HPI (history of present illness) Ask for: LIQOR AAA L Location of the symptom (forehead, wrist...) I Intensity of the symptom (scale 1-10, 6/10) Q Quality of the symptom (burning, pulsating pain...) O Onset of the symptom + precipitating factors R Radiation of the symptom ( to left shoulder and arm) A Associated symptoms ( palpitations, shortness of breath) A Alleviating factors (sitting with my chest on my knees) A Aggravating factors (effort, smoking, large meals)
Past Medical Illnesses Hx: ABCDEFGHIJK Asthma Blood pressure CVA (Stroke) Diabetes Epilepsy Fever (Rheumatic) GI- PUD/GERD Heart attack (MI) Infection (TB) Jaundice & liver Dz Kidney disease
PMH (past medical history) Search for: PAM HUGS FOSS P Previous presence of the symptom (same chief complaint) A Allergies (drugs, foods, chemicals, c hemicals, dust ...) M Medicines (any drugs the patient used) H Hospitalization for any illness in the past U Urinary changes ( esp if diabetic, elderly...) G Gastrointestinal complains (diet changes, bowel movements...) S Sleep pattern (waking up/going to sleep... sleep...)) F Family history (simmilar chief complaints/serious illness) O OB/GYN history (LMP, abortions abortions,, para...) S Sexual habits (active/preferences/STD...) S Social life (job/house/smoking/alcohol.....) (job/house/smoking/alcohol.....)
WAD SAD TOES for social history. W-Weight A-Appetite D-Diet S-Smoke A-Alcohol D-Drugs T-Travel O-Occupation E-Excercise S-Stress
Differential Differenti al diagnosis checklist nd
DIRECTION: DIRECTION:
C: Differential Differenti al Dx checklist (2 ) – VITAMINES C:
Drugs
Vascular/CVS
Infection
Infectious
Rheumatologic
Trauma/Toxin
Endocrine
Autoimmune/Allergic
Cardiovascular
Metabolic/Medication
Trauma
Inflammatory/Idiopathic
Inflammatory
Neoplastic/Nutritional/Neuronal (nervous
Other
system)
Neoplasm
Endocrine pSychiatric/Substance Congenital Drugs
For Social History I use TIA SHOE: T obacco I llicit drigs A lcohol S exual H ouse life O ccupation
E ating (diet)
LIQOR AAAAA last 2 A = associated q for d/d like weight lifting, travel history A= associated effect on sleep,diet & functioning FOR PEDIATRIC HISTORY. F E V E R C U D Seizure + P A M I F B I G D E A L S.
FEVER- Fever, Ear pulling, Vomiting, Ear discharge,eyes discharge, Rash, CUD- Chest symptoms n Cold-runny nose,cough,chest painfast respirations,shortness of breath, Urination-any increased or decreased urination,no. of wet diapers,any odour,colour of urine, Diarrhea-frequency,onset,mucus in stool,blood in stool,any cryin during defecation , Seizure-any jerky movements,any leakage of urine or stool during fits,ant post ictal irritability,or loss of consciousness.
PAM - P-Past medical,past surgical hx, previous hospitalizations. A-Allergies, M-Medications, IF I-Ill contacts, F -family history, BIG -B- birth hx, I-Immunizations, G-Growth n development,ht,wt,milestones. D-DEALS- Day care, E-Eating habits,feeding of da baby, A-Appetite, L-Look of tha baby or appearance, S- Sleep in addition to pamshugsfoss (of course you would modify it according to your patient)...
Paediatric Hx: i used BINDER - birth history, immunization history, nutrition, development, Eating, Rash... also it's good to ask where the child is during the day - (i.e. day care, school, grandmother's house, etc...) good luck
Causes of FTT/Failure to Thrive: ABCDEFGHI_M (OSCE Notes Reading- Short stature) Alone (Psychosocial deprivation) Bone Dysplasia Chromosomal Cystic Fibrosis Delayed Growth (Constitutional) Endocrine (Lo GH, Lo Thyroid) Familial GI (Malabsorption, Vomiting/Diarrhoea, IBD, Celiac) Heart/Kidney disease (CHD-Congenital heart disease, CKD) Infection (TB/Chronic) Metabolic error, Inborn
Causes of speech delay: HAMM CREP BM 1. Hearing loss (2nd common) 2. Autism 3. Mental retardation (Commonest) 4. Maturation delay (Familial)(3rd common) 5. Cerebral palsy 6. Receptive aphasia 7. Elective mutism 8. Psycho-social deprivation 9. Bilingualism 10. Mechanical
Premenopausal symptoms HAVOC H- hotflahes A-atropy of vagina V-vaginal dryness O- osteoporosis C- coronary artery diseases
I use- B HH MM SG Bleeding Hot flashes Heart racing Mood swinging Memory problem Sleep disturbance Genital dryness, itchiness, pain etc.
