History Taking Presentation PDF

HISTORY TAKING Dr Anthony Chaccour STEP 1: INTRODUCE YOURSELF IDENTIFY THE PATIENT GAIN CONSENT TO SPEAK WITH THEM GAIN CONSENT TO TAKE NOTES WHILE TALKING TO THE PATIENT STEP 2: PRESENTING COMPLAINT This is what the patient tells you is the reason for presenting, for example:...

HISTORY TAKING Dr Anthony Chaccour STEP 1: INTRODUCE YOURSELF IDENTIFY THE PATIENT GAIN CONSENT TO SPEAK WITH THEM GAIN CONSENT TO TAKE NOTES WHILE TALKING TO THE PATIENT STEP 2: PRESENTING COMPLAINT This is what the patient tells you is the reason for presenting, for example: Chest pain, vomiting, joint pain… STEP 3: HISTORY OF PRESENTIG COMPLAINT: Gain as much information you can about the specific complaint. The SOCRATES acronym is used for any type of pain history.  Site: Where exactly is the pain?  Onset: When did it start, was it constant/intermittent, gradual/ sudden?  Character: What is the pain like e.g. sharp, burning, tight?  Radiation: Does it radiate/move anywhere?  Associations: Is there anything else associated with the pain, e.g. sweating, vomiting.  Time course: Does it follow any time pattern, how long did it last?  Exacerbating / relieving factors: Does anything make it better or worse?  Severity: How severe is the pain, consider using the 1-10 scale? STEP 4: PAST MEDICAL HISTORY Gather information about a patient’s other medical problems: Including major illnesses, any previous surgery/operations, any current ongoing illness (e.g. diabetes). STEP 5: DRUG HISTORY  Find out what medications the patient is taking, including dosage and how often they are taking them, for example: once-a-day, twice-a-day, etc.  At this point it is a good idea to find out if the patient has any allergies STEP 6: FAMILY HISTORY Gather some information about the patient’s family history, e.g. diabetes or cardiac history. Find out if there are any genetic conditions within the family, for example: polycystic kidney disease. STEP 7: SOCIAL HISTORY This is the opportunity to find out a bit more about the patient’s background. Remember to ask about smoking and alcohol Depending on the case it may also be pertinent to find out whether the patient drives, e.g. following an MI patient cannot drive for one month You should also ask the patient if they use any illegal substances, for example: cannabis, cocaine, etc. Also find out who lives with the patient. You may find that they are the carer for an elderly parents or a child and your duty would be to ensure that they are not neglected if your patient must be admitted/remain in hospital. STEP 8: REVIEW OF SYSTEMS  Gather a short amount of information regarding the other systems in the body that are not covered in your HPC. These are the main systems you should cover:  Cardiovascular system  Respiratory system  Gastro-Intestinal system  Neurology  Genitourinary/Renal  Musculoskeletal  Psychiatry Please note these are the main areas. However, some courses will also teach the addition of other systems such as ENT or Ophthalmology. STEP 9: SUMMARY OF HISTORY  Complete your history by reviewing what the patient has told you  Repeat back the important points so that the patient can correct you if there are any misunderstandings or errors  You should also address what the patient thinks is wrong with them and what they are expecting/hoping for from the consultation. A useful acronym for this is ICE: Ideas, Concerns & Expectations STEP 10: PATIENT QUESTIONS / FEEDBACK During or after taking their history, the patient may have questions that they want to ask you. It is very important that you don’t give them any false information. STEP 11: When you are happy that you have all the information you require, and the patient has asked any questions that they may have, you must thank them for their time and say that one of the doctors looking after them will be coming to see them soon.  CASE PRESENTATION: A 55-year-old male presents to the emergency department with chest pain. STEP 1: INTRODUCE YOURSELF IDENTIFY THE PATIENT GAIN CONSENT TO SPEAK WITH THEM GAIN CONSENT TO TAKE NOTES WHILE TALKING TO THE PATIENT STEP 2: PRESENTING COMPLAINT The patient has a really strong chest pain STEP 3: HISTORY OF PRESENTING COMPLAINT S - Site: The patient describes the pain as being in the centre of his chest, behind the sternum. O - Onset: The chest pain started suddenly while the patient was watching TV about an hour ago. He describes it as coming on without any warning or obvious trigger. C - Character: The patient describes the pain as a heavy, crushing sensation, as though “an elephant is sitting on his chest.”  R - Radiation: The pain radiates to his left arm and jaw. A - Associated Symptoms: He reports associated shortness of breath, nausea, sweating, and light- headedness. T - Time/Duration: The pain has been continuous for the past hour, and it has not improved or worsened over that time.  E - Exacerbating/Relieving Factors: The pain is worsened by physical activity (he tried walking briefly), but nothing relieves it. Rest does not help. S - Severity: On a scale of 1 to 10, the patient rates the pain as 9/10 in severity STEP 4: PAST MEDICAL HISTORY He had an appendectomy when he was 25 years old. Blood cholesterol: LDL was 131 mg/dl (normal range: 80-130 mg/dl). STEP 5: DRUG HISTORY He just takes omega-3 and multivitamins pills every day. For the cholesterol: the Dr recommended a diet and sports  STEP 6: FAMILY HISTORY His father had a history of coronary artery disease and died of a heart attack at age 60. His mother had diabetes and breast cancer. STEP 7: SOCIAL HISTORY He is a bus driver, married and has 2 kids. He smokes 1 pack of cigarettes per day for the last 37 years. Socially drinks on weekends. Never used drugs. STEP 8: REVIEW OF SYSTEMS Vital Signs on Admission: Blood Pressure: 150/90 mmHg Heart Rate: 95 beats per minute Respiratory Rate: 20 breaths per minute Oxygen Saturation: 98% on room air Temperature: 37°C General: Alert and anxious, in mild distress. Cardiovascular: Regular rate and rhythm, no murmurs. Respiratory: Clear to auscultation, no wheezing or crackles. Abdomen: Soft, non- tender, no distension. STEP 9: SUMMARY OF HISTORY ICE: Ideas, Concerns & Expectations STEPS 10 &11: Patient questions / feedback and thank him Differential Diagnosis: Acute Coronary Syndrome (Myocardial Infarction/Angina) Pulmonary Embolism Aortic Dissection Gastroesophageal Reflux Disease (GERD) Pericarditis Investigation: ECG to look for ischemic changes, T-segment elevation in leads II, III, and aVF, indicative of inferior STEMI. Troponin levels to assess myocardial damage, Elevated troponin levels confirmed myocardial injury. Chest X-ray to rule out other thoracic causes. Blood pressure monitoring and possibly a CT scan to rule out aortic dissection. Management: Immediate Treatment: Administered aspirin and nitroglycerine. Started on anticoagulation with heparin. Pain management with morphine. Intervention: The patient was taken for urgent cardiac catheterization, where a blockage was found in the right coronary artery. A stent was placed successfully.