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Diagnosis Reveal

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Opening the consultation:

• [ ] Washes hands and dons PPE if appropriate
• [ ] Introduces themselves to the patient including name and role
• [ ] Confirms the patient’s name and date of birth
• [ ] Explain that they’d like to take a history from the patient
• [ ] Gains consent to proceed with history taking

Presenting complaint:

• [ ] Uses open questioning to explore the patient’s presenting complaint

History of presenting complaint:

• [ ] Onset: clarifies when the dyspnoea first started and if it came on suddenly or gradually
• [ ] Time course: asks how the dyspnoea has changed over time
• [ ] Exacerbating or relieving factors: asks if anything makes the dyspnoea worse or better
• [ ] Severity: asks how severe the dyspnoea is on a scale of 0-10
• [ ] Orthopnoea
• [ ] Paroxysmal nocturnal dyspnoea
• [ ] Cough
• [ ] Oedema
• [ ] Fatigue
• [ ] Chet pain
• [ ] Palpitations
• [ ] Syncope
• [ ] Explores the patient’s ideas, concerns and expectations
• [ ] Summarise the patient’s presenting complaint

Systems review:

• [ ] Screens for relevant symptoms in other body systems

Past medical history:

• [ ] Screens for conditions that increase the risk of cardiovascular disease such as hypertension, hyperlipidaemia and diabetes
• [ ] Asks about pre-existing cardiovascular disease
• [ ] Asks about other medical diagnoses and previous surgical history

Drug history:

• [ ] Asks if the patient is currently taking any prescribed medications or over-the-counter remedies
• [ ] Checks medication compliance
• [ ] Asks if the patient has any allergies and if so, clarifies what kind of reaction they had to the substance

Family history:

• [ ] Asks if there is any family history of cardiovascular disease and clarifies at what age the cardiovascular disease developed

Social history:

• [ ] Explores the patient’s general social context (accommodation, who the patient lives with, how the patient manages with activities of daily living, care needs)
• [ ] Takes a smoking history
• [ ] Takes an alcohol history
• [ ] Asks about recreational drug use
• [ ] Asks about diet and exercise
• [ ] Asks about the patient’s occupation

Closing the consultation:

• [ ] Summarises the salient points of the history back to the patient and asks if they feel anything has been missed
• [ ] Thanks the patient for their time
• [ ] Disposes of PPE appropriately and washes their hands

Key communication skills:

• [ ] Active listening
• [ ] Summarising
• [ ] Signposting </aside>