FOR all Discharges.... including Diarrhoea, Cough ...............ACCOD A-amount C -consistency C- color O- odor D- duration
Discharges I use: OCD COCA-B/D OCD as usual Color Odor Consistency Amount Blood Discharge any additional
Depression, SIGEMCAPS S-sleep I-interest G-guilt, gun E-energy M-mood C-concentration
Depression MI PASS ECG Mood Interest Psychomotor agitation/retardation Appetite Sleep Suicide
A-appetite
Energy
P-psychomotor
Concentration
S-suicide
Guilt
want to add few more to these....... M- mood ( already in list ) D - Delusion / hallucination M - memory A- attitude towards life ( positive negative frame of mind) T - thyroid dysfunctions
also need to ask ----- do u realize that u have problem ????? and do u want help ??????
( if patient was sent or asked by anyone to consult doc ) Fatigue...IMP ADH I-infection M -malignancy P-PTSD A-abuse D-depression H-hypothyroidism
For Spousal abuse, I have read the acronym SAFEGARDS somewhere. Can some complete it for me or give more add on S= Safety inquiry (Do you feel safe at home?) A= Alcohol abuse (does your hubby abuses alcohol?) F= Friends/Family who are aware/Fractures (Does anyone of your friend/Family know of this? Abuse ever resulted in fractures? E=Emergency plan (Do u have an emergency plan? Ever tried to leave/divorce? why not? G=Guns at home (are there any weapons @ home? A=any escape plan? R=Relationships with husband (how is your relationship with hubby? --> do you feel threatened when he is around? D=Depression/Drugs (have u lost weight appetite sleep ) does hubby dos drugs S=Suicidal ideation (ever felt like ending it all up? )
Differential diagnosis of tiredness ABCDEFGHI (examples in brackets) Autoimmune disease (coeliac disease, multiple sclerosis) Blood disorders (anaemia) Cancer / Chronic fatigue syndrome Depression and other depressive mental disorders Endocrine (diabetes mellitus, hypothyroid) / Eating disorders Fibromyalgia (muscle pain) Generalised infection (Infectious mononucleosis by EBV) Heart disease Immune deficiency (HIV/AIDS)
Insomnia counselling = ABCDEFGHJKLMN Avoid Bedtime Concerns (worries) Drugs (nicotine/caffeine/Alcohol) Exercise/Excitement (TV Shows) Follow Good Habits for sleep. Jetlag Keep List (Diary) Monitor Naps (day time)
Other conditions: Leukaemia / lymphoma Neurological disorders (Parkinson’s disease) Physical trauma Pregnancy Sleep deprivation Hepatic failure Uraemia Source:
http://medmnemonics.wordpress.com/2011/ 03/16/differential-diagnosis-of-tiredness-2/
Enuresis Counselling = SMILE SAM Supportive (of the child) Monitor Intake (@ Day) Limit (@ Night) Encourage Washroom (@ bedtime) Sheets ( Rubber flannel sheets) Alarms ( >5yrs ) Motivate (thru Rewards)
Counselling DM & HTN= MEDOWSA Medications (regularity) Exercise (for obese/sedentary life styles) Diet modification (Salt/Fatty foods) Ophthalmoscopic exams (annual routine) Weight Management (/control) Smoking cessation, Sugar Check-ups Alcohol reduction/stop Causes of 2º HTN- ABCDE Apnea (sleep), Aldosteronism Bad kidneys, Bruits Coarctation, Cushing’s, Catecholamines, Calcemia Drugs Endocrine
