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Clinical history (view source)

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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.
This page deals with the '''clinical history''', also known as '''history'''.  It usually refers to both the ''past medical history'' (PMHx) and ''history of present illness'' (HPI).
 
A number of 'em aren't politically correct... but I don't see that a reason to banish 'em.


==Basic approach==
==Basic approach==
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===Basics===
===Basics===
Mnemonic ''SAMPLE'':
Mnemonic ''SAMPLE'':
*Sins - [[alcohol]] use, [[smoking]][, illicit drug use.
*Sins - [[alcohol]] use, [[smoking]], illicit drug use.
*Allergies.
*Allergies.
*Medications.
*Medications.
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For adults:
For adults:
*B - Blood pressure.
*B - [[hypertension|Blood pressure]].
*C - [[Cancer]] Hx.
*C - [[Cancer]] Hx.
*D - [[Diabetes]].
*D - [[Diabetes mellitus|Diabetes]].


For adolescents:
For adolescents:
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*24 mo. - turn pages in a book.
*24 mo. - turn pages in a book.


====Ontario immunizations====
====Immunizations====
*Pentacel - 2, 4, 6, 18 mo.
=====Ontario=====
As per 2011 schedule:<ref>URL: [http://www.health.gov.on.ca/en/public/programs/immunization/docs/schedule.pdf http://www.health.gov.on.ca/en/public/programs/immunization/docs/schedule.pdf. Accessed on: 26 July 2015.</ref>
*Pentacel - 2, 4, 6, 18 months old.
**TDaP-IPV (tetanus, diphtheria, acellular pertussis, inactivated polio virus).
**TDaP-IPV (tetanus, diphtheria, acellular pertussis, inactivated polio virus).
**HiB (Hemophilus influenzae type B).
**HiB (Hemophilus influenzae type B).
*Pneumococcus - 2, 4, 6, 15 mo.
*TDaP-IPV - 4-6 years old.
*MMR (measles, mumps, rubella) - 12, 18 mo.
*Pneumococcus - 2, 4, 12 months old.
*Varicella - 15 mo.
*Rot-1 (rotavirus) - 2, 4 months old.
*Hepatitis B - in grade 8, 3 dose (0 mo., 1 mo., 6 mo.).
*Men-C-C - 12 months old.
*MMR ([[measles]], mumps, rubella) - 12 months old.
*Varicella - 15 months old.
*MMRV - 4-6 years old.
*Men-C-ACYW (meningococcal conjugate) - grade 7.
*[[Hepatitis B]] - in grade 8, 2 doses 4-6 months apart.
*[[HPV]]-4 - grade 8 (females only), 3 doses at 0, 2 and 6 months.
*Tdap - age 14-16 years and then q10 years.
*Flu vaccine -qyear.
*Flu vaccine -qyear.


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*Claudication, chest pain.
*Claudication, chest pain.
*Syncope.
*Syncope.
*Dyspnea.
*[[Dyspnea]].
*Orthopnea and paroxysmal noctural dyspnea.
*Orthopnea and paroxysmal noctural dyspnea.
*Palpitations.
*Palpitations.
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**Sputum.
**Sputum.
*Hemopytsis.
*Hemopytsis.
*Dyspnea (develop emphysema).
*[[Dyspnea]] (develop emphysema).
*Wheeze.
*Wheeze.
*Hoarseness (cancer).
*Hoarseness (cancer).
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*Cough, sputum - blood, colour.
*Cough, sputum - blood, colour.
*Fever, chills, rigors.
*Fever, chills, rigors.
*SOB, SOBOE.
*[[SOB]], SOBOE.
*Wheeze.
*Wheeze.
*Smoking.
*Smoking.
*Exposure - work, hobbies, tuberculosis.
*Exposure - work, hobbies, [[tuberculosis]].
*Travel.
*Travel.


