History Taking Pharmacy 1213
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Transcript of History Taking Pharmacy 1213
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STRUCTURED HISTORY,
DOCUMENTATION AND
DECISION SUPPORTTECHNOLOGY
Matthew Catterall
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Teaching Aim & Learning
Outcomes
Aim
To gain a working knowledge of structured historycollection from a patient, its documentation anduse of decision support technology
Learning Outcomes
Explore communication strategies
Describe and discuss the stages in the medicalmodel of assessment
Appreciate methods for documenting anassessment
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Practical Use of a Structured
History
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s ory ocumen a on s oudemonstrate the following
elements SUBJECTIVE What you find out from the patient/relatives/carers
OBJECTIVE
What you find out from your examinationmeasurable and repeatable
ASSESSMENT / ANALYSIS
Putting together the information you have gained,what do you think is going on?
PLAN
What are you going to do about it?Prescribe/Advise/Refer
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Health History
A thorough, accurate & systematic review
Explores past & present problems
Can lead to a diagnosis which can then be
confirmed or rejected by an examination of the
patient
The history gives you subjective data from
which to work
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Medical History
PC Presenting Complaint HPC History of Presenting Complaint PMH/PSH Previous medical/surgical history
DH Drug History SH Social History FH Family History ROS review of systems
O/E On Examination (focussed systemsexam)Assessment/Analysis Plan
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Presenting Complaint
Presenting complaint
A short description of the reason for seeking care
Based on what the patient tells you
E.g Faint, Left Ankle Injury, Feeling tired, Chestpain
History of the presenting complaint
The nature of the problem
How and when it started How it has progressed over time
Impact on the patient
Work, exercise, social activities
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HPC Example
2/7 ago playing football at 1100
Fell inverting left ankle whilst running for ball
Able to play on for 1/24
Becoming progessively more painful despite
analgesia
Today pain ++ with inability to weight bear
Unable to drive to work
Driven to hospital by wife
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Previous Medical/Surgical
History
Previous medical history
E.g Asthma, COPD, IBS
Previous surgical history (date)
E.g Hysterectomy (2003), CABG (2007)
Current management
Effectiveness
Prognosis
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Drug History
Drug, dose, route, frequency
Prescribed medication
Over the counter medication
Herbal remedies
Illicit, street or recreational drugs
Allergies/ senstivities/ intolerance
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Social History
Occupation/sAlcohol (ETOH) units/week
Men 21 Women 14
Smoking (cigarettes/day)Actvities of Daily Living (ADLs)Any formal/informal care Relatives, family, friends etcAccomodation
Mobility aids Hobbies Recent travel
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Family History
Current family make up
Grandparents, parents, siblings
Causes of death where relavant
Diagnosed diseases
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Review of systems (RoS)
Functional enquiry
Tailored to the presenting complaint
Record pertinent negatives as well as
positives
Includes all major systems
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Look for evidence of....
Respiratory System (RS)
Cough, Sputum, Haemoptysis, Shortness ofbreath (SOB), Wheeze
Cardiovascular (CVS) Chest pain (at rest or on exertion), Palpitations,
Shortness of breath, Odemea, Orthopnea
Gastrointestinal (GI)
Indigestion, Abdominal pain, Nausea, Vomiting,Change in bowel habit, Unintentional weight loss,
Appetite, Diarrhoea, PR bleed, Dysphagia
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Look for evidence of.... Cont
Genitoruninary (GU)
Urgency, Frequency, Polyuria, Dysuria,
Haematuria, Nocturia, Menstrual problems
(Pregnancy ?)Neurological (NS)
Faints, fits & funny turns, Loss ofconsciousness, Headache, Visual disturbances,
Dizziness or vertigo, Tingling, Incontinence,Rash, Photophobia
Musculoskeletal (MS)
Aches, Pains, Stiffness
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Documentationthe patient
has been
depressed
since he
started
seeing me
in 1983
she slipped
on the iceand her legs
wen
separate
ways in
early
December
the patient
was to have a
bowelresection.
However he
took a job as
stockbroker
instead
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Documentation
Concise Relevant Legible
Legal document & part of patients medical record
NOT DOCUMENTED = NOT DONE!!
Remember your notes may need to be defendedin court
Use ink, write legibly, use abbreviations carefully,dont write humorous comments - record factualinformation only
Include contextual information Date & Time (24 Hour Clock), Location, Your Details,
Patient Information (Name, Age, Gender, Occupation)
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On Examination (O/E)
Record an initial impression Pt sitting in chair, not distressed, responding appropriately.
Mother present during examination
Examine appropriate system/s
Consider limitations without chaperoneDuring your assessment analyse the following factors
Likely explanation for the presentation
Is the patient
Comfortable or distressed Well or ill
Well nourished/hydrated
Exhibiting classical signs (syndromes)
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Documenting System
Examinations
Respiratory System (RS)Nervous System (NS)
Abdomen (Abdo, GI, GU)
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Diagnosis & Treatment
Planning
Final diagnosis
Synthesis of history and examination
Not always clear
Impression often suffices inurgent/emergency care
Working diagnosis may be required
Enables early treatment of urgentproblems
Differenetial Diagnosis (DDx)
Dictates treatment Range of potential diagnoses
Ruled in or out by investigations
Demonstrates consideration of red flagpresentations
Tailored to patient
Specific instructions for
interventions Advice to patient
Discharge instructions
Referral
Follow up care Safety Net advice
999 if chest pain, GPreview if not resolving etc
Diagnosis (Dx) Treatment Plan (Rx)
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Decision Support Technology
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Example Algorithm
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Any questions?
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References
Bickley, L. (2003). Bates' guide to physicalexamination and history taking. Philadelphia:Lippincott, Williams and Wilkins.
Douglas, G., Nicol, F. & Robertson, C. (2009).Macleods clinical examination. (12th ed.).Edinburgh: Churchill Livingstone Elsevier.
Wardrope, J., Driscoll, P., Laird, C. & Woollard,W. (2008). Community emergency medicine.Edinburgh: Churchill Livingstone Elsevier.
This presentation has been sourced from theabove texts however there are many texts whichrefer to the same information.