Difference between revisions of "Clinical history"

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Here is a page about clinical history stuffs. When I was there... I wished there was a page with mnemonics to work from.

A number of 'em aren't politically correct... but I don't see that a reason to banish 'em.

Basic approach

A basic approach to (almost) every situation is:

  1. Establish identity, occupation, living situation (alone vs. with someone).
  2. Chief complaint (CC).
  3. L-OPQRST.
  4. Functional inquiry of system related to CC.
  5. Targeted questions.
  6. SAMPLE (Sins, Allergies, Meds, PMHx, Last meal, Events).
  7. Risk factors.
  8. Constitutional Sx.

General inquiry

Defining a symptom

Mnemonic L-OPQRST:

  • Location.
  • Onset.
  • Provoking/palliating.
  • Quality.
  • Radiation.
  • Severity.
  • Temporal course.

Basics

Mnemonic SAMPLE:

  • Sins - alcohol use, smoking, illicit drug use.
  • Allergies.
  • Medications.
  • PMHx.
  • Last meal.
  • Events leading up to presentation.

For adults:

  • B - Blood pressure.
  • C - Cancer Hx.
  • D - Diabetes.

For adolescents: Mnemonic HEADSS:

  • Home.
  • Education.
  • Activities.
  • Drugs.
  • Sex.
  • Suicide.

For children/Infants:

  • Milestones (see below).
  • Immunizations (see below).

For infants:

  • Pregnancy complications.
  • GA.
  • APGARs.
  • Birth weight.
  • d/c (from hospital) weight.
  • Breast feed?
  • Activities:
    • Pee.
    • Poo.
    • Eat.
    • Sleep.

Milestones

Speech

  • 6 mo. - makes eye contact, initiates sounds.
  • 12 mo. - two words + dadda & momma.

Social

  • 6 mo. - separation anxiety.
  • 9 mo. - stranger anxiety.
  • 2 years - says "no".

Gross motor

  • 6 mo. - flip over.
  • 9 mo. - pull to stand.
  • 12 mo. - cruise.
  • 15 mo. - walk.

Fine motor

  • 12 mo. - pincer grasp.
  • 24 mo. - turn pages in a book.

Ontario immunizations

  • Pentacel - 2, 4, 6, 18 mo.
    • TDaP-IPV (tetanus, diphtheria, acellular pertussis, inactivated polio virus).
    • HiB (Hemophilus influenzae type B).
  • Pneumococcus - 2, 4, 6, 15 mo.
  • MMR (measles, mumps, rubella) - 12, 18 mo.
  • Varicella - 15 mo.
  • Hepatitis B - in grade 8, 3 dose (0 mo., 1 mo., 6 mo.).
  • Flu vaccine -qyear.

Breaking bad news

Mnemonic SPIKES:

  • Setting.
  • Perception of patient.
  • Invitation to break news.
  • Knowledge - tell 'em in simple terms straight-up.
  • Empathy.
  • Strategy - plan follow-up.

Functional inquiry

Cardiac functional inquiry

Mnemonic Bad murmurs cause syncope DOPE:

  • Blood pressure problems.
  • Murmurs.
  • Claudication, chest pain.
  • Syncope.
  • Dyspnea.
  • Orthopnea and paroxysmal noctural dyspnea.
  • Palpitations.
  • Edema (legs).

Respiratory functional inquiry

Think about what happens when people smoke:

  • Smoking.
  • Cough.
    • Sputum.
  • Hemopytsis.
  • Dyspnea (develop emphysema).
  • Wheeze.
  • Hoarseness (cancer).

Longer version:

  • Chest pain, calf pain (DVT).
  • Cough, sputum - blood, colour.
  • Fever, chills, rigors.
  • SOB, SOBOE.
  • Wheeze.
  • Smoking.
  • Exposure - work, hobbies, tuberculosis.
  • Travel.