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Also ...
Also ...
*Pee - should screen GU system.
*Pee - should screen GU system.
*Poo - should screen GI system.
*[[Poo]] - should screen GI system.


===Breast health inquiry===
===Breast health inquiry===
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*Age.
*Age.
*Late menopause.
*Late menopause.
*Obese.
*[[Obese]].
*Nulliparity.
*Nulliparity.
*Early menarche.
*Early menarche.
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===Panic disorder===
===Panic disorder===
Mnemonic ''STUDENTS fear the 3 Cs'':<ref>TN 2005 PS13</ref>
Mnemonic ''STUDENTS fear the 3 Cs'':<ref>{{Ref TN2005|PS13}}</ref>
*Sweating.
*Sweating.
*Trembling.
*Trembling.
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Anxious person think... GAD.
Anxious person think... GAD.


Mnemonic ''BE SKIM'':<ref>TN 2006 PS14</ref>
Mnemonic ''BE SKIM'':<ref name=Ref_TN2006_PS14>{{Ref TN2006|PS14}}</ref>
*Blank mind.
*Blank mind.
*Easily fatigued.
*Easily fatigued.
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===Mania===
===Mania===
Mnemonic ''DIG FAST'':<ref>TN 2006 PS7</ref>
Mnemonic ''DIG FAST'':<ref name=Ref_TN2006_PS7>{{Ref TN2006|PS7}}</ref>
*Distractibility.
*Distractibility.
*Indiscretion  - 3 Ss: sex, shopping, substance use.
*Indiscretion  - 3 Ss: sex, shopping, substance use.
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===Schizophrenia===
===Schizophrenia===
Positive symptoms (2 of the following for 1 month):<ref>TN 2006 PS5</ref>
Positive symptoms (2 of the following for 1 month):<ref name=Ref_TN2006_PS5>{{Ref TN2006|PS5}}</ref>
*Disordered speech.  
*Disordered speech.  
*Disordered behaviour.
*Disordered behaviour.
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===Risk factors for suicide===
===Risk factors for suicide===
Mnemonic ''SAD PERSONS'':<ref>TN 2006 PS25</ref>
Mnemonic ''SAD PERSONS'':<ref name=Ref_TN2006_PS25>{{Ref TN2006|PS25}}</ref>
*Sex (male).
*Sex (male).
*Age (young <19 or old >60).
*Age (young <19 or old >60).
*Depression.
*Depression.
*Previous attempt.
*Previous attempt.
*EtOH use/abuse.
*[[EtOH]] use/abuse.
*Rational thinking loss (psychosis).
*Rational thinking loss (psychosis).
*Suicide in the family.
*Suicide in the family.
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==Gynecology==
==Gynecology==
===Ovarian cancer risks===
===Ovarian cancer risks===
Mnemonic ''NO CHILD'':<ref>TN07 GY43</ref>
Mnemonic ''NO CHILD'':<ref name=Ref_TN2007_GY43>{{Ref TN2007|GY43}}</ref>
*Nulliparity.
*Nulliparity.
*OCP, breast feeding, tubal ligation, hysterectomy -- all protective.
*OCP, breast feeding, [[tubal ligation]], hysterectomy -- all protective.
*Caucasian.
*Caucasian.
*History in the family.
*History in the family.
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===Endometrial cancer risks===
===Endometrial cancer risks===
Mnemonic ''COLD NUT'':<ref>TN07 GY40</ref>
Mnemonic ''COLD NUT'':<ref name=Ref_TN2007_GY40>{{Ref TN2007|GY40}}</ref>
*Cancer Hx (ovarian, breast, colon).
*Cancer Hx (ovarian, breast, colon).
*Obesity.
*[[Obesity]].
*Late menopause.
*Late menopause.
*Diabetes.
*Diabetes.
*Nulliparity.
*Nulliparity.
*Unopposed estrogen (PCOS, anovulation, HRT).
*Unopposed estrogen ([[PCOS]], anovulation, HRT).
*Tamoxifen use.
*Tamoxifen use.


