Reflection on health history simulation written exercise

Assignment 2: History taking written assignment Due: Fri, 23 May 2025 21:00Due: Fri, 23 May 2025 21:00 ungraded Attempt In Progress NEXT UP: Submit assignment Add comment Unlimited Attempts Allowed Details Instructions Following from your simulated patient history taking scenario, you are required to produce a three part written piece including a write-up of your history findings, a critical analysis of their significance, and a reflection on your experience of taking a patient history in this scenario. The key aim of this assignment is to encourage you to consider how clinical history taking can be used to direct patient care and to understand the importance of the questioning in history taking beyond just a list of questions. Word count: 2800 maximum Referencing: APA referencing to appropriate sources is required where relevant Structure: Submit all parts in one document using the guidelines below. Remember to include a cover page for your assignment with your name, student ID, unit name, and assignment title. Part 1: History taking findings Word count: Maximum 300 Using the structure discussed in the module resources, outline the key positive and negative findings from your history taking exercise, including: 1. Patient details (name, date of birth, age) 2. Presenting issue 3. History of presenting issue 4. Other relevant history gathered Part 2: Critical analysis of history findings Word count: Maximum 2100 Write a detailed critical analysis exploring the significance of your findings from the history taking exercise including reference to appropriate academic sources of evidence. Consider factors such as: • What does (positive / negative finding) mean? • What data supports this? • What diagnoses can be ruled out? • What diagnoses are likely based on the history? • Do multiple factors found from history taking support one diagnosis in particular? Part 3: Reflection Word count: Maximum 400 Reflect on your experience of clinical history taking using the headings and structure below, referring to literature if appropriate: What went well Consider things that you think went well in your history taking exercise and also in the completion of this written assignment. Acknowledging positive aspects is a crucial part of reflection. What I could improve • Reflect on aspects of the simulation you would improve on in future, for example missed components, items not explored in detail, getting confused with structure, etc. What I have learned: • Outline your main learning from this exercise including the simulation and the written assignment • Consider the impact areas to improve on if the simulation were a real patient, eg miss diagnosis, inappropriate referral, etc Sample sections The attached document shows some example sections and some more information on what is needed: MNP6103 2025 - assignment 1 write up sample sections.pdf Ie: MNP6103 Assignment 1 (health history simulation written exercise) – Sample sections This document contains some examples to outline the level of detail required for the written assignment: Part 1: History taking findings: Patient details: Mr Rangeev Singh, Date of birth 20/09/1984, Age 40 years old, Male Presenting issue: “Blurry spotts in my eyes” History of presenting issue: SOCRATES Site – Both eyes arround the edges of visual fields Onset – 4 days ago Character – on and off, worse today then it’s been Radiation - - Associated symptoms – feels nauseous when trying to read, has a headache on the left side at the front, feels unsteady on his feet. Timing – First came on 4 days ago, worsened in last 5 hours Exacerbating and relieving factors – Nausea and headache worse after walking or trying to read. Some relief from lying in a dark room School of Nursing and Midwifery Severity – Says the bluurry spots are much more severe today, as is the nausea and headache Other history Here you would go on to explore other history. You need to confirm or exclude critical pathology and significant red flags must be identified. The approach you take will be determined by the scenario. If there is a specific history framework for the presenting issue, use this. Otherwise, your review of systems questions will guide you. You are unlikely to have time to explore a full review of systems so you will need to carefully consider what sections to focus on. In this scenario, the headache history taking would be important, and crucial things to exclude would include intracranial bleed. Then explore the nature of the headache and present positive and negative findings. You will need to explore any associated symptoms as well. You are writing this section as though you would write in a medical record, so there is no need to use academic stye however please DO NOT USE ABBREVIATIONS! Examples: No muscle weakness, speech deficit, abnormal sensation to face, hands, arms, or legs reported. No swallowing difficulty. Has nausea but no vomiting. No abdominal pain. Denies thunderclap type headache. Reports his vision is worse in his left eye than right. Part 2: Critical discussion During the history taking excercise, it was identified that the patient had visual aura type symptoms, which have been associated with migraine headaches as the underlying cause in up to 98% of cases (Singla et al., 2021), however according to Lim School of Nursing and Midwifery et al. (2014) only 20% of migraine sufferers experience aura. This means that not having an aura does not exclude a migraine, however having aura makes migraine very likely to be the underlying diagnosis. A critical pathology to exclude in this case would be a stroke. Although Rangeev presented with a headache and nausea, which are known symptoms of a stroke (Imam et al., 