GI functional inquiry

Mnemonic HAND JOB:

  • Hematochezia.
  • Appetite.
  • Nausea & vomiting.
  • Dysphagia, dyspepsia.
  • Jaundice.
  • Obstipation/constipation.
  • Bowel habit changes.

GU functional inquiry

Mnemonic SHIT FUND:

  • Suprapubic pain.
  • Hematuria, urine colour, urine smell.
  • Incontinence.
  • Testicular pain/flank pain.
  • Frequency (of urination).
  • Urgency.
  • Nocturia.
  • Dysuria.

Neuro functional inquiry

Mnemonic Drunk HIPPE:

  • Disturbance of balance.
  • Headache.
  • Incontinence.
  • Paresthesia.
  • Paralysis.
  • Epilepsy (seizures).

Stroke/TIA

Difficulty:

  • Seeing.
  • Swallowing.
  • Speaking.
  • Standing.

Note:

  • Should to cardiac functional inquiry... or at least ask about palpitations.

Sexual history inquiry

Mnemonic 5 Ps:

  • Practises (oral, anal, vaginal).
  • Partners (same sex, opposite sex, number).
  • Protection (use of condoms).
  • Previous STDs.
  • Pregnancy protection.

Gynecology functional inquiry

  • 5 Ps of sexual history.
  • Practices -- Condom use? Contraception?
  • Periods.
  • Pregnancies (GPTAL = gravida, para, term, abortions, living).
  • Procedures.
  • Pap test, last.

Also ...

  • Pee - should screen GU system.
  • Poo - should screen GI system.

Breast health inquiry

  • Pain.
  • Discharge.
  • Lumps/mass.

Breast cancer risk factors

Mnemonic Hx ALONE:[1]

  • History (personal, family).
  • Age.
  • Late menopause.
  • Obese.
  • Nulliparity.
  • Early menarche.

Headache causes that need to be ruled-out

  • Meningitis.
  • Trauma/haemorrhage.
  • Tumour.
  • TIA/stroke.
  • Temporal arteritis (can cause blindness).

Psychiatry

Fatigue

A high yield question for sorting out organic vs. psychiatric:

Do you feel refreshed after a night of sleep when you wake-up?

  • Organic disease: typically yes, psychiatric disease often no.

General screen - everything

Mnemonic MAADPPPPs+OCD or SO MAAD PPPP:

  • Mania.
  • Abuse (verbal, physical, sexual).
  • Anxiety (GAD).
  • Depression.
  • Psychosis.
  • PTSD.
  • Phobia.
  • Panic attacks.
  • Substance use.
  • OCD.

Panic disorder

Mnemonic STUDENTS fear the 3 Cs:[2]

  • Sweating.
  • Trembling.
  • Unsteadiness.
  • Derealization, depersonalization, dizziness.
  • Elevated heart rate.
  • Nausea.
  • Tingling.
  • Shortness of breath.
  • FEAR of:
    • Losing control.
    • Going crazy.
    • Dying.
  • 3 Cs
    • Chest pain.
    • Choking.
    • Chills.

Other qualifiers:

  • Sx not explained by GMC or other mental disorder;
  • 1 month+ of worrying about more attacks,
  • thinking about the 3Cs, signif. change in behaviour.

Generalized anxiety disorder

Anxious person think... GAD.

Mnemonic BE SKIM:[3]

  • Blank mind.
  • Easily fatigued.
  • Sleep disturbance.
  • Keyed-up.
  • Irritability.
  • Muscle tension.

Other qualifiers:

  • Need 3/6 for most days for 6 months.
  • Cannot be due to other cause (GMC, other Axis I disorder).

Mania

Mnemonic DIG FAST:[4]

  • Distractibility.
  • Indiscretion - 3 Ss: sex, shopping, substance use.
  • Grandiosity.
  • Flight of ideas.
  • Activity increase.
  • Sleep deficit.
  • Talkative.

Other qualifiers:

  • 1 week duration (or 4 days for hypomania).
  • three of the above seven (in DIG FAST).

