Patient history - mnemonics Flashcards Preview

STEP 2 CS Hx Mnemonics > Patient history - mnemonics > Flashcards

Flashcards in Patient history - mnemonics Deck (15):
1

O&G History

LMP RTV CS PAP 
L => LMP (when was ur LMP?)
M => Menarchae, Menopause (how old were u when u had ur 1st period?)
P => Period (how many days ur period last?), Pain during intercourse => dyspareunia
R => Regularity (R ur periods regular?)
T => Tampoons/pads (how many pads do u use in a heavy day?)
V => Vaginal DID : Discharge, Itching, Dryness (have u ever had any vag discharge? ABCDO - Amount, Blood, Color, Consistency, Content, Duration, Odor; do u have any vag. Itching?)
C => Cramps (Dysmenorrhea) (do u have abd cramps with ur period?)
S => Spotting (intermenstrual / post coital) (Have u ever bled btw ur cycles? Did u ever notice any bleeding after intercourse?)
P => Pregnency ( Hx & complications) (Have u ever been pregnant? How many times?)
A => Abortion/miscarriage (Any miscarriages or abortions? In which month of ur pregnancy?)
P => PAP smear (Have u been getting regular PAP sm? When did u have the last PAP sm? Was it normal?)

2

Amenorrhea

FLAG HIV WC 
F => Fatigue
L => Libido
A (2) => Anorexia nervosa; Anxiety & Depresion 
G (2) => Galactorrhea; Gonnorhea - STDs 
H (3) => Hair & skin changes ( for Hypothyroid/Hirsutism of PCOS); Headaches; Hot flushes 
I => Insomnia
V (2) => Visual disturbance / Voice change “Deep” 
WAD => Weight change & Appetite & Diet
C (2) => Cold intolerance & Constipation

3

Premenopause

HA! DOC  
H => Hot flashes
A => Atrophy of vagina
D => Dryness of vagina
O => Osteoporosis (council) “increase wt bearing exercise, vit D-Ca” 
C => Coronary artery disease

Any Female >50 yr : R u taking vit.D & Ca? Have u ever tried HRT?

4

Neuro cases

CAP HIT NSGB + MMSE
C (2) => Confusion “after the event”; Consciousness “LOC; duration?” 
A => Aura “b4 problem; Sounds, Lights, Smell” 
P => Palpitations 
H (2) => Headache/lightHeaded & Hearing loss/tinnitus 
I => Incontinence “urine/Bowel”
T (2) => Tongue biting & Trauma& fall 
N => Nausea/vomit & Numb/tingling/weakness 
S (5) => Sleep disturbance; Sight difficulties; Speech difficulties; Seizure (duration?); Spinning 
G => Gait
B => Breathing difficulty 
 NB: in case of MVA (Motor Vehicle Accident); ask about last meal !

5

“LOC” => Loss Of Conciousness

  • Before LOC: Aura, Palpitation, Dizzy, Vision, Nausea/vomit, Difficulty breathing 
  • During LOC: Attending person? “shaking/something coming from mouth”, Incontinence “urine/stool”, Tongue bitting 
  • After LOC: Confusion, Concentration, Weakness/tingling/numbness, Gait

6

MMSE

NLB=R,SIR 
N => Name (Please tell me your full name?)
L => Location (Where are we right now?)
B => Birth (What is your date of birth?)
R => Remember (I’m going to tell you 3 different names and you have to repeat after me => C-A-T “Cat, Apple, Tree”, now please try to remember them, I will ask you to repeat them later)
S => Spell backwards (spell ‘rain’ backwards?)
I => Instruction => Eye (close/open your eyes)
I => Identify (Now I'm going to point at 3 different objects - Please tell me their names)
R => Recall (Now tell me what were the three names I told you to remember earlier)

7

Forgetfulness (Memory Loss /Dementia/Alzheimer’s); ADL - Activities of Daily Living; IADL - Instrumental Activities of Daily Living
 

