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Lecture 7: Sunday 25 March 2023 Presented by: Rehan Aftab History T aking SURGICAL SOCIETY JUNIOR ANATOMY SERIES | CPA LECTURE SERIESContents 1. What to expect 2. A basic structure 3. Systems review 4. Some tips and tricks S U R G S O C J A S | C P A L E C T U R E S E R I E SWhat to expect • An actor and an examiner • 11 min • They may ask you to focus on certain parts of the history – do it!! S U R G S O C J A S | C P A L E C T U R E S E R I E S Introduction & Consent - Name & role - Reason - Expected time - Would it be okay with you? - Name and DOB of patient! S U R G S O C J A S | C P A L E C T U R E S E R I E S Presenting Complaint - Think about ways to open up the conversation - What brings you in today? - What can we help you with today? TIP! - Allow the patient to flow for a bit - They’ll make life easier for you S U R G S O C J A S | C P A L E C T U R E S E R I E S History of Presenting Complaint - If pain: SOCRATES - If something else: SOCRATES still useful to use as a base - Other questions: - Has something like this ever happened to you before? - Has it been getting better or worse? S U R G S O C J A S | C P A L E C T U R E S E R I E S • Site SOCRA TES • Onset - Remember – lots of the content may have already been covered during the golden • Character minute • Radiation - Feel free to stick in brief symptom-related systems review as part of ‘A’ • Associated symptoms • Time • Exacerbating/alleviating factors - This is a good place to include interim • Severity (/10) summary S U R G S O C J A S | C P A L E C T U R E S E R I E S Past Medical History - Do you have any other medical conditions? - Is there anything you regularly see your GP for? - Any previous admissions to hospital? TIP! - Listen carefully to PMH - They might give you - Any previous surgeries? indications as to what meds they may be on! S U R G S O C J A S | C P A L E C T U R E S E R I E S Drug History - Any medications? - Any over-the-counter medications or herbal treatments? - Drug allergies or other allergies TIP! - Listen carefully to the meds TIP! - They might give you a clue - Links nicely in with as to the PMH ‘E’ in SOCRATES! S U R G S O C J A S | C P A L E C T U R E S E R I E S Family History - Are there any medical conditions that run in the family? - You may want to be more specific depending on the PC - Find out ages at Dx, death TIP! - Good place to show the examiner how empathetic you are! S U R G S O C J A S | C P A L E C T U R E S E R I E S Social History - Smoking - Alcohol - Recreational drugs - Occupation ± stress - Living circumstances - Exercise tolerance - ADLs - Diet TIP! - Sleep - Be sensitive! - Travel - We’ll go over some examples S U R G S O C J A S | C P A L E C T U R E S E R I E S How to ask questions in the social history DON’T DO Launch straight in with ‘do you do drugs’ Signpost Make specific parts a big deal State that you ask all these questions to everyone, during your signposting Ask ‘What’s your job’/’what do you do for work’ Ask if they’re working, and then follow up Ask ‘who do you live with?’ or make any Ask ‘is there anyone at home with you?’ assumptions about living situations/partners S U R G S O C J A S | C P A L E C T U R E S E R I E S ICE - Ideas, concerns and expectations - May dredge up something not covered in the history! TIP! - Doesn’t have to be at the end, nice to intersperse and react to the patient! S U R G S O C J A S | C P A L E C T U R E S E R I E S If you have time for a full systems review… - Neuro: headaches, weakness, sensation changes - Cardioresp: syncope, dyspnoea, chest pain, cough - GI: bowel movements - Uro: urinary symptoms (LUTS, haematuria) - Other: skin changes, joint pains, recent infections/illness S U R G S O C J A S | C P A L E C T U R E S E R I E SAbdominal Pain • An example history • Your turn to get involved! S U R G S O C J A S | C P A L E C T U R E S E R I E S Introduction & Consent - Must start off with the introduction - Who are you? What’s your role? Why are you here? Will it be confidential? Is it ok with the patient? S U R G S O C J A S | C P A L E C T U R E S E R I E S PC & HPC SOCRATES - Crucial in an abdominal history to cover all elements of SOCRATES S U R G S O C J A S | C P A L E C T U R E S E R I E S Abdo Pain: Associated Sx and Systems Review - CIBH including blood in stools (colour, amount etc), last BM - Nausea ± vomiting (colour, amount etc) - Dysphagia/odynophagia - FLAWS - Don’t forget! Other systems live there too! - Urinary symptoms - Gynae (ask about pregnancy, periods) - Chest pain & other cardioresp symptoms eg: dyspnoea S U R G S O C J A S | C P A L E C T U R E S E R I E S PMHx/FHx & DHx - Previous abdominal surgeries -> adhesions -> ?SBO - Previous abdominal surgeries rule out conditions - Certain drugs are likely to cause constipation/pancreatitis/immunosuppression - Certain conditions eg: IBD, cancer, nephrolithiasis are associated with FHx S U R G S O C J A S | C P A L E C T U R E S E R I E S Social History - EtOH – very relevant for chronic liver disease, pancreatitis - Smoking a risk factor for cancer - Recent things the patient has eaten - Ask about travel – relevant for ID S U R G S O C J A S | C P A L E C T U R E S E R I E S • An example history Breathlessness • Think about how to adapt a common history (abdo pain) to one which is less 2 year material S U R G S O C J A S | C P A L E C T U R E S E R I E S TASK: Adapt SOCRATES to fit breathlessness - When did the breathlessness start? (acute: PE/pneumothorax, chronic: COPD) - Is it always there? - How would you describe the SOB? Eg: deep breaths, can’t get air in, hyperventilation? - What makes the breathlessness worse/better? - Orthopnoea (eg: CHF) - Worse during the week (?occupational exposure) - Worse in the cold/with animals/exercise? (eg: asthma) - How bad is the breathlessness (how far can you walk? How many stairs etc) S U R G S O C J A S | C P A L E C T U R E S E R I E S Associated Symptoms Symptom Potential Cause Central chest pain Stable angina/ACS Pleuritic chest pain PE/pleural disease Palpitations Tachyarrhythmia, anxiety Syncope Tachyarrhythmia Wheeze Asthma, COPD Cough (nature?) COPD, infection FLAWS, haemoptysis Cancer, infection S U R G S O C J A S | C P A L E C T U R E S E R I E S PMHx/FHx/DHx - Known autoimmune disease - Known malignancy - Previous procedure/surgery (eg: radiotherapy, pleurodesis) - Beta blockers may worsen asthma symptoms - Some medications may cause pulmonary toxicity S U R G S O C J A S | C P A L E C T U R E S E R I E S Social History - Smoking is so essential (pack year history to be elicited in a resp history for sure) - Can get a vaping history - Travel history relevant for infectious disease - and also for PE (DVT) - This is where the pets become interesting! -> hypersensitivity pneumonitis - Job – occupational exposure eg: asbestos-related lung disease S U R G S O C J A S | C P A L E C T U R E S E R I E S In Summary Intro into what the CPA The basic structure of a Lots of tips along the way may be like history Specific focus on Specific focus on dyspnoea Questions and feedback abdominal pain form please ☺ S U R G S O C J A S | C P A L E C T U R E S E R I E S Rehan Aftab rehan.aftab20@imperial.ac.uk JAS Leads CPA Lead: Mohamad Abou-Eid (ma2219@ic.ac.uk) Phase 1a Lead: Sree Kanakala (sk1821@ic.ac.uk) Phase 1b Lead: Ananya Jain (aj620@ic.ac.uk) Feedback