8976 Lecture Notes - Lecture 5: Angina Pectoris, Sputum, Auscultation
2 Jul 2018
School
Department
Course
Professor
History Taking
Subjective Assessment
Backstory
- Share understanding of situation so far
oReferral
oMedical File
Personal details
Assessment and progress notes
Anaesthetic and operation resports
Consultation notes – medical plan?
Results – spirometry, x-ray?
oCharts
Observations: temp, BP, HR, RR, SpO2 + O2
Medications
Nursing care plan
Fluid balance
oTalk to Nurse
Hows the patient been today
Any new information
Procedures, tests
Obs stable?
Anny concerns?
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Talking to the Patient
- Introduce
- Briefly outline their story
- Fill in gaps, ask questions
- Symptoms:
oOnset pattern
oPain? Site and radiation
oSeverity
oAggrivating and easing factors
oAssociated symptoms
Dyspnoea: breathlessness
Decreased exercise tolerance ie. No. of stairs
Chest pain: exclude cardiac origin
Causes: PE, angina, trauma, aurgery, pneumonia, pleural
effusion, pneumothorax, musculoskeletal
Palpitations: rapid, irregular heart beat
Cough: clearance, isease, reflux, post-nasal drip
Wheezes: narrowing, sputum or stridor obstruction
Anxiety
- Past History
oPresenting illness: details
oSimilar episodes?
oCurrent treatment/drug therapy
oExtent of impairment
oPast history: illness, treatments + operations
oAllergies
oBlood transfusions
- Social History
oOccupation/education
oSmoking, alcohol and analgesic use
oOverseas travel and immunisation
oHome
Who do they live with? Marital status and social support
Where do they live?
Mobility, functioning of daily living
Exercise tolerance
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