2020), the pattern of onset of symptoms makes stroke less likely as by day 4 it would be unlikely for him to have not suffered significant deterioration without medical intervention. Furthermore, he does not have the other classical symptoms of stroke monofocal weakness, sensory deficit, and speech disturbance (Imam et al., 2020). However it is important to note that Aura can indeed be present in the context of stroke, particularly in patients with migraine with aura (MwA). Migraine with aura is recognized as a significant risk factor for ischemic stroke, especially among younger individuals. The association between MwA and stroke is supported by various studies, which indicate that the presence of aura symptoms can complicate the clinical picture of stroke, leading to potential misdiagnosis. Research has shown that migraine with aura is linked to an increased risk of ischemic stroke, with some studies reporting a risk ratio of approximately 2.14 for stroke in individuals with MwA compared to those without (Sen et al., 2018; Øie et al., 2020). School of Nursing and Midwifery Part 3: reflection What went well I felt I interacted with the patient well and managed to get through most of the key questions in the time given. I was also happy that I was able to answer the examiners questions correctly and with good detail which showed that I have engaged with the learning materials What I could improve I got very flustered when the patient began getting upset, I just wanted to get through the exercise and I was worried that if I spent too much time trying to reassure him, I would go off topic. This caused me to get distracted and I did not ask about if the patient had any swallowing difficulty. Next time I would ensure to ask all necessary questions to complete the history taking. What I have learned: I have a much greater understanding of the importance of history taking and from the simulation, I am aware of the areas of this I lack confidence in. From the written exercise, I have gained a better appreciation of how the findings of history taking can point you towards or away from a diagnosis (Zou et al., 2023). However, by missing asking about swallowing difficulty, I missed an important part of assessing for a stroke, which in a real patient could have had catastrophic consequences and led to a misdiagnosis (Zhang et al., 2022). Reference List School of Nursing and Midwifery Imam, Y., Kamran, S., Saqqur, M., Ibrahim, F., Chandra, P., Perkins, J. D.,...Shuaib, A. (2020). Stroke in the Adult Qatari Population (Q-Stroke) a Hospital-Based Retrospective Cohort Study. Plos One, 15(9), e0238865. https://doi(dot)org/10.1371/journal.pone.0238865 Sen, S., Androulakis, X. M., Duda, V., Alonso, Á., Chen, L. Y., Soliman, E. Z.,...Rosamond, W. D. (2018). Migraine With Visual Aura Is a Risk Factor for Incident Atrial Fibrillation. Neurology, 91(24). https://doi(dot)org/10.1212/wnl.0000000000006650 Zhang, G., Li, Z., Gu, H., Zhang, R., Meng, X., Li, H.,...Liu, G. (2022). Dysphagia Management and Outcomes in Elderly Stroke Patients With Malnutrition Risk: Results From Chinese Stroke Center Alliance. Clinical Interventions in Aging, Volume 17, 295-308. https://doi(dot)org/10.2147/cia.s346824 Zou, L., Su, J., Li, J., Wang, J., Kang, J., Yin, A.,...An, P. (2023). Application of Bilingual Simulated Patients in the Medical History Collection for International Medical Students in China. BMC Medical Education, 23(1). https://doi(dot)org/10.1186/s12909-023-04480-1 Øie, L. R., Kurth, T., Gulati, S., & Dodick, D. W. (2020). Migraine and Risk of Stroke. Journal of Neurology Neurosurgery & Psychiatry, 91(6), 593-604. My draft so far: Part 1: History taking findings Apart from the patients first name, Chris, the ‘actor’ would only say confirmed when I sought to gain three types of identification and three types of orientation. So, for this exercise, in consultation with the preceptor post interview, I placed this patient in the geriatric age group and have made up the following patient details and orientation: Patient details: Chris Noone, date of birth: 14/02/1950, Age 75 years old, Male who resides at 4 Anywhere Road, Joondalup. Orientation: Patient was asked if they could tell me the day of the week, the month of the current year and what season we were currently in. Response: Wednesday, April, Autumn – all correct. Presenting issue: Shortness of breath History of presenting issues: Using the mnemonic SOCRATES, the following was discovered during the first phase of the interview: Red flags Site Shortness of breath – chest Shortness of breath Onset Some time ago, but getting worse recently Character Patient would only state ‘pressure’ Radiation Occasionally this ‘pressure’ extended to his left arm ‘Pressure’ extending to left arm (myocardial ischaemia?) Association Dizziness when attempting to stand up (severe aortic stenosis or hypertrophic cardiomyopathy?) Timing Some time ago Exacerbating Talking and eating large meals exacerbates shortness of breath Severity No pain, general discomfort from shortness of breath and feeling of pressure on chest Health system of concern - cardiovascular: I then proceeded with cardiovascular review of systems: Red flags Stated pressure in chest Sometimes radiating to left arm (myocardial ischaemia?) Shortness of breath Increases with exertion Shortness of breath Uses 3 pillows to sleep Still sometimes wakes up gasping for breath (cardiac failure?) Feet tight, swelling of lower limbs Oedema (circulation?) Tummy bloated Fluid (aseities?) Heart Feels like it is ‘fluttering’ Blackout None experienced Dizziness When standing up (severe aortic stenosis or hypertrophic cardiomyopathy?) Activities of daily living Due to oedema, moving items around the house closer, within