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Mnemonic ''AGE IS Low'':<ref>First trimester bleeding. WP. URL: [http://en.wikipedia.org/wiki/First_trimester_bleeding http://en.wikipedia.org/wiki/First_trimester_bleeding].</ref>
Mnemonic ''AGE IS Low'':<ref>First trimester bleeding. WP. URL: [http://en.wikipedia.org/wiki/First_trimester_bleeding http://en.wikipedia.org/wiki/First_trimester_bleeding].</ref>
*Abortion.
*Abortion.
*Gestational trophoblastic neoplasia.
*[[Gestational trophoblastic neoplasia]].
*Ectopic pregnancy.
*[[Ectopic pregnancy]].
*Implantation bleed.
*Implantation bleed.
*Spotting.
*Spotting.
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===Cervical cancer risks===
===Cervical cancer risks===
Mnemonic ''HPV + 6 Ss'':<ref>TN06 GY45</ref>
Mnemonic ''HPV + 6 Ss'':<ref name=Ref_TN2006_GY45>{{Ref TN2006|GY45}}</ref>
*[[HPV]].
*[[HPV]].
*Smoking.
*Smoking.
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*Started early, early first intercourse.
*Started early, early first intercourse.


===OCP use===
===[[OCP]] use===
====Contraindications====
====Contraindications====
Mnemonic ''ABBCCCD'':<ref>TN05 FM44; TN06 GY20</ref>
Mnemonic ''ABBCCCD'':<ref name=Ref_TN2005_FM44>{{Ref TN2005|FM44}}</ref><ref name=Ref_TN2006_GY20>{{Ref TN2006|GY20}}</ref>
*Acute or chronic liver disease (e.g. [[Wilson's disease]]).
*Acute or chronic liver disease (e.g. [[Wilson's disease]]).
*Bad migraines (with focal neurological signs).
*Bad migraines (with focal neurological signs).
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====Advantages====
====Advantages====
Mnemonic AABCDE:<ref>TN05 FM44; TN06 GY20</ref>
Mnemonic AABCDE:<ref name=Ref_TN2005_FM44>{{Ref TN2005|FM44}}</ref><ref name=Ref_TN2006_GY20>{{Ref TN2006|GY20}}</ref>
*Acne reduced, Anemia reduced.
*Acne reduced, [[Anemia]] reduced.
*Benign breast disease reduced.
*Benign breast disease reduced.
*Cancer reduced (ovary, endometrium).
*Cancer reduced (ovary, endometrium).
*Dysmenorrhea Sx better.
*Dysmenorrhea Sx better.
*Endometriosis Sx better.
*[[Endometriosis]] Sx better.
*Pregnancy prevention.
*Pregnancy prevention.


==Urology==
==Urology==
===Obstructive LUTS===
===Obstructive lower urinary tract symptoms (LUTS)===
Mnemonic ''I WISH 2p'':<ref>TN06 U5</ref>
Mnemonic ''I WISH 2p'':<ref name=Ref_TN2006_U5>{{Ref TN2006|U5}}</ref>
*Intermittency.
*Intermittency.
*Weak stream.
*Weak stream.
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====Caregiver related====
====Caregiver related====
*Hx of abuse (as child).
*Hx of abuse (as child).
*Psych illness.
*Psychiatric illness.
*Substance use.
*Substance use.
*Single.
*Single.
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==Internal medicine==
==Internal medicine==
===Myocardial infarction treatment===
===[[Myocardial infarction]] treatment===
Mnemonic ''BE NORMAL'':<ref>STEMI. Harrison's 16th Ed.</ref>
Mnemonic ''BE NORMAL'':<ref>STEMI. Harrison's 16th Ed.</ref>
*Beta-blocker - metoprolol 5 mg IV q5-10 min (if sBP>95, HR>50, no CHF).
*Beta-blocker - metoprolol 5 mg IV q5-10 min (if sBP>95, HR>50, no CHF).
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====Clot lysis contraindications====
====Clot lysis contraindications====
Mnemonic ''A Big TV HIT'':<ref>TN06 C25</ref>
Mnemonic ''A Big TV HIT'':<ref name=Ref_TN2006_C25>{{Ref TN2006|C25}}</ref>
*Aortic dissection suspected.
*[[Aortic dissection]] suspected.
*Bleeding, active.
*Bleeding, active.
*Trauma to head (recent).
*Trauma to head (recent).
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*Tumour, brain.
*Tumour, brain.


