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Difference between revisions of "Clinical history"
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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). | 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). | ||
==Basic approach== | ==Basic approach== | ||
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*24 mo. - turn pages in a book. | *24 mo. - turn pages in a book. | ||
====Ontario | ====Immunizations==== | ||
*Pentacel - 2, 4, 6, 18 | =====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, | *TDaP-IPV - 4-6 years old. | ||
*MMR ([[measles]], mumps, rubella) - 12 | *Pneumococcus - 2, 4, 12 months old. | ||
*Varicella - 15 | *Rot-1 (rotavirus) - 2, 4 months old. | ||
*[[Hepatitis B]] - in grade 8, 3 | *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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*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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====Caregiver related==== | ====Caregiver related==== | ||
*Hx of abuse (as child). | *Hx of abuse (as child). | ||
* | *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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===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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*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== | ||