eSign Personal Medical History Made Easy

Esign personal medical history

my name is Kevin Kennedy education training officer for Simon's Service NHS Trust today I'm going to be talking you through the history taking model and I'm going to be assisted by my colleague Erin who's going to be a simulated patient with today the his taking module looks at nine subsections and we're going to be talking through each of those as we go through the process of this history take if you're taking starts off with your normal smart approach good general observations and your introduction to the patient more than sir my name is Carolyn from the Alex service what's your name sorry I have a nice to meet you and I believe you called trouble nine today is that correct yeah yeah okay what seems to be the problem I've just got this chest pains quite sharp okay all right at this moment Tommy you okay Rogers privacy in text yeah please check see no I'm absolutely fine thank you okay so what I want to do then is if I can just got a little bit more history about what's been happening yeah now I've started off my initial presentation my primary survey identifies that his Airways clear he's breathing he doesn't appear to be having any distinctive short of breath and circulation well he looks a good color he's alert and he's sitting there talking to me at this moment in time it's really good a little bit more history before I get my basic underlying physiological readings sorry you said you've got some chest pain tell me a little bit more about that if you can please yeah it's just been probably the last day it seems quite sharp hmm wife said just to see if you guys the call I was quite happy just carry on as normal for me okay so I've identified my primary survey my pulse is 76 and his RESP rate is 16 those are normal physiological parameters for me and as a previously identified he looks a good color and he's pulling alert so we're now going to take a little bit more history in regards to the current medical history and we're going to use the analogy of old cars so I mean you said the onset was two days ago yes okay in this pain we're bouts exactly is it just sort in my chest okay so it's located you holding more towards the left there would you say it's sort of central to left yeah just about yours okay and this pain does it come and go in duration or is it continuously therefore their last two days um it's been weird actually five I sort of lean back I notice it more okay what about if you were to lean forward and is there anything else that you've identified that maybe aggravates or alleviates it you know if you cough for example does that make it worse yeah it does yeah okay what about if you take a deep breath in for me does that make it worse as well yeah okay what about if you just generally move your body yes I don't think it's anything muscular okay and this pain itself you say it's sort of a central select yeah sharp in nature and does it seem to radiate anywhere else so do you feel it like in your neck we draw back arms or shoulders no and he says definitely sharp pain yes sharp okay it's not tight across your chest not pushing down on your chest no much Hendershot and I'm paying school of 1 to 10 we want me into the vision I paid and ten being the worst pain you've ever experienced in your life and where would you score it it's a good six six of them I know okay and this is always been a sick so is he yeah well I'll leave that when I leaned back it I know you know it's worse than okay it's okay if it's gonna be sick as you are if you were to live flat now okay and then they have sort of associated symptoms with it so have you had a cough okay you know it's just any sort of right cause or shivers and shakes I have actually I've been taking some paracetamol okay I felt a little bit woozy recently okay it's probably just one of those winter things that are going around all right you say no cough no you have a bit of a cough cough sorry you seen any mucus fantastic so I'm just going to actually now some questions about your past medical history and I'm sure we probably will come back to your current history but you normally fit in well I am okay I'm now just gonna use the pneumonic jump threads to ask you some questions about your history and they're just simple yes or no really have you ever so good week jaundice in the past okay anemia or any other blood disorders know any TB I had the injection at school okay that's absolutely fine yeah any heart disease or high blood pressure no any rheumatic fever asthma and I've already mentioned about it you not have an epilepsy but if you ever had any seizures in the past what about childhood illnesses if you sort of normally fit in well as a child you had all your vaccinations as you are aware you had all my injections I had chickenpox as a kiss that's correct occasions are the operations do you know what I'd say four days ago okay the dentist oh there's something in forest tooth was it was it one of your other pack in wisdom teeth okay and if you noted any sort of issues with that you say you've had some sort of shivers and shakes over the last few days whether that's linked in or not it could be yeah yeah this was a specific pain or discharge that you're aware of I'm well knowing they did give me some tablets for it though okay just some antibiotics okay so operations apart from your tooth extraction anything else no nothing okay and medication was [Music] medication in a minute to know what some sort GP and I'm just going to ask any psychiatric or mental health ponds I need to be a well known okay so let's go on to meds then see you mentioned about a prescribed medication which is your antibiotic do you know what they're called met are you on any other medication that's prescribed no I'm not okay nothing by GP no see them off okay were you taking that any other over-the-counter medications that you've taken I've brought some some multivitamins from the chemist okay just because it's winter okay and they sort of come and meet your homo pathak sort of remedies did you take anything else anything like st. John's wort No okay that's absolutely fantastic no allergies any allergies to any food no any allergies 20 medication no okay any allergies to anything from the environment no great stuff just nothing lasts you a couple of questions regarding parents if that's okay parents sisters a half yes okay what if you go okay so just gonna have some questions again about though it's just simple yes or no so jaundice an email or any other politicise any cancers no TV no any heart disease or high blood pressure any emphysema no asthma diabetes no no seizures that you're aware of and they still fits in yes that's great sir it's gonna actually some questions now about your house and where you live in your job and everything you do outside of work so your habit size this your house yeah it is yeah okay and you normally able to look after it yourself yeah okay what do you do for a living - education okay excellent you enjoy the job I do yeah okay stressful it comes yeah what about recreation what are you doing in your own time do you like getting out and about yeah I'm quite lucky I live next to commit Chase will do a lot of mountain by having a great and I think I can play squash in regards to smoking or drinking I quit smoking pool but six years ago okay yeah okay how many did you smoke before you quit a day you found your health improved since you stopped smoking yeah yeah good good good that's what I see and what about everyday activities or holidays trips abroad anything like that I like to go on holiday yes I've been since okay not being exposed to anything new or anything okay what about family support are you married yet married two kids okay yeah and you don't need care to look after you no okay okay just gonna ask you now some final questions this is what's known as it's just noise review okay so general daily lifestyle able to get up get about yeah the kids ready for school you would and you mentioned about shivers and shakes over the past couple of days but looking at the stopped you going around rhythm started getting out and about and sure there's pain that you've got no sort of shortness of breath with it you haven't found yourself short getting up and about no sort of loss of muscle tone any fits face blackouts or giddy turns no making problems would be here and were you balanced no excellence and you mentioned about a cough yeah but no sort of productive cough no nothing no mucus and you mentioned about a short of breath you've had none of that okay any sort of identification of palpitations in your chest I know you've had this chest pain but and sort of fluttering sensations like extra beads or your heart's racing no no just funneling back just when you leave yeah to your abdomen eating okay you have some bowel motions okay this morning and no indications are blurred you're an Asian yeah all good okay again passing your eye frequently not all the smells nope any sensations no no charge no color okay good and your limbs all looking working and absolutely fine yeah they do all right that's great okay I think I've got most of the history I need at this moment in time and what I'd like to do now is doing much more in-depth assessments from the information you're telling me I do believe that we've got some form of infection going on that could be related to your hearts a condition known as pericarditis and to be just to identify what is actually happening we're going to do a respiratory and cardiovascular system exam is that okay yeah that's fine