24 year-old female presents to GP with abdominal pain HISTORY TAKING.
-
Upload
xavier-hughen -
Category
Documents
-
view
214 -
download
0
Transcript of 24 year-old female presents to GP with abdominal pain HISTORY TAKING.
![Page 1: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/1.jpg)
HISTORY-TAKING
![Page 2: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/2.jpg)
24 year-old female presents to GP with abdominal pain
HISTORY TAKING
![Page 3: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/3.jpg)
HISTORY TAKING
Presenting Complaint
History of presenting complaint
Past Medical History
Drug History
Family History
Social History
Systems Review
Ideas, concerns, expectations
![Page 4: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/4.jpg)
ash HandsWIPER
ntroduce self, check patient details
ermission
xpose patient (examination only)
ight-hand side of bed (examination only)
HISTORY TAKING
![Page 5: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/5.jpg)
HISTORY TAKING
Presenting Complaint (PC)OPEN QUESTIONS:
“Why have you come in today?”
“Could you tell me more about the……….?”
![Page 6: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/6.jpg)
History of Presenting Complaint (HPC)For PAIN, use a mneumonic:
SQITASite
uality
ntensity
iming
ggrevating and relieving factors
ymptoms associated
HISTORY TAKING
![Page 7: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/7.jpg)
HISTORY TAKING
SUMMARISE the presenting complaint
![Page 8: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/8.jpg)
HISTORY TAKING
Past Medical History (HPC)
HISTORY TAKING
Medical conditions
Hospitalisations
Serious illnesses / injuries
Operations
![Page 9: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/9.jpg)
Drug History (DH)
HISTORY TAKING
ALLERGIESCurrent medications:• Prescribed• Over-the-counter
• Name• Dose• Frequency
Recreational drugs
![Page 10: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/10.jpg)
Family History (FH)
HISTORY TAKING
Anyone in family had similar problem?
Any serious illnesses in the family?
![Page 11: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/11.jpg)
Social History (SH)
HISTORY TAKING
Work
Home circumstances
• Current smoker?• Past smoker?• How many years?• Cigarettes/ roll-ups / cigars?• How many per day?
Smoking
• Who lives at home – partner? Children?• Stairs at home?• Need help with housework, shopping, cooking?
• Do you drink alcohol?• What? Wine? Beer?• How much? • Calculate units/week
Alcohol
![Page 12: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/12.jpg)
Systems ReviewCouple of questions for each body system e.g:
• Fits, faints, funny turns• Headaches• Vision problems
CNS (central nervous system)
• Shortness of Breath (SOB)• Cough – blood (red flag)
RS (respiratory system)
• Chest pain• “Heart fluttering” (palpitations)• Ankle swelling
CVS (cardiovascular system)
• Change in bowel habits – blood (red flag)• Nausea or vomiting• Weight loss – red flag
GI (gastrointestinal system)
• Change in waterworks• Blood in urine• Menstrual problems
GU (genitourinary system)
• Joint or muscle pain• Skin rashes• Lumps or bumps
Other
HISTORY TAKING
![Page 13: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/13.jpg)
ICE
Ideas
Concerns
Expectations
HISTORY TAKING
![Page 14: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/14.jpg)
Closing“Is there anything you’d like to add or think I’ve missed?”
“Do you have any questions?”
THANK the patient!!!!!
HISTORY TAKING
![Page 15: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/15.jpg)
HISTORY TAKING
SQITASite
uality
ntensity
iming
ggrevating/relieving factors
ymptoms associated
Pain SOCRATESite
nset
haracter
adiation
ssociated symptoms
iming
xacerbating/relieving
everity
![Page 16: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/16.jpg)
RED FLAGS
HISTORY TAKING
Symptoms that may indicate serious underlying condition
Different for each body system
e.g. coughing-up blood (haemoptysis) and lung cancer
![Page 17: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/17.jpg)
HISTORY TAKING
Signposting“I’d like to ask you about ….”
• Your general health• Your previous health• Your background• etc
WHY?
Patient and examiner know you have a structure
![Page 18: 24 year-old female presents to GP with abdominal pain HISTORY TAKING.](https://reader036.fdocuments.in/reader036/viewer/2022062620/551a97b25503466b3a8b525f/html5/thumbnails/18.jpg)
HISTORY TAKING
THANK YOU