues and soft tissue injuries are the cause of low
back pain. The injuries can include damage to the intervertebral discs; compression
of nerve roots, and improper movement of the spinal joints.
Ask the patient about origin/Nature of pain
- Common cause is from muscle strain and ligament => usually happens
suddenly or can develop slowly over time from repetitive movements.
- Lifting of heavy objects or twisting the spine while lifting.
- Sudden movement that place too much stress on the low back such as a fall.
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- Trauma
- Poor posture/sitting over a long time.
- Sports injuries, especially in sports that involve twisting or large forces of
impact.
N/B: Sprain and strains typically don’t cause long-lasting pain, but the acute pain
can be quite severe.
Causes of chronic lower back pain ( 3months duration)
Chronic pain in the lower back most commonly implies a disc problem, a joint
problem and/or an irritated nerve root.
- Spinal stenosis: Causes pain through narrowing of the spinal canal where
the nerve roots are located.
- Degenerative disc disease: As people age over time, the disc loose
water/hydration and wear down. As a result, the disc loses its cushion effect
and can’t resist forces as well. Force are transferred to the disc wall that may
develop tears and cause pain or weakening that can lead to herniation
- The disc can also collapse and contribute to stenosis.
- Spondylolitesis: Occurs when a vertebra slips over the adjacent ones.
- Osteoarthritis: Result from wear and tear of the disc and facet joints. It
causes pain, inflammation, instability, and stenosis to a variable degree, and
can occur at a single level or multiple levels of the lower spine.
- Spinal osteoarthritis is associated with ageing and is slowly progressive.
(Spondylosis/Degenerative joint disease.)

- Deformity: Scoliosis/kyphosis can cause lower back pain if it leads to the

breakdown of the disc, facet joints, sacroiliac joints or stenosis.
- Compression fractures: A fracture that occurs in the cylindrical vertebrate
in which the bone especially caves in on itself, can cause sudden pain. This
presentation of osteoporosis is more common in older people.
Less common causes of low back pain
- Infection (Osteomyelitis): Spinal infection can be caused by surgical
procedures, injections, or spread through the blood stream. Compromised
immunity increases risk of developing spinal infection.
- Metastatic spine malignancy: Most Common CA spreading to spine
include: Breast, Prostate, Kidney, Thyroid or lung CA.
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*Ask about recent weight loss, drenching night sweats and maybe low grade
fever.
- Autoimmune disease may include ankylosing spondylitis, rheumatoid
arthritis, Lupus, crohn’s disease, fibromyalgia etc

CLERKING DISCHARGING SINUS

Sometimes, sites of discharging wounds and pain on the limbs can be an
orthopedic presentation (chronic wounds)
- Common causes of persisted discharging sinus:
1. Chronic Osteomyelitis: Most commonly implicated cause
2. Fungal infections
3. Foreign body presence
4. Epithelialization of sinus tract
5. Diabetes mellitus
6. Scar tissue around sinus
7. Malignant transformation
Carefully observe the discharging site: This can tell you about possible malignant,
scar tissues, foreign body presence or epithelialization of sinus tract.
- Ascertain patient’s diabetic status or ask about the features of diabetes to
rule out DM as a possible cause.
Ask about bone pain, low grade fever to rule out or implicate osteomyelitis.
Tying it up
The different presenting complaints discussed above occur in clusters to implicate
certain pathologies.
In two sections, we explore some of these clusters and associations

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.
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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.
6. Inability to use affected limb
7. Deformity: Shortening of limbs and abnormal positioning
8. If it is an open fracture, there may be obvious bleeding.
In most fractures, there’s the history of trauma (blunt force). Although some are
pathological – attempt to rule these out.
Also try to eliminate possible involvement of other parts.

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.

CLERKING RHEUMATOID ATHRITIS

Most common presentation is as polyarthritis of small joints of the hands viz:
- Proximal interphalangeal (PIP)
- Distal Interphalangeal (DIP)
- Wrist joint
- Metacarpophalangeal joints e.t.c
Other commonly affected joints include: Elbows, shoulders, hips, knees, ankles
and Metatarsophalangeal (MTP)
- Joint involvement occurs insidiously over period of months in most cases.
- Early morning stiffness is prolonged usually > 1 hour
- Rheumatoid nodules may be present in 20% of patients over the extensor
surfaces at elbows, heels and toes.
- Differential warmth in affected joint.
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Common deformities present:

1. Trigger finger--- Finger tenosynovitis
2. Boutonniere ---Flexion at PIP and extension at DIP
3. Swan Neck deformity ---Flexion at DIP and extension at PIP
4. Subluxation of MCP joints
5. Ulnar deviation of fingers
6. Carpel tunnel syndrome may also be present

- *You should actively try to establish presence or absence of these

presentations, including deformities as you work up to your provisional
diagnosis.

