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Published byCoral Watts Modified over 9 years ago
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Chest Pain History Virginia Lam Daniella Marks Philesha Walter
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First things first… WIPE Check wrist band for name and date of birth
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Presenting complaint Ask a nice open-ended question “So, what’s brought you in today?”
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History of Presenting Complaint Site – Where: Central? Widespread? – Does it radiate? Quality – Type of pain? Dull: MI Sharp: pleuritic plan Burning: GORD – Has it changed at all? Intensity – VAS: 1/10 Time – Constant? Intermittent? – How long have you been having it? – What were you doing at the time? – Related to certain activities? Aggravating/alleviating factors – What you have done to help the pain – What makes it better? – What makes it worse? Symptoms associated with it – Cough – SOB – PND – do you wake up SOB? – How many pillows do you sleep with? Is this the first time or have you experienced this before?
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Red Flags Blood anywhere? Lumps and bumps? Weight loss? If you haven’t asked already… Any cough? Shortness of breath?
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Past Medical History Do you see your GP/go to hospital regularly for any condition? Have you had operation before? Have you ever been told you that you have: – Hypertension? – Diabetes? – High cholesterol? Have you been told that you have a heart condition? Have you been told that you have a lung condition?
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Drugs, drugs, drugs Do you take any tablets regularly? Do you take anything over-the-counter? Any supplements? Herbal remedies? Vitamins? Do you use any recreational drug? Do you have any drug allergies? Any allergies at all?
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Family history Do you know of any condition that run in your family? – Any heart problem? – Any lung condition? – Any cancer? – Any diabetes? Do you have brother/sister? How are they? Do you have children? How are they? BE EMPATHETIC! **I am sorry to hear that….**
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Social history Do you work? I would like to ask you a couple of questions about your lifestyle. – Do you smoke? If yes, how much, how long… – Do you drink alcohol? If yes, how much, how long… – How would you describe your level of physical activity? (Trying to find out what they normally can do and how that’s changed) Who is at home with you? – Do you have anyone who help you out at home/are they supportive? – What type of home do you live in? (Trying to find out about stairs, mobility issues…)
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Systems Review If you don’t mind, I’d like to run through a couple of yes/no-like questions with you, to get an idea about your general health. – Any headaches/fits/faints/dizziness? – Any changes in your vision? – Any changes in your hearing? – Any problems with swallowing? – Do you feel like your heart is racing? – Any pains or aches anywhere? – Any changes in your bowel movements? – Any changes in your waterworks?
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ICE What is your idea about what is going on? Is that anything concerning you right now? What do you expect we can do for you?
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Thank you! Is there anything I have not asked but you think it’s important? Do you have any question for me? THANK YOU! ***Wash your hands
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Some words of wisdom! Try to get through the major topics: – WIPE – SQUITAS – ICE (we like to say it ASAP – ensures that you get those points If you feel like you’re running out of time, you can shorten sections to one statement questions: – Any conditions run in the family? – Anything unusual symptoms that you’d like to tell me? (Systems review)
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GOOD LUCK! You’ll all be fine!
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