Smoking Cessation counselling = SPANCSTER Stressor ( any stress in life/tension etc. ) Problems ( Heart /Lung/ CA) Advantages ( Improved breathing & Increased energy) Nicotine Patch ( I can offer you reading materials ) Counsellors ( I can refer u/ give # ) Support systems ( I can refer u /give #) Taper down ( if u can’t do cold turkey then just taper down a bit) Exercise Programs ( e.g. Swimming ) Rewards ( reward yourself, treat yourself with a dinner 4m money saved off of quitting)
STD / HIV Counselling STRIP BIMBO! SAFE SEXUAL PRACTICES TRANSMISSION ( to partners ) RISKS ( acquiring more STD's) IMMUNIZATIONS ( for Influenza/ Pneumococcal ) PREVENTION COUNSELLING ( REFER TO SW /CAN GIVE #) BEHAVIOUR COUNSELLING (REFER / CAN GIVE #) INTERVENTIONAL COUNSELLING ( REFER /CAN GIVE #) MEDICATIONS BARRIER METHODS (CONDOM) OPPURTUNISTIC INFECTIONS/OBSERVATION (FOR LABS)
HOPI For A CC OF URINARY COMPLAINT FINISHED PUBS Frequency ( How frequent do u Ux) Incontinence( Do u hav trouble holding Ux) Nocturia ( do u hav 2 wak up @ Night) Incomplete emptying ( do u feel fullnes after Ux) Stream (How is ur stream?) Hematuria ( did u notic any blood) Hesitancy (do u hav 2 wait b4 starting Ux) Dysuria (Did u hav diff Ux) Pyuria ( did u pus in Ux) Urgency (do u hav 2 rush) Burning (dysuria) (does it burn) Strain (Do u hav to strain during Ux) My way- PD FUN SHID U FIDO AAA Pain/Dysuria during urine Frequency/Urgency/Nocturia/Polyuria Hesitancy/Stream poor/Dribbling at end/Incomplete evacuation (sense of) Urine- COCA-B Fluid intake Incontinence Discharge (OsCfD Q-COCAB ST UVWFE AAA) Oedema (Scrotum/Face/Ankle)
AAALocal- Redness, Itchiness, Blisters/rash/excoriation Same- Kidney stones/UTI before Adjacent- STI/PID/Prostatitis, any other abdominal disease RF- Foreign body/STI/↓immunity/Fecal incontinence C&C- Reiter’s syndrome (eye redness), Anatomic abnormalities Constitutional & ROS
CC of Memory Loss/Dementia/Alzheimers/MID/Creutfeldt jakob/Pseudotumor cerebrii etc HOPI Particularts to ask -ADL = Activities of daily living = DEATH Dressing Eating Ambulation (can u find ur way thru home) Toiletry (do u manage ur toiletry un assisted) Housing
IADL - Instrumental acitivities of daily living =SHAFT Shopping Housekeeping? unsure about that Accounting Food (do u do ur cooking ,etc) Transportation (do u drive )
Shoulder pain case ( I read this one somewhere) DEFORMS Dislocation ( Ant/Post) Elderly Abuse Fracture ( Head/Shaft) Osteoporosis /Osteoarthritis Rotator Cuff Tear Multiple myeloma Subacromial Bursitis Syncope/ Loss of Consciousness/Spells
Dizziness is DENTAL CAMPUS (Or, CAMPUS
CAMPUS
ENT)
CAD
Diabetic comp (Orthostatic/Autonomic
Arrhythmia/Aortic Stenosis Anemia/Autonomic (DM)
instability)
Migraine
Neural tumors/Neuropathy
Meds (Anti-HTN drugs- α/β/CC blocker, vasodilator, PDE
Thyroid
inhibitor sildenafil, tadalafil)
Anaemia
Metabolic (Hypotension, Hypoglycemia)
Leave me
Psychiatric (Panic attack, Conversion-
CAMPUS is same as is for
Hyperventilation)
Unexplained Syncope (Vasovagal syncope, Carotid
Ear problems (Meniere's/ BPV)
SPELLS/LOC/SYNCOPE
Sinus Hypersensitivity)
Seizures/Strokes/TIA