Notes:

  • If there are delusions/hallucinations for two (or more) weeks when mood Sx are absent it's schizoaffective disorder.

Schizophrenia

Positive symptoms (2 of the following for 1 month):[5]

  • Disordered speech.
  • Disordered behaviour.
  • Hallucination (usually auditory).
  • Delusions.
  • Negative symptoms (4 As):
    • Alogia.
    • Avolition.
    • Alone - autistic (social withdrawal).
    • Affective flatting.

Depression

Mnemonic DEAD SWAMP:

  • Depressed mood.
  • Energy decreased.
  • Anhedonia.
  • Death, thoughts of.
  • Sleep problems.
  • Worthlessness or guilt.
  • Appetite changes.
  • Mentation changes.
  • Psychomotor slowing.

Notes:

  • Need 4/9 criteria.
  • Duration for two weeks.

Risk factors for suicide

Mnemonic SAD PERSONS:[6]

  • Sex (male).
  • Age (young <19 or old >60).
  • Depression.
  • Previous attempt.
  • EtOH use/abuse.
  • Rational thinking loss (psychosis).
  • Suicide in the family.
  • Organized plan.
  • No supports, no spouse.
  • Serious sickness (chronic illness).

Suicide assessment

  • Attempt details.
    • What? How much? When? - Ask for empty bottles.
    • Circumstances that brough 'em to ER - found accidentally? - patient came on their own?
  • Passive ideation.
  • Active ideation.
  • Plan.
  • Access to elements needed for plan.
  • Suicide note written.
  • Prized possessions given away.

Screen for...

  • Homicidal ideation.
  • All the psych things.

Mental status exam

Mnemonic ASEPTIC:

  • Appearance & behaviour.
  • Speech (fast, slow...).
  • Emotion (mood, affect).
  • Perception (hallucination, illusions).
  • Thought content & process (delusions, though insertion/withdrawal/broadcasting, suicidal ideation, homicidal ideation, paranoia).
  • Insight & judgment.
  • Cognition, cooperative?

Notes:

  • Cognition - do Mini-mental status exam.

Gynecology

Ovarian cancer risks

Mnemonic NO CHILD:[7]

  • Nulliparity.
  • OCP, breast feeding, tubal ligation, hysterectomy -- all protective.
  • Caucasian.
  • History in the family.
  • Increasing age (>40).
  • Late menopause.
  • Delayed child-bearing.

Endometrial cancer risks

Mnemonic COLD NUT:[8]

  • Cancer Hx (ovarian, breast, colon).
  • Obesity.
  • Late menopause.
  • Diabetes.
  • Nulliparity.
  • Unopposed estrogen (PCOS, anovulation, HRT).
  • Tamoxifen use.

First trimester bleeding

Mnemonic AGE IS Low:[9]

  • Abortion.
  • Gestational trophoblastic neoplasia.
  • Ectopic pregnancy.
  • Implantation bleed.
  • Spotting.
  • Lower GU tract causes.
    • Vaginal bleeding.
    • Cervical bleeding.

Notes:

  • Common -- seen in approx. 25% of all clinically recognized pregnancies.[10]

Vaginal bleeding

Mnemonic VAGINA BLEEDS:

  • Vaginal trauma.
  • Abortion, adenomyosis.
  • Genital cancer (e.g. cervix, endometrium).
  • Infection (PID).
  • Neoplasm.
  • Abruptio placentae (placental abruption).
  • Bleeding disorder or drugs (e.g. warfarin).
  • Leiomyomata.
  • Ectopic pregnancy.
  • Endometriosis, Endocrinopathy.
  • DUB (Dx of exclusion).
  • Sores + trauma.

Cervical cancer risks

Mnemonic HPV + 6 Ss:[11]

  • HPV.
  • Smoking.
  • SES (socioeconomic status), low.
  • STIs (other than HPV).
  • Stud magnet - high risk partners.
  • Slutty - many sexual partners.
  • Started early, early first intercourse.

