Difference between revisions of "Clinical history"

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Clinical history (view source)

Revision as of 19:31, 7 June 2020

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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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*B - [[hypertension|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.
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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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*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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Mnemonic ''NO CHILD'':<ref name=Ref_TN2007_GY43>{{Ref TN2007|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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Mnemonic ''COLD NUT'':<ref name=Ref_TN2007_GY40>{{Ref TN2007|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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*Started early, early first intercourse.
*Started early, early first intercourse.


===OCP use===
===[[OCP]] use===
====Contraindications====
====Contraindications====
Mnemonic ''ABBCCCD'':<ref name=Ref_TN2005_FM44>{{Ref TN2005|FM44}}</ref><ref name=Ref_TN2006_GY20>{{Ref TN2006|GY20}}</ref>
Mnemonic ''ABBCCCD'':<ref name=Ref_TN2005_FM44>{{Ref TN2005|FM44}}</ref><ref name=Ref_TN2006_GY20>{{Ref TN2006|GY20}}</ref>
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====Advantages====
====Advantages====
Mnemonic AABCDE:<ref name=Ref_TN2005_FM44>{{Ref TN2005|FM44}}</ref><ref name=Ref_TN2006_GY20>{{Ref TN2006|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 name=Ref_TN2006_U5>{{Ref TN2006|U5}}</ref>
Mnemonic ''I WISH 2p'':<ref name=Ref_TN2006_U5>{{Ref TN2006|U5}}</ref>
*Intermittency.
*Intermittency.
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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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*Tumour, brain.
*Tumour, brain.


===Congestive heart failure===
===[[Congestive heart failure]]===
Mnemonic ''LMNOP'':
Mnemonic ''LMNOP'':
*Lasix.
*Lasix.
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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===
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===Hyperthyroidism===
===Hyperthyroidism===
{{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>
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.
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==Surgery==
==Surgery==
===Small bowel obstruction DDx===
===[[Small bowel obstruction]] DDx===
*Strictures (think IBD).
*Strictures (think IBD).
*Hernia.
*Hernia.
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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).
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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).
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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).
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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
48,454

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