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).

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

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