OCP use

Contraindications

Mnemonic ABBCCCD:[12]

  • Acute or chronic liver disease (e.g. Wilson's disease).
  • Bad migraines (with focal neurological signs).
  • Bleed per vagina - undiagnosed.
  • Cancer (endometrial, breast).
  • Cardiovascular disease.
  • Cardiovascular disease risk factors.
    • Smoking >35 years.
    • Uncontrolled BP.
  • DVT.
  • Suspected pregnancy.

Advantages

Mnemonic AABCDE:[13]

  • Acne reduced, Anemia reduced.
  • Benign breast disease reduced.
  • Cancer reduced (ovary, endometrium).
  • Dysmenorrhea Sx better.
  • Endometriosis Sx better.
  • Pregnancy prevention.

Urology

Obstructive LUTS

Mnemonic I WISH 2p:[14]

  • Intermittency.
  • Weak stream.
  • Incomplete emptying.
  • Straining.
  • Hesitancy.
  • Post-void dribbling.
  • Prolonged voiding.

Paediatrics

Colic

Irritable & crying.

Memory device rule of 3s:

  • >3 hours/day.
  • >3 days/week.
  • >3 weeks.

Tx of colic

  • Check diaper.
  • Distract:
    • Car ride.
    • Music.
    • Vacuum.
  • Cuddle:
    • Hold.
    • Soother.
  • Change feeding.
    • Change formula to casein hydrosylates.
    • Stop giving cow's milk formula.

DDx

  • Abuse.
  • Allergy.

Abuse risk factors

Family related

  • Domestic violence.
  • Poverty.

Child related

  • Temperament.
  • Disability.

Caregiver related

  • Hx of abuse (as child).
  • Psych illness.
  • Substance use.
  • Single.
  • Social skills & vocational skill suck.
  • Stupid (low scholastic achievement).

Internal medicine

Myocardial infarction treatment

Mnemonic BE NORMAL:[15]

  • Beta-blocker - metoprolol 5 mg IV q5-10 min (if sBP>95, HR>50, no CHF).
  • Enoxaparin - heparin 60 U/kg IV (loading) then 12 U/kg/hr.
  • Nitrates - nitrospray 0.3 mg SL q5 (x3 max), NO PDE inhibitors (sildenafil, tadalafil) within 48 hr.
  • Oxygen - 2-4 L/min.
  • Repeat (EKG, markers).
  • Morphine - 2-4 mg IV q5 'til OD Sx.
  • ASA - 325 mg PO - SHOULD BE CHEWED.
  • Lipitor, lysis.

Clot lysis contraindications

Mnemonic A Big TV HIT:[16]

  • Aortic dissection suspected.
  • Bleeding, active.
  • Trauma to head (recent).
  • Vascular malformation (of brain).
  • Hemorrhage, intracranial (any time in past).
  • Ischemic stroke (recent).
  • Tumour, brain.

Congestive heart failure

Mnemonic LMNOP:

  • Lasix.
  • Morphine.
  • Nitrates.
  • Oxygen.
  • Position (elevate head).

Diabetes complications

Mnemonic HELP:

  • H - HbA1c, HTn.
  • E - eye.
  • L - lipids.
  • P - podiatry, proteinuria, Pneumococcus vaccine.

DDx of dementia

Mnemonic VITAMIN D VEST:[17]

  • Vitamin deficiency (B12, folate, thiamine).
  • Infection (HIV).
  • Trauma.
  • Anoxia.
  • Metabolic (Diabetes).
  • Intracranial tumour.
  • Normal pressure hydrocephalus.
  • Degenerative (Alzheimer's, Huntington's, CJD).
  • Vascular.
  • Endocrine.
  • Space occupying lesion (chronic subdural hematoma).
  • Toxins (alcohol).