===Congestive heart failure===
===[[Congestive heart failure]]===
Mnemonic ''LMNOP'':
Mnemonic ''LMNOP'':
*Lasix.
*Lasix.
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*Position (elevate head).
*Position (elevate head).


===Diabetes complications===
===[[Diabetes]] complications===
Mnemonic ''HELP'':
Mnemonic ''HELP'':
*H - HbA1c, HTn.
*H - HbA1c, HTn.
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===DDx of dementia===
===DDx of dementia===
Mnemonic ''VITAMIN D VEST'':<ref>TN06 PS19</ref>
Mnemonic ''VITAMIN D VEST'':<ref name=Ref_TN2006_PS19>{{Ref TN2006|PS19}}</ref>
*Vitamin deficiency (B12, folate, thiamine).
*Vitamin deficiency (B12, folate, thiamine).
*Infection ([[HIV]]).
*Infection ([[HIV]]).
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*Endocrine.
*Endocrine.
*Space occupying lesion (chronic subdural hematoma).
*Space occupying lesion (chronic subdural hematoma).
*Toxins (alcohol).
*Toxins ([[alcohol]]).


===DDx of delirium===
===DDx of delirium===
Mnemonic ''I WATCH DEATH'':<ref>TN06 PS18</ref>
Mnemonic ''I WATCH DEATH'':<ref name=Ref_TN2006_PS18>{{Ref TN2006|PS18}}</ref>
*Infections (meningitis).
*Infections (meningitis).
*Withdrawal (from drugs).
*Withdrawal (from drugs).
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*Trauma (CNS, post-op).
*Trauma (CNS, post-op).
*CNS pathology (stroke, hemorrhage).
*CNS pathology (stroke, hemorrhage).
*Hypoxia (PE, CHF, anemia).
*Hypoxia ([[PE]], CHF, [[anemia]]).
*Deficiency of vitamins (B12, folate, thiamine).
*Deficiency of vitamins (B12, folate, thiamine).
*Endocrinopathy (Cushing's, Addison's, Thyroid, Parathyroid, Diabetes).
*Endocrinopathy (Cushing's, [[Addison disease|Addison's]], [[Thyroid]], [[Parathyroid]], Diabetes).
*Acute vascular (vasculitis, TIA, stroke).
*Acute vascular ([[vasculitis]], TIA, [[stroke]]).
*Toxins (morphine).
*Toxins (morphine).
*Heavy metals (arsenic, lead, mercury).
*Heavy metals (arsenic, lead, mercury).
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===Hyperthyroidism===
===Hyperthyroidism===
Mnemonic ''hyperTHYROIDISM'':<ref>TN06 E24</ref>
{{Main|Hyperthyroidism}}
Mnemonic ''hyperTHYROIDISM'':<ref name=Ref_TN2006_E24>{{Ref TN2006|E24}}</ref><ref>URL: [http://www.prep4usmle.com/forum/thread/6731/2/ http://www.prep4usmle.com/forum/thread/6731/2/]. Accessed on: 1 May 2012.</ref>
*Tremor.
*Tremor.
*HR elevated, palpitations.
*HR elevated, palpitations.
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*Restlessness.
*Restlessness.
*Oligomenorrhea, amenorrhea.
*Oligomenorrhea, amenorrhea.
*Intolerance to heat.
*Diarrhea.
*Diarrhea.
*Irritable.
*Irritable.
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==Surgery==
==Surgery==
===Small bowel obstruction DDx===
===[[Small bowel obstruction]] DDx===
*Strictures (think IBD).
*Strictures (think IBD).
*Hernia.
*Hernia.
*Adhesions.
*Adhesions.
*Volvulus.
*[[Volvulus]].
*Intussusception.
*Intussusception.
*Neoplasm.
*Neoplasm.
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*Wind - atelectasis (POD 1-2), pneumonia (POD 3+).
*Wind - atelectasis (POD 1-2), pneumonia (POD 3+).
*Wound - wound infection duh!
*Wound - wound infection duh!
*Water - urinary tract infection (UTI).
*Water - [[urinary tract infection]] (UTI).
*Walk - [[pulmonary embolism]].
*Walk - [[pulmonary embolism]].
*Womb (for obstetrics/gyne).
*Womb (for obstetrics/gyne).
*Wonder drugs.<ref name=pmid1745617>PMID 1745617</ref>
*Wonder drugs.<ref name=pmid1745617>{{Cite journal  | last1 = Min | first1 = DI. | last2 = Monaco | first2 = AP. | title = Complications associated with immunosuppressive therapy and their management. | journal = Pharmacotherapy | volume = 11 | issue = 5 | pages = 119S-125S | month =  | year = 1991 | doi =  | PMID = 1745617 }}</ref>


