Comprehensive Medical History and Clinical Research Insights

Posted on Jan 16, 2025 in Medicine

General Information / Demographics

Name, age, date of birth (DOB), gender/sex, marital status, religion, address, occupation, language, birthplace, schooling, blood type, race, contact information, emergency contact.

Chief Complaint

History of the chief complaint (when did it start/onset), location, evolution of symptoms, radiation, association, type of pain, intensity, medication, exacerbation (activities), if it’s the first time.

Family History / Family Diseases

Relevant medical information of first-line relatives (mother, father, siblings, grandparents) of diseases of importance.

Social History / Non-pathological History

Nutritional status, lifestyle, hygiene, physical activity, living arrangements, exposure to pets or animals, drug abuse (tobacco, alcohol, recreational drugs), occupation, sleep pattern, allergies, hobbies, tattoos.

Past Medical History

Hospitalizations, emergency room visits, blood transfusions, chronic diseases, surgeries, bone fractures (broken bones), allergies, immunizations (vaccines), sex life (number of partners), past illnesses (cardiac infarction, strokes, etc.), childhood diseases, medications.

OB/GYN History

Menarche, thelarche, pubarche, sex life (number of partners), period/menstruation (frequency, last period date, quantity, pain), birth control (contraceptive methods), pregnancies, deliveries, C-sections, abortions, Pap smear, STDs history, mammography, menopause.

Review of Systems (ROS)

  • Nervous system: Headache, consciousness, memory
  • Cardiovascular system: Chest pain, palpitations
  • Respiratory system: Dyspnea, cough, chest pain
  • Gastrointestinal system: Constipation, abdominal pain, vomiting, diarrhea
  • Genitourinary system: Urine frequency, color, quantity, anuria, oliguria, odor, blood in urine, dysuria
  • Endocrine system: Weight loss, weight gain, voice change, sweating, tremors
  • Musculoskeletal system: Pain, injuries, joint pain, loss of movement, loss of sensibility
  • Skin: Rash, sun exposure, dryness, pigmentation changes, dryness

Physical Examination

Vital signs, general appearance.

  1. Past medical history: Total sum of a patient’s health status prior to the presenting problem.
  2. Review of systems: Inventory of the body system that is obtained through a series of questions in order to identify signs and/or symptoms.
  3. Social history: Section of the medical history that addresses the familial, occupational, and recreational aspects of the patient that are clinically significant.
  4. Family history: This section of the medical history may help risk-stratify patients with conditions with genetic links.
  5. Abstract: Summary of the case, the problem it addresses, and the message it conveys.
  6. Conclusion: Section that briefly gives readers the key points covered in the case report.
  7. Discussion: Section of the case report that focuses on explaining why the case is noteworthy and the problem that it addresses.
  8. Introduction: Brief overview of the problem that the case addresses.
  9. Case: Section that provides the details of the case.
  10. Reasons for publishing a case report, except: To share knowledge of a known disease to students.
  1. What is the definition of clinical research? Branch of medical science that determines the safety and effectiveness of medication, devices, diagnostic products, nutrition or behavior changes, and treatment regimens intended for human use.
  2. In this phase of a clinical trial, the main objective is to ensure the safety of the new medication in humans: PHASE I
  3. In this phase of clinical trials, the population has the disease, it is a population bigger than 300, and the duration is longer than 3 years: PHASE III
  4. Briefly describe the different parts of a scientific article:
    • Title: A brief sentence that gives an idea of what the article is about.
    • Authors: The first one must be the main author or principal investigator, and the rest in alphabetical order.
    • Introduction: Gives a general idea of what the article is about and the context around the research.
    • Materials and methods: How we are going to find the information.
    • Results: The outcomes of the research process and the statistical analysis.
    • Discussion: Interpretation of the results.
    • Conclusion: The importance of the research that was performed.
    • References: The sources of the information from the article.
  1. What is the meaning of an open-label RCT, and what are the disadvantages of that type of study? Open: Both parties are aware of the treatment. Not very effective as your attitude can potentially affect your reliability in taking the test medication or even your response to the treatment. Overall purpose is the acquisition of new knowledge, not the treatment per se.
  2. In a case report, it is important to include a complete medical history with all the information from the record of the patient: FALSE
  3. The structure of a case report includes, EXCEPT: MATERIALS AND METHOD
  4. A case report is useful for the following reasons, EXCEPT: TO REINFORCE PREVIOUS KNOWLEDGE OF A WELL-KNOWN DISEASE
  5. An RCT gives the best level of evidence for evidence-based medicine: TRUE
  6. When asking an expert opinion about a clinical issue, what level of evidence do we have? V
  7. In the social history section of the clinical history, we should add the following information: Nutritional status
  8. In the past medical history section of the clinical history, we should add the following information: Surgeries
  1. A medical record is a legal document that has all the information about the medical history of the patient. It should include all the information available about the patient, except personal information: False
  2. This medical term describes excessive hunger or increased appetite: Polyphagia
  3. The structure of a case report includes, except: Materials and methods
  4. How often should a female patient have a Pap smear test done (if an abnormality is found)? Once a year
  5. When submitting a case report, any discrepancies between the current management of the patient’s conditions and evidence-based recommendations should always be avoided: False
  6. A case report is useful for the following reasons, except: To reinforce previous knowledge of a well-known disease.