D/D Confusion Pneumonic = DEMENTIA Diabetes /Dementia/ Drugs Epilepsy Migraine/Multi Infarct Dementia Ethanol (withdrawal/ Toxicity) Neurological Deficit diseases= BETA (Bleeds, Encephalitis, Tumors, Abscess, Meningitis) TIA/Trauma Insulin/Infections (Sepsis/UTI) Alzheimer’s/Abscess Check list accordingly :- Numbness weakness/Headache, Flashes, N/V /Jerky movements, LOC/Insulin use /PHx Trauma/FHx of Alzheimer + Risk factor screen (Cholesterol, HTN, DM etc). For
Suspected DEMENTIA =Instrumental inquiry = SHAFT Q's (Shop/Housekeep/Account/Food prep/Transport), & Daily activity inquiry =DEATH Q's (Dress/Eat/Ambulate/Toilet/Hygiene)
Causes of fall in elderly: I HATE FALLING TN12 Handbook p124 (My modification- see below)
Elderly causes of fall- ABC_EFGHIJ_L_N_P Arrhythmia
Inflammation of joints
Balance
Hypotension
Coordination
Audio-visual deficit
Eye/Ear problem
Tremor (PD)
Foot problem
Equilibrium/Balance
Gait problem
Foot problems
Hypotension
Arrhythmias
Illness
Leg length discrepancy
Joint problem
Lack of coordination (Cerebellar)
Leg length discrepancy
Illness
Nutrition
Nutrition
Parkinson’s Dz
Gait problem
Geriatric checklist: Geriatric Giants: 7 I’s Impairment of Vision & Hearing Instability/fall Incontinence & Constipation Iatrogenic (Polypharmacy) Immobility (DEATH/SHAFT) Intellect & Memory Impaired homeostasis (Chronic disease)
Psychiatric Hx Checklist MISS SPEARS PAD MATCHED Mood, Idea ( abt de problem?), Stress, Support, Sleep ,Plan,Energy ,Aims, Routine , Suicide, Pills (drugs),Apetite ,Duration,Memory, Alone,Concentration, Hopes, Hallucinations , Delusions
Personality Disorders Borderline PD: IMPULSIVE (=/>5/9) Impulsive behaviour in =/> of these areas-
Panic Disorder: STUDENTS FEAR 3C (≥ 4/15) = Panic Attack, if with AWC = Panic Disorder
sex, spending, substance, driving, binge eating
Sweating
Mood reactivity and affective instability
Tremor
Paranoid ideation (or Dissociative symptoms)-
Unsteady (Dizzy)
things others will cause harm/malevolent
Depersonalization
intention
Derealization
Unstable self image (Identity disturbance)
Excessive Heart Racing
Labile (or Intense) relationships
Nausea/Vomiting
Suicidal behaviour
Tingling sensation/Numbness
Intense anger
SOB
Vulnerable to abandonment
Fear of > Dying; > Loosing control > Going
Emptiness
Crazy Chest Pain Choking Chills or hot flashes AWC Anticipatory Anxiety of this kind of attack for > 1 month Worry about consequences of the attack Changes made to lifestyle
GAD Duration >6mo What are the things that you are fearing? Blank mind makes him Irritable, so he gets Keyed up and Sleep disturbance. So he gets Muscle Tension and gets Easily Fatigued. BE SKIM (≥3/6 for 6 mon, 1/6 in children) Blank Mind Easily Fatigued Sleep Disturbance Keyed Up- Always on the edge? Irritable Muscular Tension
Phobic Disorders
OCD: WRITE
Fear of anxiety for something specific (e.g.
Do you have certain thoughts or behaviours
Height)
over and over again that you think you need
HE Avoids
to get rid of?
Happens: What happens if you are in these
What are they?
places of situations?
Repetitive? Thoughts come back again and
Excessive: Is you reaction reasonable or
again? (OBSESSION) > Do you feel driven to
excessive?
do them? (COMPULSION)
Avoid: Do you avoid these
Intrusive & Inapropriate?
place/situations/things?
Time: Are they time consuming? Excessive or not reasonable?