FORGETS HIM + DEATH (ADL) SHAFT (IADL) + MMSE 
F => Fall/ FAINTING / Flashes/ FHx of Alzheimer
O => ORTHOSTATIC HYPOTENSION “Lightheadedness”
R => RUNNING URINE “INCONTINENCE”
G => GAIT
E => EYE “VISION”
T => TRAUMA/TINGLING & Numbness & Weakness
S => SEIZURES/ Sleep/ Speech/ Support 
H => HEADACHE
I => INFECTION [SYPHILIS, MENINGITIS] 
M => MOOD “feel sad” 
D => Dressing 
E => Eating
A => Ambulation (can you find your way thru home)
T => Toiletry (do you manage your toiletry unassisted) 
H => Hygiene
S => Shopping
H => Housekeeping
A => Accounting “pay bills”
F => Food prep (do u do your cooking )
T => Transportation (do you drive? How is your sight, hearing?)

8

Foot/Heel/Knee/Shoulder/Back pain

  • WET SURF-D-CIS
  • Weakness / weight loss
  • Eye infection / exposure to cold effects
  • Trauma / tenderness / tingling or numbness / tick bite
  • Stiffness (morning) / swelling / standing hours 
  • Urethral discharge / ulcer / use 
  • Rash / redness / rom / rheumatologic 
  • Fever, chills, night sweats / fatigue / footwear 
  • Deformity / disability / dysuria
  • Cancer 
  • IV drugs 
  • Steroids for a long time 

9

Depression

  • SIGME CAPT + 2 + MMSE 
  • Sleep, suicide, support, stress
  • Interest
  • Guilt
  • Mood, memory
  • Energy level
  • Concentration
  • Appetite, weight / Attitude
  • Psychomotor, psychiatric
  • Thyroid => ABCD HV for hypothyroidism
    • Do you realize you have a problem ? 
    • Do you accept getting help ?

10

Hearing loss

PDF IN RST

  1. Pain 
  2. Discharge 
  3. FB 
  4. Infection / Imbalance
  5. Noise 
  6. Ringing
  7. Spinning
  8. Trauma / tinnitus

11

THYROID

ABCD HV

  1. Appetite, weight, diet / Apathy
  2. Bowel movements 
  3. Cold intolerance 
  4. Depression => SIGME CAPT 
  5. Hair and skin
  6. Voice change 

12

Nasuea & Vomiting

MANGO IP

  1. Metabolic / Meds 
  2. Anorexia 
  3. Neurological => BETA => Bleed, Encephalitis, Tumor, Abscess
  4. Gastroenteritis 
  5. Obstruction
  6. Inflammation - Itis 
  7. Pregnancy 

13

Erectile dysfunction

LIM PENIS

  1. Libido
  2. Injury
  3. Medication use , Mellitus - diabetes 
  4. PMH, Pyrenoi's, Performance anxiety 
  5. Erections in the morning
  6. Nocturia, neurologic disorders
  7. Incontinence - urine, stool 
  8. Stress / depression 

14

Domestic Abuse

SAFE GARDS 

  1. Safety/Sex ever inforced : do you feel safe at home ?
  2. Alcohol abuse/Addictions : does your husband use recreational drugs ? does your husband drink alcohol ? 
  3. Family/Fractures - does anyone from your family/friends know about your situation ? Have you ever had fractures from the abuse ?
  4. Emergency plan - do you have an emergency plan ? have you planned your escape ? why ?
  5. Guns at home - are there guns at your home ?
  6. Afraid/Attacked with weapons/Attacked children
  7. Relationship with husband
  8. Depression - SIGME CAPT
  9. Suicidal - idea/plan/attempt, have you ever felt like ending it all up ?

15

Diabetic patient

DIABETICS

  1. Duration of disease; Diet; 
  2. Insulin treatment or oral drugs ? - type, dosages, times, injections sites, side effects 
  3. A1c Hg => glucose monitoring, Appetite, diet weight, Abdomial complaints - gastroparesis ?
  4. Blurry vision - retinopathy 
  5. Extriemities - foot ulcer/infection; Exercise; Eye exam on yearly basis 
  6. Tingling/numbness/neuropathy, Treatment compliance
  7. Infections
  8. Cardio : hypertesion, angina, hypercholesterolemia, 
  9. Sugar checkup/Sexual performance;