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Y1 History Taking Presenting Complaint ▶ Open questions ▶ “So what has brought you in today?” ▶ “Ok, can you tell me more about that?” ▶ Allow for the ‘golden minute’ ▶ Opportunity for active listeningHPC (Cardio) - Chest pain - Palpitations - Shortness of breath - Orthopnea/PND - Syncope - Symptoms of peripheral vascular disease? - Oedema?HPC (Resp) ▶ Breathlessness ▶ Cough ▶ Sputum ▶ Haemoptysis ▶ Wheeze ▶ Chest pain ▶ Can go through SOCRATES for each symptomPast Medical History ▶ Have you ever been in hospital before? ▶ Do you see the doctor regularly for anything?Drug History ▶ Do you take any medications at all ▶ Any over the counter medications ▶ Do you have any allergies ▶ If yes → check what happens when they take the medicineFamily History ▶ Any history of anything like this in the family? ▶ If relevant, ask around age of deathSocial History - Smoking - Alcohol - Recreational drugs - Occupation - Diet - Activity level - HobbiesSystems Enquiry 1. Neuro -> headache? Change in hearing/vision? 2. Resp -> shortness of breath? Fever? Sputum? 3. Cardio -> chest pain? palpitations? 4. GI/GU -> change in appetite? Stools? Urine? Weight loss? 5. MSK -> muscle weakness? 6. Neruo -> changes in sensation? Motor dysfunction? Balance? **There are many ways to do a systems enquiry!ICE 1. Ideas 2. Concerns 3. ExpectationsSummarize (SBAR) 1. Situation 2. Background 3. Assessment 4. RecommendationQ&APractice Scenario Mr Smith is an 56 year old male attending the GP practice due to chest pain. Please take a history from this patient.PC - Chest pain - yes S - central chest, 7/10 pain (when present) - Palpitations - none O - sudden - Shortness of breath - none C - dull, tightness - Orthopnea/PND - none R - no radiation - Syncope - none A - resting - Symptoms of peripheral vascular disease? - none T - around 5 minutes - Oedema? - none E - exercise, sometimes going up the stairs S - nilPMH + FH PMH + allergies: - GP said his BP was high (unsure number) - Otherwise ‘fit and well’ - Not on regular medications - Broke his wrist as a teenager - ‘Allergic’ to penicillin Family History: - Father died from heart attack (age 62) - Mother had nothing significantSocial History - Used to smoke (smoked for 20 years, half a pack a day) - Social drinker - No recreational drugs - Lorry driver - Lives with wife at home along with two young childrenICE I = want an explanation, further testing needed? C = worried he will die from heart attack like his father E = get an answer from the GPSystems enquiry Practice asking a systems enquiry!Summary Mr. Smith is a 56 year old man who presented today due to chest pain on exertion. He rates the pain as 7/10 which lasts for 5 minutes and is relieved by rest. He is currently not on any regular medicationFeedback Please take a minute now before you leave to fill in a quick feedback form: Individual links will be provided for you AIM Facebook Page ▶ Give our Facebook page a like for updates and opportunities,just search @AIMEdinburghThank you for coming! ▶ If you have any more questions, feel free to email me at example@ed.ac.uk, or email accessibilityinmedicine@gmail.comFeedback https://app.medall.org/training/feedback/anonymous?organisation=acces sibility-in-medicine&keyword=3951196e78548d57e97df08d