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HISTOR Y TAKING F I N A L Y E A R M E D I C A L S T U D E N T U N I V E R S I T Y O F L E E D SOPENING THE CONSUL T A TION • 1 Wash your hands • 2 Introduceyourself to the patient including your name + role • 3 Confirm the patient's name and DOB • 4 Explainthat you'd like to take a history from the patient + gainntSOB • 87 F • SOB DIFFERENTIALS OF SOB • Cardiac • MI • PE • HF • Pericardial effusion • AF/VT/VF/SVT • Resp • Asthma, COPD +/- exacerbation • PE • Pneumonia • Pleural effusion • Pneumothorax • Psych • AnxietySTART Duration WITH AN OPEN QUES Onset – Sudden/gradual? Progression -> Sx worsening? Prev. Episodes CARDIAC HX • SOB • On exertion? • Or at rest? • Orthopnoea – How many pillow? Prev. pillow number? • PND – ever woken up gasping for air? • Current exercise tolerance (ET) • Prev. ET • CP • SOCRATES. On exertion? • Palpitations – duration, frequency, can you tap it out, triggers? • Dizziness + syncope • Leg swelling • Bilateral?SOCRATES RESP SX • Cough • ?productive – colour, amount, changing colour • Wheeze • Haemoptysis • PE • Leg swelling • Travel hx • CP -> pleurtic • Chest infections -> bronchiectasisGI SX • N&V -> Nausea + vomiting • Difficulty swallowing/Dysphagia • Heartburn/Dyspepsia • Abdo pain • SOCRATES • Bowel habits -> frequency + consistency • Blood – PR • Colour, amount, etc. • Melaena • Mucus • Steatorrhea • JaundiceURIN AR Y SX • Dysuria • Increased frequency • Blood • Colour changes? • Dark urine + pale stools = obstructive jaundiceNEUR O • Headache • Visual changes • Numbness, weakness, tingling? SYSTEMIC SX • Fever • Wt loss • Loss of appetite • Night sweats • FatigueICE • Ideas • Was there anything that you think was going on? • Concerns • Anything in particular that you were concerned about? • Expectations? • Was there anything else you were hoping to discuss?P AST MEDICAL HISTOR Y CVD such as HTN, hyperlipidaemia Previhistorygical hospitalisation and diabetesDR UG HISTOR Y • Any regular meds or over-the-counter meds • Allergies + reaction F AMIL Y HISTOR Y • CVD disease – age • Any hx of sudden death + age • Cancers, DM, etc.SOCIAL Smoking history + pack years – how many + duration HISTOR Y Alcohol history – What, amount + frequency Recreational drug use Occupation Do you live alone? In a house/flat/bungalow Do you manage at home independently? ADLs Diet and exercise87F SOB • 3 month hx + worsening SOB • Orthopnoea + PND • Increased number of pillows from 2 to 4 • Decreased ET • Used to be able to walk long distances without any problems. Now ET = 100 yards • Cough • White frothy sputum every day • B/L ankle swelling • Nil other sx • Has well controlled DM on metformin, smoker 20 pack yr hx, no FH.WHA T NEXT? • Examination • Spo2 = 88%. HR 112. RR 25. BP 150/95 • Raised JVP. nd • HS 1 + 2 + ejection systolic murmur heard loudest over right 2 ICS • B/L widespread crepitations • B/L leg swelling with sacral oedema. • Dx • Acute HF secondary to aortic stenosisIX • Bedside • Full set of obs • ECG • LVH + L-axis deviation • ABG! • Showed T1RF -> Hypoxia without hypercapnia -> due to pulmonary oedma • Bloods • FBC, U&E, LFT • BNP • Imaging • CXR • EchoMX • O2 • 15L/min via NRM • Sublingual/IV GTN • Furosemide • Senior inputFATIGUE •74yr old femaleDDX • Endocrine • Hypothyroidism • Psych • Depression • Anaemia • DiabetesF A TIGUE • Hypothyroidism • Mood, cold intolerance • Wt gain • Constipation • Depression sx • Mood, energy levels, sleep, concentration • Loss of appetite, wt loss • Risk assessment – suicidal thoughts, plan, prev. attempts. Thoughts of self-harm or hurting anyone else?F A TIGUE • DM • Polyuria, polydipsia • Wt loss • Anaemia • Blood loss – vomit, haemoptysis, PR loss, haematuria • SOB, dizziness, syncope, CP • PR loss • Frequency • How much, colour, black stool, mixed in with stool/in toilet bowl/on wiping? • Cancer • Wt loss, loss of appetite, night sweats, fever • Quantify wt loss – how much over how long + intentional?F A TIGUE • Few months hx of fatigue • Tired all the time • PR blood loss – mixed in with stool • Change in bowel habits – loose stools • Reports wt loss + loss of appetite. • Feels a bit SOB and light-headed sometimes.IX • Examination • Abdo • Cardio-resp • PR • Ix • Bloods -> FBC, U&E, LFT, CRP • Stool sample • Mx • 2WW referral • Colonoscopy + biopsy Feedbackform THANK YOU FOR LISTENING!