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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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*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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====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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==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== | ||