Post Traumatic Stress Disorder (PTSD) TRAUMA (for >1 month) Traumatic event (Precipitator) Re-experience the event? Avoid stimuli which remind of the event? Unable to function in interpersonal/social/work life? More than a Month duration? Arousal increased
OBESITY risks
Obesity counseling
OBESITY-DISC
ABCDEF
Osteoarthritis Breathing problems
Avoid Advice (e.g. Sedentary/Steroids)
Excess Cholestrol
Advantages Advice (Low Heart/Brain/Ca etc
Sleep Apnea
risk)
Increased Incidence Ca's
Books (self-help reading material)
(Endometrial/Breast/Colon)
Counseling/Consult/ Cholesterol checks
Type 2 DM
Dietitian
hYpertension
Exercise
Depression
Fatty Food (cut backs)
Incontinence Stress Cholelithiasis/Cycle disturbances/Cardiac
D/D = BACK PAIN Mnemonic = DR.LIMCOTS Degenerative- disk/joint/ligament, Ankylosing spondylitis Referred (Aorta/Renal/Ureter/Pancreas)
Lumber Spinal stenosis Intervertebral disc herniation Multiple Mye/Mets (Prostate, Breast ,Lung) Cauda Equina syndrome/Cancer Osteoporosis/Osteoarthritis /Osteomyelitis
Original LIMCOTS
Lumbar Spinal stenosis Intervertebral disc herniation Multiple Myeloma/ Mets (Prostate, Breast ,Lung) Cauda equina syndrome/ Cancer Osteoporosis/Osteoarthritis Trauma/ TB Strain (muscle)
Trauma/TB Strain of Muscle
Check list= SIQQOR AAA & then ROS =Age/ Bone pains/ constipation=MM/Bowel, bladder/Relieving factors/ Phx of trauma/Surgical Hx(Prostate) /Chest pain, hemoptysis, Fever &chills/ With bone & joint problems =Functional impairment (SOS=Help)Q's i.e Sleep/Occupation/Support
Back pain red flags- BACK PAIN (TN2014)
Bowel/bladder control lost Anesthesia – saddle region Constitutional/malignancy- prostate/breast/lung/thyroid Khronic illness Paresthesia Age >50y IV drug user Neurologic deficit (sensory/motor)
Headache DDx (TN2014 N38) ER VISITS Eye (Glaucoma/strain), Earache, Toothache, Throat pain, Sinusitis (= ALL LOCAL) Recurrent/chronic (Migraine, Tension, Cluster, TMJ, Cx OA) Vascular (Temporal arteritis, SAH, ICH) Infectious (Meningitis, Encephalitis) Systemic (HTN/Preeclamsia, Anemia, Anoxia, CO) ICP raised (HTN encephalopathy, SOL) Trauma (Concussion, SDH, EDH) Spouse abuse/pSychotic
Nausea & Vomiting = A MOPING Anorexia Medications Metabolic (DKA/CRF) Obstruction (pyloric /Intestinal) Pregnancy Inflammation( Pyelo/Cholecysto/Appi/Pancreas/PID) Neurological (BETA)= Bleed/Encephalitis & Ear problems/Tumor/Abscess Gastroenteritis
Here's a mnemonic for the ObGyn Hx : LMP RTV CS PAP LMP !! Menarchae Period ( lasts .... days?) Regularity ( every .... wks?) Tampoons/Pads # per day Vaginal discharge, itching , dryness Cramps (Dysmenorrhea) Spotting ( intermenstrual / post coital ) Pregnency ( Hx & complications) Abortion /miscarriage PAP smear ( last time result ?, Hx of past abnormal result ? )
OCP counselling Contraindications:
Advantage: ABCDEF
Pr.ABCD.Smoker.Trigly.HTN.CVA/IHD.Migrain
Anemia↓
Pregnancy (known/suspected)
Acne↓
Active Liver Disease
Benign breast Dz↓
Bleeding P/V, undiagnosed
Bone protection (possibly)
Cancer, Hx of – in family
Cancer↓ (Ovarian & Emdometrial)
DVT, PHx of
Cycle control
Smoker + age>/=35
Cyst↓
Congenital Triglyceridemia, Hx of
Dysmenorrhea↓
HTN, Uncontrolled
Effective & Reversible
CVA/IHD, Hx of
Fibroid↓
Migraine w/ focal neurological signs