Our:

  1. What is the main use of an RCT in clinical research? Its main use is based on analyzing the effect of certain medications or treatments. Likewise, it has high reliability to know if a treatment is effective or not.
  2. What is the main purpose of the randomization process in an interventional trial? This is intended to ensure that all potential confounding factors are divided equally among the groups that will later be compared.
  1. What are the limitations of the open-label trials, including the bias that may be found in this study? For example, if their attitude could affect their reliability in taking the test medication or even their response to treatment.
  2. What is the importance of the bioethical principles and the monitoring of the patients in clinical research under these principles? It is important that these patients be followed up since they should be in complete monitoring to be able to attach and collect the data that each patient presents.
  3. What is the main use of the observational studies in research? Associations between things or factors, for example, risk factors, help to assess associations between diseases and exposures.
  1. Please describe the different phases of clinical trials, the main purpose, and the principal characteristics of each one:
    • Preclinical study – Phase 0: Evaluation of toxicology and immune response (animals).
    • Phase I – Healthy subjects <100, 1 year or less: Safety assessed.
    • Phase II – 100-300 patients, 1-2 years: Efficacy and safety.
    • Phase III – 300-thousands, 3 years or more: Efficacy confirmed, also safety and side effects with similar treatments.
    • Phase IV – +200 participants, to assess long-term effects of treatment, drug is approved.
  2. What are the main limitations of a retrospective cohort?
    • Resp 1: The primary disadvantage of this study design is the limited control the investigator has over data collection. The existing data may be incomplete, inaccurate, or inconsistently measured between subjects.
    • Resp 2: Susceptible to recall bias or information bias, less control over variables.
    • Resp 3: An advantage of the retrospective study design analysis is the immediate access to the data. A disadvantage is the limited control over the data collection.

Diabetes Mellitus (DM)

  1. In addition to diet modification, which of the following would be the next treatment option for optimizing this patient’s diabetes management? Continue metformin, start dulaglutide (GLP-1 agonist), 0.75mg once a week. Advise the patient to monitor glucose before each meal and send a glucose profile back for review and adjustment in medication in 2 weeks.
  2. Kidney disease is one of the possible complications of diabetes. What are the risk factors for the development of kidney failure? Diabetes, hypertension, >60 years, cardiovascular disease, family history of kidney disease.
  3. You perform some lab tests with the following results: Hb A1c 8.2%, serum creatinine 1.4 mg/dL, GFR 73 mL/min/1.73, urine albumin: creatinine 27mg/dL, unchanged from prior evaluation 6 months. This patient does not have diabetic kidney disease on the basis of having UACR <30 mg/dL.
  4. You counsel the patient that this target HbA1C% and blood sugars should be which of the following: HbA1C <6.5-7.0%, fasting/preprandial blood sugar 80-130 mg/dL.
  5. The pathophysiology of the diabetes mellitus of this patient is characterized by which of the following: A and B correct.

