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Imperial College London Surgical Society Junior Anatomy Series CPA SUMMARY GUIDE History T aking Sahil Misri Defne Artun (CPA Lead) Anya Nanchahal (Phase 1a Lead) Andrea Perez Navarro (Phase 1b Lead) Imperial College London Surgical Society Junior Anatomy Series The Basic Structure of a History INTRODUCE YOURSELF & CONSENT Presenting complaint - Get the patient to open up - Let the patient speak until they’re no longer giving you the information you want! History of presenting complaint - SOCRATES - Tailor a systems review specific to the PC - FLAWS Past Medical History & Drug History - These are very much interlinked – take advantage of this fact to make the most of time! - Not just conditions! - Surgeries, allergies, past admissions Family History - in presentations like ACS, asking in detail very important, including age of death - Also procedures, like stenting, significant for IHD FHx Defne Artun (CPA Lead) Sahil Misri Imperial College London Surgical Society Junior Anatomy Series Social History - Smoking (pack years) - Drugs - Alcohol - Occupation - Living circumstances - Stairs? - Someone there to look after them? - Pets - Diet - Exercise - Sleep - Trave l - ADLs - Washing , cooking, grocery shopping ICE - Nice to intersperse with the history - May give you some clues as to PMHx, FHx etc Systems review - Neuro: headaches, weakness, changes in sensation - Cardioresp: syncope, cough, chest pain, dyspnoea - Abdo: GI (bowel), uro (urine), gynae (periods + preg) - Other: skin changes, joint pains Defne Artun (CPA Lead) Sahil Misri Imperial College London Surgical Society Junior Anatomy Series Abdominal Pain INTRODUCE YOURSELF AND CONSENT! Presenting complaint - Get the patient to open up - Let the patient speak until they’re no longer giving you the information you want! History of presenting complaint - SOCRATES - FLAWS - Bowel habit? - Constipation/diarrhoea? ± blood? - Dysphagia/odynophagia? - Vomiting± blood? - Urological symptoms? - LUTS - Haematuria - ‘loin to groin pain’ - Gynae? - Periods - Pregnancy Defne Artun (CPA Lead) Sahil Misri Imperial College London Surgical Society Junior Anatomy Series Past Medical History/Drug History/Family History - Surgeries - IBD? Cancer? Both PMHx and FHx - Immunosuppression/hepatotoxicity etc? Social History (most relevant of the list) - Smoking (pack years) - Drugs - Alcohol - Occupation - Living circumstances - Stairs? - Someone there to look after them? - Diet - Travel, recent meals (for infection) - ADLs - Washing, cooking, grocery shopping ICE - Nice to intersperse with the history - May give you some clues as to PMHx, FHx etc Systems review - Neuro: headaches, weakness, changes in sensation - Cardioresp: syncope, cough, chest pain, dyspnoea - Other: skin changes, joint pains Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series Breathlessness INTRODUCE YOURSELF & CONSENT Presenting complaint - Get the patient to open up - Let the patient speak until they’re no longer giving you the information you want! History of presenting complaint - Adapted SOCRATES - Focus on onset, time duration, exacerbating/alleviating factors, severity - Syncope? - Pleurisy or central chest pain? - Cough ± haemoptysis? Productive/dry? - Wheeze? - Palpitations? - FLAWS Past Medical History/Drug History/Family History - Surgeries - Cancer, cardiac disease? - Already having certain conditions can predispose to others, eg cancer for a pleural effusion, HIV for TB Defne Artun (CPA Lead) Sahil Misri Imperial College London Surgical Society Junior Anatomy Series Social History (most relevant of the list) - Smoking (pack years) – REALLY IMPORTANT FOR RESP - Drugs - Alcohol - Occupation - Relevant for occupational lung disease, hypersensitivity pneumonitis - Living circumstances - Stairs? - Someone there to look after them? - Travel (infection, PE) - ADLs - Washing, cooking, grocery shopping ICE - Nice to intersperse with the history - May give you some clues as to PMHx, FHx etc Systems review - Neuro: headaches, weakness, changes in sensation - Abdo: GI (bowels), urinary (LUTS, blood), gynae - Other: skin changes, joint pains Defne Artun (CPA Lead) Sahil Misri Imperial College London Surgical Society Junior Anatomy Series ST A TION TIPS Just do whatever the signs tell you to do! If it says to focus on lifestyle, focus on lifestyle! If it says you don’t have to do a systems review, don’t waste time on it! Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series WE HOPE YOU ARE ENJOYING OUR SERIES! Feedback Please fill out the following feedback form. Let us know if there is anything we can improve on: ü Are we missing anything? ü Want to see more of something? ü What are we doing well? ü Finding anything confusing? Sahil Misri sm3019@ic.ac.uk Defne Artun (CPA Lead) da1019@ic.ac.uk Anya Nanchahal (Phase 1a Lead) sn1119@ic.ac.uk Andrea Perez Navarro (Phase 1b Lead) ap6418@ic.ac.uk