CLERKING OSTEOATHRITIS (DENEGERATIVE JOINT DISEASE)

- 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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--Other types of arthritis

a. Gouty Arthritis This is usually associated with severe, sudden onset
pain, joint redness and swelling and often involves the big toes.
- Monoarthritis
- Ask about high protein/Red meat intake and also high level of beer and
alcohol beverage intake
- Pay attention to weight too
- Some medications like ACE inhibitors, low – dose Aspirin, thiazide,
diabetics are also implicated.
- Family history of similar condition (Tend to be familiar)
- Age & Sex: Commoner in men and post-Menopausal female
- Recent trauma/surgery
b. Septic arthritisJoint inflammation following infections and deposition of
micro-organism to joint.
- Chills and fever
- fatigue and generalized weakness
- Severe pain in the affected joint, especially with movement
- Red and warm joint – because of increased blood flow
- Swelling (increased fluid within joint)
- Various micro organism can cause it
- Past prosthetic surgeries

CLERKING CHRONIC OSTEOMYELITIS

This is a severe, persistent and sometimes incapacitating infection of bone and
bone marrow
 An often recurring condition because of its difficulty to treat definitively
- May occur from poorly treated acute osteomyelitis
Staphylococcus aureus = most common bacterial cause
- Chronic conditions like DM increases risk – Ask about it.
Also ask about the following:
- Sickle cell disease
- HIV/AIDS
- Intravenous drug use
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- Alcoholism
- Long term steroid use
- Compromised blood supply
- Fever, irritability, fatigue commonly seen
- Tenderness, redness and warmth in area of the infection
- Swelling around the affected bone
- Lost range of motion
- Osteomyelitis in the vertebrae makes itself known through severe back pain
especially at night.

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 standardMetabolic/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.

List of provisional diagnosis in Orthopedic

1. Right femoral fracture
2. Colle’s fracture (RT)
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3. Segmented open fracture of left tibia

4. Mid shaft fracture of right ulnar & radius
5. Chronic osteomyelitis of the right femur
6. Osteoarthritis of the hip joint
7. Bilateral rheumatoid arthritis of the hands
8. Right knee osteoarthritis
9. Right tibia fracture 20 to multiple myeloma
10.Metastatic spine CA of the lumbar vertebrae. Etc
Note: These are just attempts to familiarize you with how your provisional
diagnosis should come.

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)
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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
- No neck pain----cervical spine intact
- No chest pain, Hemoptysis---thoracic cavity spared

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
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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)

ENDOCRINOLOGY
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.

Most times, a cluster of non-specific symptoms are suggestive of endocrine

disorders. Thus, it is important that we note that endocrine disorders do not fit
neatly into a system-based model.

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
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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

Common presenting complaints in Endocrinology

Some complaints are very common endocrine presentations while some others are
rarer and show a little more specific to pathologies.

The presenting complaints (PC) include

a. Thirst and polyuria
b. Weight gain or redistribution
c. Weight loss
d. Muscle weakness
e. Cold intolerance
f. Heat intolerance
g. Increased sweating
h. Tremor
i. Palpitations
j. Postural unsteadiness
k. Cramps and ‘Pins and needles’
l. Nausea
m. Fasting symptoms
n. Dysphagia
o. Impotence
p. Gynaecomastia
q. Galactarrhoea
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r. Amenorrhoea
s. Skin changes
t. Bowel disturbances
u. Excess hair growth

EXPLAINING COMMON SYMPTOMS IN ENDOCRINICOLOGY

A. Thirst and Polyuria

polydipsia ----Excessive thirst
polyuria -----Increased urine output. These are the most important
presentations in diabetes Mellitus
--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.

