Patient history - mnemonics Flashcards
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?)
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
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?
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 !
“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
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)
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?)
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
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 ?
Hearing loss
PDF IN RST
- Pain
- Discharge
- FB
- Infection / Imbalance
- Noise
- Ringing
- Spinning
- Trauma / tinnitus
THYROID
ABCD HV
- Appetite, weight, diet / Apathy
- Bowel movements
- Cold intolerance
- Depression => SIGME CAPT
- Hair and skin
- Voice change
Nasuea & Vomiting
MANGO IP
- Metabolic / Meds
- Anorexia
- Neurological => BETA => Bleed, Encephalitis, Tumor, Abscess
- Gastroenteritis
- Obstruction
- Inflammation - Itis
- Pregnancy
Erectile dysfunction
LIM PENIS
- Libido
- Injury
- Medication use , Mellitus - diabetes
- PMH, Pyrenoi’s, Performance anxiety
- Erections in the morning
- Nocturia, neurologic disorders
- Incontinence - urine, stool
- Stress / depression
Domestic Abuse
SAFE GARDS
- Safety/Sex ever inforced : do you feel safe at home ?
- Alcohol abuse/Addictions : does your husband use recreational drugs ? does your husband drink alcohol ?
- Family/Fractures - does anyone from your family/friends know about your situation ? Have you ever had fractures from the abuse ?
- Emergency plan - do you have an emergency plan ? have you planned your escape ? why ?
- Guns at home - are there guns at your home ?
- Afraid/Attacked with weapons/Attacked children
- Relationship with husband
- Depression - SIGME CAPT
- Suicidal - idea/plan/attempt, have you ever felt like ending it all up ?
Diabetic patient
DIABETICS
- Duration of disease; Diet;
- Insulin treatment or oral drugs ? - type, dosages, times, injections sites, side effects
- A1c Hg => glucose monitoring, Appetite, diet weight, Abdomial complaints - gastroparesis ?
- Blurry vision - retinopathy
- Extriemities - foot ulcer/infection; Exercise; Eye exam on yearly basis
- Tingling/numbness/neuropathy, Treatment compliance
- Infections
- Cardio : hypertesion, angina, hypercholesterolemia,
- Sugar checkup/Sexual performance;
