CLINICAL SKILLS CHEATSHEET- Taking Histories

Introduction
- Greeting, exchange names
- Explain what you are doing, obtain consent, and let patient know they can
stop at any time

Presenting complaint (ask with open questions)
- History of complaint (sequence of events)
- SOCRATES
- Confirm key problems and screen from associated symptoms
- What have you tried so far? What makes it better or worse
- SUMMARISE

Patient beliefs
- What do you think this is?
- Beliefs, concerns, expectations, effect of life, feelings, motivation for
lifestyle modification, self management strategies
- SUMMARISE

History
- Medical history
o Medical conditions- including mental, ongoing treatment and self-
management
o Past surgeries and hospitalisations, inc obstetrics
o Medications- dose, frequency, OTC/herbal
o Adherence to medications (hows it working/side effects)-
patients thoughts on medications
o Allergies/adverse effects
o SUMMARISE

- Family History
- Personal, occupational and social history
o Smoking/alcohol
o Drug use, history
o Sexual history
o Lifestyle
o SUMMARISE

Review of symptoms
- EXPLAIN WHY (check if we missed)- head to toe, be careful of what
patient has already said, ~10 things (specific to gender)


CONCLUSION
- Summarise key points for patient
- Check any other issues and concerns
- Tell them what the plan is after interview, leave in courteous manner


Take note of:
- What is going on
- What subsequent examination to do (or order tests)
- Management issues
- Any social or cultural issues



PHYSICAL EXAMINATION CHEATSHEET

Make sure to tell patient what youre doing for each step
Wash hands!

- start off with hand examination, go to vital signs (pulse, respiratory rate, blood
pressure and ear temperature)
Vital signs
- Make sure to elevate arm to heart heart

Hand Exam
- Look, feel, move
- Get patient to shake/move, check tremors
- Skin (scars, dry)
- Nails (clubbing, whiteness- liver)
- Circulation- color, temperature, pulses, capillary return
- Assess carpal, metocarpals, interphalangeal joints, MCPJs, CMCJs bones-
pain
- Motor function-
o Radial- extend wrist
o Medial- abduct pollis brevis (thumb)
o Ulna- abduct little finger
- Sensory function
o Radial- thumb
o Medial- middle palm
o Ulnar- little finger
- Specific things to check for

ENT exam
- Gross examination of paranasal sinuses, nose, throat, glands, mouth, neck
and ears (back)
- Oral cavity with spatula and torch (teeth, lips, tongue back, gingival
recesses, buccal mucosa, hard and soft palate, throat, pharynx)
- Nose and nasal passages with torch/spatula (check chonchae, swelling)
- Examaine paranasal sinuses
- Examine and palpate salivary glands (parotid, sublingual, submandibular,
mental)
- Palpate lymph nodes (submental, submandiubular, tonsillar,
preauricular) and check tonsils
- Ear exam