When patients are older, obtaining a good history—including information on social circumstances and lifestyle in addition to medical and family history—is crucial to good health care. Please try again soon. The differential diagnosis includes MI, angina pectoris, pneumonia, pericarditis and oesophageal reflux. Certain lower limb pathologies can be inherited or seem to have a familial predisposition, especially diseases that are neurological in nature such as Friedreich’s ataxia and Charcot–Marie–Tooth disease. She was unwilling to compromise on the style of footwear she wore and provision of a suitable orthotic was impossible. Patients should be asked if they are currently taking, or have taken in the past, any tablets or other medicines, or if they are using or have used any ointments or creams prescribed by their doctor. The social history was very helpful in this situation and can be applied to almost any patient. • Are you exposed to passive smoking at home? Patients should also be asked if they are currently taking or have taken in the past any tablets or medicine or used any ointments or creams which they have purchased from a chemist. When it does occur it usually follows entry of an antigenic drug into the circulation of a sensitised individual. Bacteraemia in patients with a history of endocarditis or rheumatic valvular disease may lead to bacterial growth on the previously damaged heart valves or endocardium. Taking a history is a highly skilled exercise and one that requires practice to achieve and maintain competency. For a new patient or consult, the clinician might say, "The past medical history shows that she has longstanding hyperllipidemia. Have you ever been under the care of a consultant or a hospital specialist? This condition can have a direct effect on the ability of the muscles to function under strain. patient’s medical history, inappropriate or unsafe treatment may be provided. Dyspnoea (shortness of breath) may occur as a result of pulmonary oedema. A properly taken medical and social history is concerned with the patient as a whole and not just the lower limb complaint with which the patient has presented. Step 3: Social History. Lack of home support may rule out certain forms of treatment. Yes, this is not the whole picture but with the help of a detailed medical history, doctors can … A 27-year-old female sales executive attended the clinic with heel pain. Registered users can save articles, searches, and manage email alerts. Diagnosis: Plantar fasciitis. In the case of surgical treatment the practitioner must establish who is going to transport the patient to and from surgery and who is going to assist them through the immediate postoperative recovery period. In some individuals, contact with certain allergens will stimulate the production of an antibody of the immunoglobulin E (IgE) class, which has the ability to adhere to mast cells in tissues and basophils in the circulation. A history of jaundice should alert the practitioner to the possibility of hepatitis, whereas a history of haemophilia, blood transfusion, foreign travel or intravenous drug use may place the patient – and thus the practitioner – at risk from a blood-borne infection. Inadequate knowledge of the patient’s existing medication could lead to adverse inter-drug reactions with newly prescribed treatment. Seriously underweight patients may have a range of systemic conditions or they could be poorly nourished due to alcoholism, drug misuse or anorexia nervosa. In particular, details of any adverse reactions, either by the patient or any member of the patient’s family, to previous local anaesthetic injections and other drugs (e.g. The following questions will reveal important information about the patient’s general health: • Are you under the doctor or consultant for any treatment currently? “So how is your son doing in college?” “Did you plant a garden again this year?”. And it should also involve the marital and living status of the patient. Hypertension is a risk factor for many life-threatening conditions such as MI, renal failure and cerebral vascular accidents (strokes). The assessment of the patient with a sports injury is considered in detail in Chapter 15. The author’s favourite quote from a patient was that ‘they don’t make old bones in my family!’. For a new patient or consult, the clinician might say, "The past medical history … zinc oxide strapping) may be known to the patient and should be noted because of the risk of anaphylaxis. In females, a particularly common procedure is hysterectomy, which has implications for the lower limb in that the effect on hormone balance can lead to premature osteoporosis. Rheumatic fever is a febrile disease occurring as a sequel to group A haemolytic streptococcal infections. A systematic approach to history taking will ensure that the practitioner covers all relevant areas in the enquiry process. 800-638-3030 (within USA), 301-223-2300 (international). Arch Intern Med. to maintaining your privacy and will not share your personal information without For immediate assistance, contact Customer Service: The practitioner should be alert to the possibility of a patient developing an allergy or adverse reaction to medications used during treatment. Small plaques of brown lipid under the eyes, seen in hyperlipidaemia, are associated with atherosclerosis. Example of a Complete History and Physical Write-up Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart. Treatment may fail or cause the patient’s presenting condition to worsen because inadequate history taking has prevented accurate diagnosis of the presenting foot complaint. Anderson, Ruric (Andy) MD, MBA; Schiedermayer, David MD, Assistant dean for medical education, NorthShore University HealthSystem, and clinical associate professor of medicine, University of Chicago Pritzker School of Medicine, Evanston, Illinois; [email protected]. Fatigue and weight changes are symptoms of many systemic illnesses and are always worthy of note, especially if weight change seems to be rapid. Thankfully, fatal anaphylaxis is rare. The item(s) has been successfully added to ", This article has been saved into your User Account, in the Favorites area, under the new folder. A history of cardiovascular