C. Weight gain or redistribution

Note: An increase in body weight is a predictable result of reduced body metabolic
rate. Generally, obesity is rarely a consequence of any specific endocrine
dysfunction (except being a rare phenomenon in leptin deficiency).
 MOSCO’S GUIDE

Most times, simple obesity is due to long-standing imbalance between energy

intake and expenditure, often beginning in childhood, and is usually familial.
---Primarily hypothyroidism presents also as weight gain
---Cushing’s syndrome (excess glucocorticoid) ---increase in body fats,
predominantly involving abdominal, omental and interscapular fat (truncal
obesity) with a rather paradoxical thinning of the limbs due to muscle atrophy.

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.
- In the elderly, hyperthyroidism may be occult or may simulate the gradual
weight loss of malignant disease.
- Anorexia nervosa is a psychogenic disorder characterized by long history of
low body weight in the absence of other features of ill health.
*it is commonly implicated in young women.
Amenorrhea may be associated with weight loss in women.

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.
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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.

Rem. Increased sweating should be distinguished from flushing that occurs

physiologically at the time of the natural menopause.
Flushing however, may be a PC in serotonin-secreting carcinoid tumours of the gut
and usually indicates extensive disease with hepatic metastasis.

H. Palpitations: Heightened, unpleasant awareness of the heartbeat.

Feature of thyrotoxicosis, but are more likely due to anxiety.
Other causes of rapid heart rate = paroxysmal tachyarrthymia.

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).

Essential tremor is not as rapid as thyrotoxic tremor. It is variable and worse in

certain postures, and usually involves head and neck.

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.
 MOSCO’S GUIDE

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.
- Double vision (Diplopia) on lateral or upward gaze often results from
medial or lateral rectus muscle tethering in dysthyroid eye disease.
- Apparent Magnification of vision (Macropsia) can occur in hypoglycaemia.

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.

M. Cramps and ‘Pins and needles’ (Paresthesia)

Paresthesia/intermittent cramps and ‘pins and needle’, especially if bilateral, can be
due to decreased level of circulating ionized calcium. This may be due to
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hypoparathyrodism or associated with a fall in the ionized component of serum

calcium because of an increased extracellular PH (alkalosis). This is more common
in hyper-ventilatory states (respiratory alkalosis) and hypokalaemia (metabolic
alkalosis).
- Can also due to complications of DM (Peripheral Neuropathy) median nerve
nerve compression at the wrist (carpal tunnel syndrome) can also cause
similar presentation in the hands.

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.
Occasionally, thrytoxicosis may present with nausea and vomiting, although
looseness of stools is the more common GIT manifestation.

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.

P. Neck Pain and Swelling (Goitre)

Superficial discomfort in the neck may lead to incidental findings of thyroid
enlargement. Modest degrees of thyroid enlargement are very common, whereas
pain from the thyroid is comparatively unusual.
- Most common cause of local discomfort and tenderness in the neck is
inflammatory lymphadenopathy.
Severe thyroid tenderness, usually accompanied by fever and signs of
thyrotoxicosis, suggests a diagnosis of viral subacutethyroiditis (de
Quervian’s thyroiditis)
- Occasionally autoimmune thyroiditis may give rise to pain and tenderness,
which mimics a viral thyroiditis but is less severe.
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- Sudden onset of localized pain and swelling on the thyroid indicates

bleeding into a pre-existing thyroid nodule, and is a recognized complication
of multinodular goitre (self-limiting symptom too).
- Painless enlargement of the thyroid gland, (goitre) presents with either
pressure effects (resulting in dysphagia progressing to tracheal compression
and stridor, or cosmetic disturbance.
Underlying cause of thyroid enlargement is often difficult to establish, family
history and investigation may point to autoimmune thyroiditis or
dyshormonogenesis.
- Rapid enlargement of gland (especially in the elderly) – Anaplastic thyroid
- Coexisting severe diarrhea – Medullary CA of thyroid
- Consider goitrogenic drugs e.g. Lithium
- Consider residence in iodine deficient areas.
- Previous exposure to neck irradiation or radioactive iodine
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
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S. Amenorrhoea:
Absence of menstrual periods (menses).Most common cause of primary
amenorrhea  Physiological delay of puberty.

Important pathological causes:

- Defects in lower genital tract development
- Hypothalamic – Pituitary dysfunction (e.g due to tumours)
- Thyroid dysfunction
- Ovarian failure (eg failure of normal ovarian development or cytotoxic
chemotherapy).
Diagnostic pointers in history taking
1. Symptoms suggestive of thyroid disease
2. Visual disability that might indicate compression of the optic chiasma by a
hypothalamic/pituitary tumour.
Secondary Amenorrhea (Cessation of previously established menses) has similar
causes. Marked weight loss as in inflammatory Bowel disease and anorexia
nervosa can also cause 20 Amenorrhoea.
Rigorous physical training can cause amenorrhoea/oligomenorrhoea
Most common cause of 20 amenorrhoea = Normal pregnancy

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.
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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
Actively try to establish presence/absence of these features, as they will serve as
significant positive supporting your provisional diagnosis.

