Clinical history

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).

Warning: A number of 'em aren't politically correct!

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.

Immunizations

Ontario

As per 2011 schedule:

• Pentacel - 2, 4, 6, 18 months old.
  • TDaP-IPV (tetanus, diphtheria, acellular pertussis, inactivated polio virus).
  • HiB (Hemophilus influenzae type B).
• TDaP-IPV - 4-6 years old.
• Pneumococcus - 2, 4, 12 months old.
• Rot-1 (rotavirus) - 2, 4 months old.
• 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.

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:

• 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:

• 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:

• 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:

• 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):

• 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:

• 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:

• 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:

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

First trimester bleeding

Mnemonic AGE IS Low:

• 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.

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:

• 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:

• 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:

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

Urology

Obstructive lower urinary tract symptoms (LUTS)

Mnemonic I WISH 2p:

• 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).
• Psychiatric illness.
• Substance use.
• Single.
• Social skills & vocational skill suck.
• Stupid (low scholastic achievement).

Internal medicine

Myocardial infarction treatment

Mnemonic BE NORMAL:

• 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:

• 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:

• 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:

• 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

Main article: Hyperthyroidism

Mnemonic hyperTHYROIDISM:

• Tremor.
• HR elevated, palpitations.
• Yawn (fatigue).
• Restlessness.
• Oligomenorrhea, amenorrhea.
• Intolerance to heat.
• 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 - urinary tract infection (UTI).
• Walk - pulmonary embolism.
• Womb (for obstetrics/gyne).
• Wonder drugs.

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 difficile.
• Campylobacter jejuni.

Diarrhea

Mnemonic THOSE FADS WILT:

• 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).

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):

"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

• Physical examination.

External links

• Medical mnemonics - medicalmnemonics.com.