Clinical history

From Libre Pathology
(Redirected from Clinical)
Jump to navigation Jump to search

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

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:

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:[1]

  • 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:[2]

  • 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:[3]

  • 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:[4]

  • 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:[5]

  • 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):[6]

  • 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:[7]

  • 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:[8]

  • 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:[9]

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

First trimester bleeding

Mnemonic AGE IS Low:[10]

Notes:

  • Common -- seen in approx. 25% of all clinically recognized pregnancies.[11]

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:[12]

  • 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:[13][14]

  • 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][14]

  • 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:[15]

  • 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:[16]

  • 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:[17]

  • 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:[18]

  • 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:[19]

  • 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:[20][21]

  • 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)

Note:

  • POD = post-op day.

Lower GI bleed

Mnemonic CHAND:

Hemorrhagic diarrhea

Mnemonic ESC:

Diarrhea

Mnemonic THOSE FADS WILT:[23]

  • 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):[24]

"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

References

  1. ↑ 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.
  2. ↑ http://www.medicalmnemonics.com/cgi-bin/detailsrate.cfm?mnemonic_id=924
  3. ↑ Yeung, J.C.; Leonard, Blair J. N. (2005). The Toronto Notes 2005 - Review for the MCCQE and Comprehensive Medical Reference (2005 ed.). The Toronto Notes Inc. for Medical Students Inc.. pp. PS13. ISBN 978-0968592854.
  4. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. PS14. ISBN 978-0968592861.
  5. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. PS7. ISBN 978-0968592861.
  6. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. PS5. ISBN 978-0968592861.
  7. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. PS25. ISBN 978-0968592861.
  8. ↑ Greenwald, J.; Heng, M. (2007). Toronto Notes for Medical Students 2007 (2007 ed.). The Toronto Notes Inc. for Medical Students Inc.. pp. GY43. ISBN 978-0968592878.
  9. ↑ Greenwald, J.; Heng, M. (2007). Toronto Notes for Medical Students 2007 (2007 ed.). The Toronto Notes Inc. for Medical Students Inc.. pp. GY40. ISBN 978-0968592878.
  10. ↑ First trimester bleeding. WP. URL: http://en.wikipedia.org/wiki/First_trimester_bleeding.
  11. ↑ http://emedicine.medscape.com/article/266110-overview
  12. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. GY45. ISBN 978-0968592861.
  13. ↑ 13.0 13.1 Yeung, J.C.; Leonard, Blair J. N. (2005). The Toronto Notes 2005 - Review for the MCCQE and Comprehensive Medical Reference (2005 ed.). The Toronto Notes Inc. for Medical Students Inc.. pp. FM44. ISBN 978-0968592854.
  14. ↑ 14.0 14.1 Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. GY20. ISBN 978-0968592861.
  15. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. U5. ISBN 978-0968592861.
  16. ↑ STEMI. Harrison's 16th Ed.
  17. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. C25. ISBN 978-0968592861.
  18. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. PS19. ISBN 978-0968592861.
  19. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. PS18. ISBN 978-0968592861.
  20. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. E24. ISBN 978-0968592861.
  21. ↑ URL: http://www.prep4usmle.com/forum/thread/6731/2/. Accessed on: 1 May 2012.
  22. ↑ Min, DI.; Monaco, AP. (1991). "Complications associated with immunosuppressive therapy and their management.". Pharmacotherapy 11 (5): 119S-125S. PMID 1745617.
  23. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. G13. ISBN 978-0968592861.
  24. ↑ R.R.O. 1990, Reg. 965, s. 31 (1). URL: http://www.ontario.ca/laws/regulation/900965#BK23. Accessed on: 18 December 2015.

External links

Retrieved from "https://librepathology.org/w/index.php?title=Clinical_history&oldid=50826"