Addison’s disease: Reduced production of cortisol and aldosterone due to adrenal

gland damage.
- Depression
- Diarrhea
- Fatigue
- Hypoglycemia
- Missed menstrual periods
- Nausea, with or without vomiting
- Unexplained weight loss
- Weakness
- Low BP (Hypertension)
- Salt cravings

Cushing: Excess cortisol produced by the adrenal glands

- Buffalo lump (fat between the shoulder blades)
- Skin discolouration such as bruising
- Thinning and weakening of bones (osteoporosis)
- Frequent urination
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- High BP
- Obesity of the upper body
- Weakness (los of strength)
- High blood sugar
- Irritability and mood changes
Graves: A type of autoimmune hyperthyroidism resulting in excessive thyroid
hormone production.

Common symptoms of Graves’ disease

- Bulging eyes (Graves ophthalmopathy)
- Diarrhea
- Difficulty sleeping
- Fatigue and Weakness
- Goitre (enlargement of thyroid)
- Heat intolerance
- Irregular heart rate
- Irritability and mood changes
- Rapid heart rate(Tachycardia)
- Thick or red skin on the skins
- Tremors
- Unexplained weight loss

Hashimoto’s thyroiditis (Hypothyroidism)

Often times asymptomatic, but symptoms include:
- Cold intolerance
-Constipation
-Dry hair and loss of hair
-Fatigue
-Goitre Neck joint & Muscle pain
-Missed Menstrual periods
-Slowed heart rate
-Weight gain

Prolactinoma (Hyperprolactinemia)
-Erectile dysfunction
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-Infertility
-Loss of libido
-Missed menstrual periods
-Unexplained milk production (Common in females)

Risk factors of Endocrine diseases

1. Elevated history of endocrine disorder
2. Elevated cholesterol levels
3. Inactivity
4. Personal history of autoimmune disorders Include these risks factors
Eg. DM, Pernicious anaemia when stating significant
5. Poor diet positives
6. Pregnancy (As in hyperthyroidism)
7. Recent surgery, trauma, infections or serious injury

Complications of endocrine disease

- Anxiety or insomnia (in many thyroid conditions)
- Coma (in hypothyroidism)
- Depression (in hypothyroidism)
- Nerve damages
- Poor quality of lite
- Heart disease
- Organ failure
- Loss of vision
- stroke

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 )
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Obesity is BMI greater than or equal 30kg/m2

Classification based on BMI

Underweight 18.5 (Kg/m2)
Normal weight 18.5 – 24.9
Overweight 25 – 29.9
Obesity class 1 30 – 34.9
Obesity class 2 35 – 39.9
Extreme obesity class 3 >40

Example 1
PC
Blurring of vision - 6/12
HPC
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.

Past medical (surgical history)

Have had caesarian section about 2 years ago with associated severe waist pain
which subsidized after taking some medication
- No history of blood transfusion
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- Nil HTN, Epilepsy, Asthma and SCD

Drug & Allergy
No significant drug and Allergy history
Gynaecology
Gave birth to 7 children (1 died) – 3 boys and 3 girls
- Gave birth to the last via CS
Family History
4thChild in a family of 6 children.
No significant history of similar illness in 1st degree relatives.
Social history
Doesn’t drink alcohol or smoke/take tobacco in any form.

- No orthopnea, No palpitation -No PND, - No dizziness, No loss of

consciousness.

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.
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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.
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.

Drug & Allergy Hx

Patient is currently on metformin.
No significant food/drug allergies.

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
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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.

Diabetic foot ulcer with amputated toes.

? Peripheral artery disease 20 to atherosclerosis
Important positives
1. Known diabetic on medication
2. The history of paresthesia
3. Blurring of vision
Take note how attempt was made to establish or rule out all the other
complications of DM (Nephropathy, CVA and coronary artery disease, Peripheral
vascular disease causing claudication).
Attempts were made to rule out other causes of ulcers viz:
- Not trauma -Not chronic or contact with chronic cough
- No claudication (peripheral vascular disease)