Diverticulosis

  1. With the information provided above, what diagnosis would you initially give to this patient? Diverticulitis.
  2. Based on your diagnosis, what would be the next step for the management of this patient? Ambulatory treatment with antibiotics, a diet rich in fiber, exercise, and analgesics.
  3. Based on your diagnosis, what would be your differential diagnosis with this patient? Appendicitis, Crohn’s disease, ulcerative colitis.
  4. What test would give you the final diagnosis of this patient? Hematology lab test, C-reactive protein, CT scan, physical exploration.
  5. Risk factors: Hypertension, kidney failure.

Ectopic Pregnancy

  1. What is the initial diagnosis for your patient? Ectopic pregnancy.
  2. What is the first step you would take with this patient that would be important for your diagnosis? Pregnancy test.
  3. What differential diagnosis would you give to this patient? Appendicitis, ovarian torsion.
  4. In the description of the case, what is the main risk factor that this patient has for her diagnosis? Pelvic inflammatory disease in the past.
  5. What is the treatment for this patient, based on your initial diagnosis? Surgery.

Hypertension

  1. With this information, what would you tell the patient? C and D are correct.
  2. What are the patient’s risk factors for the high blood pressure measurements? Smoker, unhealthy diet, alcohol, race.
  3. If a diagnosis of hypertension is confirmed, besides a pharmacologic treatment for this patient, which would be a calcium channel blocker, what recommendation would you give to the patient? DASH diet, exercise, stop smoking and alcohol.
  4. A diagnosis of hypertension is confirmed, and you start amlodipine. You have Danny’s sprained ankle has healed, and all swelling has cleared. His blood pressure at the moment is 135/86 mmHg. What would you suspect to be the cause of this new symptom, and what would you do about it? Edema and stop the medicine.
  5. You perform an EKG on the patient. With the history of his symptoms, what would you expect to find? Left ventricular hypertrophy as a consequence of high blood pressure.

Hypothyroidism

  1. What is the clinical diagnosis that you would give to this patient, based on the symptoms described above? Hypothyroidism.
  2. If you decide to initiate treatment for this patient, what would this treatment be? Levothyroxine.
  3. What laboratory or imaging test would you perform to confirm your diagnosis? TSH, T3, T4, USG.
  4. What result would you expect to find in the patient’s results of the tests that you performed? Decreased T3, T4, normal or increased TSH.

Pancreatitis

  1. Which of the following is considered a hallmark symptom of pancreatitis? Mid-epigastric pain that radiates to the back.
  2. Patient admitted with DM, malnutrition, osteomyelitis, has a serum amylase level of 280 U/L and serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? Alcohol abuse.
  3. Which of the following is not used in the treatment of acute pancreatitis? Corticosteroids.

Hyperthyroidism

  1. What is the likely diagnosis, based on the information provided above? And which lab test is needed to confirm this information? Hyperthyroidism, TSH.
  2. What are the symptoms that made you consider that diagnosis? Palpitations, period irregularity, sleepiness, sweating.
  3. What physical findings supported the diagnosis? 3 nodules, 2 on the right and one on the left, a total gland size of 60 grams.
  4. Which lab data supported the diagnosis? T3.
  5. What is the principal complication of this condition? Graves’ disease.

EVC (Stroke)

  1. What is the diagnosis of this patient based on the information provided above? EVC (Stroke).
  2. What are the clinical findings to consider that diagnosis? Diathesis, facial paralysis, and hemiplegia.
  3. What are the risk factors that the patient has for the condition he is presenting? Diabetes, hypertension, smoking, alcohol.
  4. What is the aim of treatment for this patient? Anticoagulants.
  5. What is the cause of the infarction of this patient, meaning a quick description of the pathophysiology of the disease? A clot that reaches the cerebral artery, generating infarction due to lack of circulation.