Note:
Note:
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===Lower GI bleed===
===Lower GI bleed===
Mnemonic ''CHAND'':
Mnemonic ''CHAND'':
*Colitis (infection, ischemic, IBD, radiation).
*Colitis (infection, [[ischemic colitis|ischemic]], [[IBD]], [[radiation colitis|radiation]]).
*Haemorrhoids.
*Haemorrhoids.
*Angiodysplasia (usually older).
*[[Angiodysplasia]] (usually older).
*Neoplasm.
*Neoplasm.
*Diverticular disease.
*[[Diverticular disease]].


====Hemorrhagic diarrhea====
====Hemorrhagic diarrhea====
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===Diarrhea===
===Diarrhea===
Mnemonic ''THOSE FADS WILT'':<ref>TN06 G13</ref>
Mnemonic ''THOSE FADS WILT'':<ref name=Ref_TN2006_G13>{{Ref TN2006|G13}}</ref>
*Travel Hx.
*Travel Hx.
*Homosexual behaviour.
*Homosexual behaviour.
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===Upper GI bleed===
===Upper GI bleed===
*Peptic ulcer disease (PUD).
*[[Peptic ulcer disease]] (PUD).
*Gastritis (EtOH, NSAID, stress, idiopathic).
*Gastritis (EtOH, [[NSAID]], stress, idiopathic).
*Mallory-Weiss tear (excessive vomiting).
*Mallory-Weiss tear (excessive vomiting).
*Varices.
*Varices.
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*Oropharyngeal bleed (epistaxis).
*Oropharyngeal bleed (epistaxis).


==Clinical history and pathology==
*Pathologists are consultants and every good consult should have a question.
===Clinical history and the law===
In Ontario, the law says that a history should be provided as per ''R.R.O. 1990, Reg. 965, s. 31 (1)'':<ref name=reg965>R.R.O. 1990, Reg. 965, s. 31 (1). URL: [http://www.ontario.ca/laws/regulation/900965#BK23 http://www.ontario.ca/laws/regulation/900965#BK23]. Accessed on: 18 December 2015.</ref>
:"Where tissues are removed from a patient during an operation or curettage, the surgeon performing the operation or curettage shall cause all tissues removed from the patient to be sent, together with a short history of the case and a statement of the findings of the operation, to a laboratory for examination and report."
==See also==
==See also==
*[[Physical examination]].
*[[Physical examination]].
*[[Pathology requisitions]].


==References==
==References==
Michael
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