- Past medical history – 2007 Myocardial Infarction/2005 Coronary Artery Disease/ 2003 Type 2 Diabetes Mellitus
- Risk factors – Diabetes/ Age/Overweight
- Medication –
- Aspirin 75mgs once daily
- Bisoprolol 5mgs once daily
- GTN Spray 2 puffs as required
- Simvastatin 20mgs at night
- Metformin 500mg twice daily
- Social history – Widowed lives alone. carer for grandchildren on a regular basis. Enjoys spending time with grandchildren but finds it hard work at times
- Stress – Mary has been experiencing a lot of worry recently, due to family circumstances. At times she feels panicky, with ‘butterflies’ in her stomach, shaking and sweating. At these times she can also experience angina symptoms. Mary’s daughter’s marriage has recently broken down and Mary feels that it is her responsibility to help with financial problems and look after her grandchildren.
Pulse point
Holistic assessment is essential. Patients should be encouraged to tell their history in their own words and then attention focussed on clarifying what might be important and questions about any missing bits of information, which are required to make up the full jigsaw.
You may wish to review module 2 for further information on these skills.
Useful References to support Holistic Assessment: NICE: Medicines Adherence.
Secondary Prevention: SIGN 148: Acute coronary syndrome (.pdf)
Page last reviewed: 03 Jun 2020
