history taking : chest pain
DESCRIPTION
steps to take history of chest pain with presented caseTRANSCRIPT
HISTORY TAKING:CHEST PAIN
OBJECTIVES OF HISTORY TAKING To make a DD or Dx Ta assess FUNCTIONAL CAPACITY To establish a meaningful Dr Pt rapport To develop a problem list To assess socio-economic status and
preferences
OVERVIEW OF HISTORY
CHIEF COMLPLAINT HISTORY OF PRESENT ILLNESS PAST HISTORY FAMILY HISTORY SOCAIL HISTORY DRUG HISTORY REVIEW OF SYSTEMS
PRESENTING COMPLIANT
Mr. Aslam 50 year old ,male , labourer by profession, resident of peoples colony presented in emergency on 15 December with the
CHIEF COMPLAINT of chest pain for 4 hours
What diagnosis comes in your mind?
DIFFERENTIAL DIAGNOSIS
Cardiac causeRespiratory causeMusculoskeletal causeGI and Mediastnal causes
DIFFERENTIAL DIAGNOSIS
CARDIAC-• Angina• Myocardial infarction• Pericarditis• Myocarditis
RESPIRATORY-• Pneumothorax• Pulmonary embolism• Tracheitis• Pleuritis
GI AND MEDIASTNAL-• Aortic dissection or aneurysm• Esophagitis• Esophageal rupture• Esophageal spasm
MUSCULOSKELETAL-• Soft tissue and bone injury• Osteochondritis• Osteoarthritis• Herpes zoster• REFERRED PAIN
HISTORY OF PRESENT ILLNESS
When was the patient well last? 2 months ago 1. SETTING(Onset):pain was
SUDDEN when patient woke up in the morning
2. INTENSITY: pain was SEVERE
3. SITE AND RADIATION: pain was CENTRAL, radiating to left arm and jaw
4. DURATION: from last four hours
5. CHARACTER: pain was CONSTRICTING and SQUEEZING in nature
6. ASSOCIATED COMPLAINT: palpitation, BREATHLESSNESS, sweating, nausea,and feeling of anxiety
7. MODIFYING FACTORS:o Aggravating factoro Relieving factors
For the history of pain we use acronym SOCRATES.
PAST HISTORY
MEDICAL- hypertensive diabetic SURGICAL- no
PERSONAL HISTORY
SMOKER from last 15 years No other H\O of drug addiction
FAMILY HISTORY
Family history of• diabetes• hypertension• ischemic heart disease Father died of MI 15 year back
DRUG HISTORY
Anti-hypertensive Metformin for diabetes
SUMMARAY OF HISTORY
IdeasConcernsExpectations