Clinical history

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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.

A number of 'em aren't politically correct... but I don't see that a reason to banish 'em.

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.

Ontario immunizations

  • Pentacel - 2, 4, 6, 18 mo.
    • TDaP-IPV (tetanus, diphtheria, acellular pertussis, inactivated polio virus).
    • HiB (Hemophilus influenzae type B).
  • Pneumococcus - 2, 4, 6, 15 mo.
  • MMR (measles, mumps, rubella) - 12, 18 mo.
  • Varicella - 15 mo.
  • Hepatitis B - in grade 8, 3 dose (0 mo., 1 mo., 6 mo.).
  • 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:[1]

  • 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:[2]

  • 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:[3]

  • 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:[4]

  • 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):[5]

  • 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:[6]

  • 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:[7]

  • 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:[8]

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

First trimester bleeding

Mnemonic AGE IS Low:[9]

  • 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.[10]

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:[11]

  • 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:[12]

  • 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:[13]

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

Urology

Obstructive LUTS

Mnemonic I WISH 2p:[14]

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

Internal medicine

Myocardial infarction treatment

Mnemonic BE NORMAL:[15]

  • 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:[16]

  • 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:[17]

  • 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:[18]

  • 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

Mnemonic hyperTHYROIDISM:[19]

  • Tremor.
  • HR elevated, palpitations.
  • Yawn (fatigue).
  • Restlessness.
  • Oligomenorrhea, amenorrhea.
  • 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 - UTI.
  • Walk - pulmonary embolism.
  • Womb (for obstetrics/gyne).
  • Wonder drugs.[20]

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 difficle.
  • Campylobacter jejuni.

Diarrhea

Mnemonic THOSE FADS WILT:[21]

  • 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).

See also

References

  1. http://www.medicalmnemonics.com/cgi-bin/detailsrate.cfm?mnemonic_id=924
  2. TN 2005 PS13
  3. TN 2006 PS14
  4. TN 2006 PS7
  5. TN 2006 PS5
  6. TN 2006 PS25
  7. TN07 GY43
  8. TN07 GY40
  9. First trimester bleeding. WP. URL: http://en.wikipedia.org/wiki/First_trimester_bleeding.
  10. http://emedicine.medscape.com/article/266110-overview
  11. TN06 GY45
  12. TN05 FM44; TN06 GY20
  13. TN05 FM44; TN06 GY20
  14. TN06 U5
  15. STEMI. Harrison's 16th Ed.
  16. TN06 C25
  17. TN06 PS19
  18. TN06 PS18
  19. TN06 E24
  20. PMID 1745617
  21. TN06 G13

External links