History Taking – Chest Pain - PowerPoint PPT Presentation

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History Taking – Chest Pain

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  1. Drugs: • Are you on any medications? - Prescription /over the counter/herbal remedies/recreational • SH: • Home – who lives with, mobility care/needs • Happy family – relationships • Hobbies – is the problem stopping you from doing anything? • Habits - Smoking - Do you smoke? How long for and how many? Have you • ever smoked? • - Alcohol(men 21 units, women 14 units per week) • Occupation • FH: • Are there any illnesses/diseases that run in your family? • Does any of your family have heart disease? Any high blood pressure or high cholesterol? • Are your parents still with us? (If have died of a heart attack, ask how old) • Sys Rev: • CVS – Any ankle swelling/palpitations/shortness of breath/claudications • GIT – Any nausea/vomiting/heartburn/difficulty swallowing)/changes in bowel habits • GU – Any problems with your waterworks? • CNS – Any headaches/blackouts/dizziness/LOC • Locomotor – Any joint pain/stiffness/swelling • General – Any fatigue/weight loss/fever • THANK PATIENT: • Is there anything you feel we haven’t covered today? History Taking – Chest Pain Notes: There are four systems that can cause chest pain – cardiovascular, respiratory, GI, musculoskeletal. If you want to jot down the history structure before you start – do – just explain to the patient what you are doing Practise timing – it can be tricky to fit it all in in 7 mins! Introduction: Give your name and status Ask patients name and age, check wrist band Get permission to take a history PC: Open questions What has brought you in today...? HPC: S – Site, does it radiate? Q – Quality I – Intensity (1-10) T – Time – Did the pain start suddenly or gradually? How many times have you had it? How long does it last for each time? A – Aggravating and relieving factors. Does it hurt when you move/breathe/after exercise/after eating? S – Symptoms associated with the pain. Any shortness of breath? CVS – Any ankle swelling/palpitations/shortness of breath/syncope ICE: Ideas – “What do you think is going on?” Concerns – “What concerns you the most about this problem?” Expectations – “How can I best help you with the problem?” PMH: Have you had any medical problems in the past? Any operations? Are you seeing your doctor for anything else at the moment? Have you been told that you have diabetes/HT/high cholesterol/asthma? Do you have any allergies?