reach. Exercise: use to walk, but not anymore Cold or blue hands Forgot to ask this of the patient. In saying this the patient consent to come into the practice for a full physical examination. Blood pressure Patient confirmed he has a history of high blood pressure. Consent: I then advised the patient that his ideas and concerns were obviously concerning to him, but before we go down the pathway of medications and exploratory investigations, I would like to obtain a full medical history, medication history, family and social history for our records and ongoing health management planning – consent granted. Allergies: Reassurance was given to the patient, advising that I would be asking numerous questions to gain as much information as I can to create a holistic picture of your health, so let’s start with: do you have any medication and/or food allergies? Red flags Medications Patient believes he is allergic to all types of penicillin Swelling Food Nil known allergies Vaccinations: I then asked the patient if he was up to date with his vaccinations? Flu? COVID19? and asked if he could provide a copy of his Medicare immunisation history statement for our records – consent given. Current medications: Are you on any regular medications? What are they? What are they for? Do you know the dose and frequency that you take these medications? Red flags Valsartin 80mg orally, daily – patient did not know why he was taking this medication, how long he had been on it or if it had been reviewed. Medication for heart failure Aspirin 100mg orally, daily - patient did not know why he was taking this medication, how long he had been on it or if it had been reviewed. Blood thinner Metoprolol Patient stated was taking 5mls orally, daily and did not know why he was taking this medication, how long he had been on it or if it had been reviewed. For this exercise I am presuming that the patient is prescribed 50mg not 5mls. Medication of heart failure Over the counter medications Nil Herbal medications Nil Any medications recently ceased and/or stopped No Past medical history: Patient consent to have his medical records transferred to our practice and informed me that there were no other health care providers involved in his current health care plan. I then asked the patient about his past known medical history: Red flags Past medical history Heart attack about 10 years ago Red flag Past surgeries About 10 years ago coronary artery bypass graft (CABG) surgery with 4 stents 10+ years ago: Coronary artery bypass graft with 4 stents Other hospitalisations Nil Relationship status ie: married/widowed/single Do not believe that he heard me correctly as he stated he was experiencing shortness of breath again Deafness? Smoking history Quit 5 years ago, but use to smoke 60 cigarettes per day Smoker Alcohol Stated enjoys a few drinks on the weekend (this is what he does now, did not elaborate on history of drinking) Alcohol Activities of daily living Has been re-arrange house to make things more assessable due to shortness of breath Home care Height and weight Patient advised that his height is 178cm and weighs 70kgs (BMI 22.1 – healthy range), but has put on a few kilos recently Weight gain – fluid? Previous cancers No Bleeding disorders No Family medical history: Patient advised that following: Red flags Cancer(s) and type Nil Heart Father had heart failure, but patient cannot recall how old his father was when he passed. Heart failure Gene No Arthritis No Anything else No Wrap up of telehealth appointment: I thanked the patient for their time in completing this health history with me today. The information gathered will greatly contribute to your overall health care moving forward. I would like to get you in for a physical examination and arrange some pathologies and referrals to specialist before making any medication changes, is this ok with you? Consent given by patient to attend practice in person. End of Telehealth appointment. Suggested note for file on patient: 75 year old male presented with shortness of breath. During further investigation it was noted that the patient is experiencing pressure on the chest radiating to the left arm which is becoming worse. Currently on medication for heart conditions. Patient history: heart attack 10+ years ago and coronary artery bypass graft (CABG) surgery with 4 stents. 60+ cigarettes per day (quite 5 years ago) and drinks alcohol. Family history: father died from heart failure. Query heart failure - for in-person examination and subsequent pathologies and specialist referral. Part 3: Preceptor round up and what did I miss? On reflexion, I jumped straight to cardiology assumption with a view of heart failure. I stated to the preceptor that the patient did not have a cough or any wet cough. The preceptor advised that I did not ask these questions. I had assumed/formed my idea and totally skipped the respiratory system questions. The preceptor asked about diet. I did not consider asking these questions. When I had asked the patient about his living arrangements ie: married/widowed/single he went on to explain about his shortness of breath again. Upon reflection, a geriatric patient, complaining of fleeing bloated, male, single without any home help, may have an inadequate, nutrient poor, high in fat (take away/easy meals) and high in sodium. I should have asked specific gastrointestinal system questions. The patient stated that he had lower limb oedema, yet I did not ask genitourinary system questions, in particular his renal system ie: about his urine output, difficulty or pain in passing urine. The preceptor asked me what I thought was the possible diagnosis and I stated heart failure. The preceptor confirmed heart failure, but that I could have asked more questions.