DDx of delirium

Mnemonic I WATCH DEATH:[18]

  • Infections (meningitis).
  • Withdrawal (from drugs).
  • Acute metabolic (lytes, renal, hepatic).
  • Trauma (CNS, post-op).
  • CNS pathology (stroke, hemorrhage).
  • Hypoxia (PE, CHF, anemia).
  • Deficiency of vitamins (B12, folate, thiamine).
  • Endocrinopathy (Cushing's, Addison's, Thyroid, Parathyroid, Diabetes).
  • Acute vascular (vasculitis, TIA, stroke).
  • Toxins (morphine).
  • Heavy metals (arsenic, lead, mercury).

Seizure - triggers

Mnemonic stress:

  • Stress.
  • TV.
  • Rx and street drugs.
  • EtOH.
  • Strobe lights.
  • Sleep deficit.

Hyperthyroidism

Mnemonic hyperTHYROIDISM:[19]

  • Tremor.
  • HR elevated, palpitations.
  • Yawn (fatigue).
  • Restlessness.
  • Oligomenorrhea, amenorrhea.
  • Diarrhea.
  • Irritable.
  • Sweating.
  • Muscle wasting/weight loss.

Surgery

Small bowel obstruction DDx

  • Strictures (think IBD).
  • Hernia.
  • Adhesions.
  • Volvulus.
  • Intussusception.
  • Neoplasm.
  • Gallstone ileus (rare).

Large bowel obstruction DDx

  • Neoplasm.
  • Diverticular disease.
  • Volvulus.
  • Strictures.

Post-op complications (fever)

  • Wind - atelectasis (POD 1-2), pneumonia (POD 3+).
  • Wound - wound infection duh!
  • Water - UTI.
  • Walk - pulmonary embolism.
  • Womb (for obstetrics/gyne).
  • Wonder drugs.[20]

Note:

  • POD = post-op day.

Lower GI bleed

Mnemonic CHAND:

  • Colitis (infection, ischemic, IBD, radiation).
  • Haemorrhoids.
  • Angiodysplasia (usually older).
  • Neoplasm.
  • Diverticular disease.

Hemorrhagic diarrhea

Mnemonic ESC:

  • Enterohaemorrhagic Escherichia coli (EHEC)
  • Shigella.
  • Clostridium difficle.
  • Campylobacter jejuni.

Diarrhea

Mnemonic THOSE FADS WILT:[21]

  • Travel Hx.
  • Homosexual behaviour.
  • Outbreaks.
  • Seafood.
  • Extra-intestinal manifestations of IBD.
  • FHx - IBD, IBS.
  • Abx use, recent.
  • Diet.
  • Steatorrhea.
  • Weight loss.
  • Immune incompetent.
  • Laxatives, abuse.
  • Tumour history.

Upper GI bleed

  • Peptic ulcer disease (PUD).
  • Gastritis (EtOH, NSAID, stress, idiopathic).
  • Mallory-Weiss tear (excessive vomiting).
  • Varices.
  • Erosive esophagitis.
  • Vascular malformation.
  • Neoplasm.
  • Oropharyngeal bleed (epistaxis).

See also

References

  1. ↑ http://www.medicalmnemonics.com/cgi-bin/detailsrate.cfm?mnemonic_id=924
  2. ↑ TN 2005 PS13
  3. ↑ TN 2006 PS14
  4. ↑ TN 2006 PS7
  5. ↑ TN 2006 PS5
  6. ↑ TN 2006 PS25
  7. ↑ TN07 GY43
  8. ↑ TN07 GY40
  9. ↑ First trimester bleeding. WP. URL: http://en.wikipedia.org/wiki/First_trimester_bleeding.
  10. ↑ http://emedicine.medscape.com/article/266110-overview
  11. ↑ TN06 GY45
  12. ↑ TN05 FM44; TN06 GY20
  13. ↑ TN05 FM44; TN06 GY20
  14. ↑ TN06 U5
  15. ↑ STEMI. Harrison's 16th Ed.
  16. ↑ TN06 C25
  17. ↑ TN06 PS19
  18. ↑ TN06 PS18
  19. ↑ TN06 E24
  20. ↑ PMID 1745617
  21. ↑ TN06 G13

External links

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