Side effects: ABCDEF-VW Amenorrhea Appetite↑ Breakthrough bleeding (Spotting) Breast Heaviness & Tenderness Cancer (Liver Adenoma) – Rare DVT – Common Edema & Fluid retention Vomiting & Nausea Weight↑
Pregnancy Counselling: NEW FILM RG Nutrition: Folate, Calcium, Vit. D, Iron Exercise: Under physician guidance Weight gain: How much to expect? Too much + HA + Vision => VISIT ED Food: Caffeine limited, Avoid raw food (meat, fish , poultry, egg, unpasteurized milk) Immunization: Avoid live vaccines (Polio, MMR, Varicella) Lifestyle: Abuse, Smoking, Alcohol, Cocaine, Avoid cats, Sick contact Medication: Consult MD before. C/I - ACE inhibitor, TC, Retinoids, Misoprostol. Anticonvulsant, Lithium, Warfarin Radiation –avoid Genetic screening – offer every pregnant
Vaginal bleeding in Premenopausal women: ED LAB + P Endocrine (Hypothalamic- Stress, Exercise, Wt. loss; Pituitary-↑prolactin; Hypo/hyperthyroid; Ovary PCOS-↑Estrogen; Liver/renal failure- ( ↑Estrogen) Drugs (OCP, HRT, Blood thinners/Anticoagulants, Phenothiazines/Neuroleptics (^Prolactin), Steroids, St. John’s wort, Ginseng)
Local (Tumor, Trauma, TB, infecTion- 4Ts- Tumour- fibroid, polyp, adenomyosis, endometrial/Cx cancer, Ectropion etc.) Anovulatory (?) Bleeding Dz (Hematological- vWD, Platelet disorders- ITP, Clotting factors deficiency; Systemic- Marrow failure (blood cancer), Hypothyroidism, Liver failure, Renal failure)
Pregnancy related (T1- Ectopic, Threatened abortion, Molar pregnancy; T2 <20wk- E ctopic, Miscarriage, Cervical incompetence, Abraptio; T2 >20wk+T3 – Abruption, Placenta previa, Vasa previa, Uterine rupture)
Here's one for the causes of Dyspareunia : DATIVE! ( u have to be on a date to have sex ) Domestic abuse Atrophic vaginitis ( don't forget to ask about s/s of Menopause) Tumor ,Pelvic Infection ( lower : Vulvovaginitis - Cervicitis / Upper : PID ) Vaginismus Endometriosis ( don't forget to ask 'bout Cyclic pelvic pain )
Skin review of systems which aReNT SIMMBEL R (rash) N (nail changes) T (temperature) S (sensation) I (itching) M (masses) M (moles) B (bleeding/bruises) E (edema) L (lesions)
Gastrointestinal Hx- ABCDEFGHIJ+MNOP Appetite BOWEL HABITS {OsCfD Q(COCA-B)ST AA A(PTLC- pain/tenesmus/lesion/control)} CONSTIPATION Dysphagia, Diarrhea EATING HABITS. Fullness/bloating Girth of the abdomen
HAEM IN STOOL Heartburn
Incontinence JAUNDICE Medications eg iron tabs causing constipation or antibiotics causing diarrhea Nausea/Vomiting Orthostatic assessment (DTHU- Dizzy? Thirsty? Heart racing? Urine less in amount?) Pain abdomen
Trauma pt ask for AMPLE A Allergy M Medication P past med Hx L Last meal E Events before accident
Menstrual History FM DIAL F Frequency M Menarche D Duration I Intensity A Amount L LMP
For back pain "red flags" TUNA FISH Trauma Unexplained weight loss Neurological signs Age > 50 Fever Intravenous drug use Steroids for long time History of cancer
Foot pain after asking all liqoraaa ask WET SURF Work Eye infection redness Trauma to foot Stiffness in other joints Urethral discharge Rash/Reiter’s syndrome Fever (Myself)- Checklist for paraneoplastic syndrome/serotonergic symptoms 4FsFlushing- Any face flushing? Flutter- Ever felt heart racing? Faeces- Having any diarrhoea? Fear- Ever had a feeling of impending doom? >Yes> Ooooh! It must be hard!