disease should be taken with respect to systemic, peripheral and haematological disease states, followed up by a review of symptomatology. An increase in blood pressure is often asymptomatic and many hypertensive people do not realise they have the condition until they develop symptoms (e.g. For example, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate asthma attacks. For example, prednisolone, commonly used in the treatment of rheumatoid arthritis, can reduce skin thickness and impair wound healing. Disorders of skin and nails may manifest themselves in the hand: for example, psoriasis and eczema may cause hypertrophy and anhydrosis of the skin; pulmonary or cyanotic heart disease may cause clubbed or hippocratic nails. penicillin) should be sought and explored. Patients should be observed from the moment they enter the consulting room. Patients with chronic foot disorders may shuffle rather than stride because a propulsive gait could cause more pain. Active sportsmen and women may make the association between their sport and a lower limb problem, but those who participate in occasional sporting activities and hobbies may not. may email you for journal alerts and information, but is committed This information will help to determine the inherited nature of any foot condition and, in the case of pes cavus, hallux valgus and lesser digit deformity, could indicate the degree of severity that the patient’s presenting condition may eventually achieve. A patient’s medical history may include details about past diseases, illnesses running in the family, previous diagnoses, medical abstract, therapies, allergies, and medication. In general, patients who are unwell are not good candidates for invasive procedures or treatments that are likely to demand close compliance on their behalf. In females, a particularly common procedure is hysterectomy, which has implications for the lower limb in that the effect on hormone balance can lead to premature osteoporosis. Patients on long-term steroid therapy can develop a ‘moon’ face. Other less-specific systemic cardiac symptoms include fatigue and decreased exertional tolerance. The questionnaire also covers details about the respondent’s schooling, family history, employment and medical history. Introduction 2. A fertilised female, gaining access to human skin, burrows beneath the surface where it becomes engorged with blood. _____ Birth/ Delivery: Was the child full term? The diagnosis in a patient presenting with difficulty walking will be influenced by a positive family history of a condition such as these. • Have you ever been under the care of a consultant or a hospital specialist? Further questioning revealed that her weakness could more accurately be described as fatigue and heaviness of her legs walking to and from work. Sitting down relieved the pain but prolonged sitting tended to make her ankles swell. The tense tired face of those in chronic pain will appear similar to those suffering from depression. This may manifest clinically as vertebral collapse, leading to spinal. lead to ectopic calcification in tendon, muscle and periarticular tissue. The consultation should begin with a handshake as considerable information can be gleaned from this simple contact. If drugs are prescribed (or omitted) in the absence of a detailed medical history, an existing condition may be exacerbated. In the drive for efficiency and reliance on technology, the connection between patient and doctor need not be lost.1 We should aim to at least equal good hairstylists, who keep track of personal details on cards or in memory so they can make connections with their clients. In such cases the skin around the area of the injection shows an immediate, localised inflammatory reaction. Please try after some time. The pain was on the anteromedial aspect of the plantar heel pad and had been present for some time. An X-ray revealed a compression fracture to the head of the first metatarsal, which has predisposed degeneration of the joint. Before history taking begins, the practitioner will gain some impressions about the patient’s current health status from simple observation. The site of penetration is usually found under the toe nail of the barefooted patient, but can occur on the plantar aspect of the foot. Certain rhythms such as ventricular tachycardia predispose to cardiac arrest. Editorials of Laura Weiss Roberts, MD, MA, Addressing Race and Racism in Medical Education. a thrombosis or blood clot (deep vein thrombosis [DVT]), Angiotensin-converting enzyme (ACE) inhibitors, Central, crushing pain that radiates into the arms and jaw. The clinician must therefore be aware of the patient’s medical and social history as they may have implications for the diagnosis and management of lower limb problems. Hypothyroidism will lead to a loss of hair from the outer third of the eyebrows, baldness, and coarse, thickened facial skin. 800-638-3030 (within USA), 301-223-2300 (international) The range of motion of the joint was reduced, with painful crepitus evident on dorsiflexion. Cardiac disease such as arrhythmias and aortic stenosis can cause syncope by decreasing the cerebral blood supply. Literally, her dog caused her to seek care. In CHF there is an inadequacy in the supply of oxygenated blood. Patients with acute foot or leg pain will walk with a limp as they try to ‘guard’ the injured part. “My dog becomes visibly agitated and starts barking after smelling my breath when I'm getting sick,” she offered quickly … The systems enquiry 4. Did you have any major childhood illnesses? 4. All registration fields are required. For example, repeatedly exceeding the recommended daily dosage of vitamins A and D supplements may. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. Summary 5. Social History Assessment is the first resource to offer practical guidance about interpreting the social history. Alcohol consumption is generally measured in units. Are you exposed to passive smoking at home? Adequate history taking will identify those patients who have previously developed adverse reactions. H-LABOR is a daily email-based discussion group formed in 1993 that reaches over a … Weight abnormalities affect the lower limb and should be noted on the first meeting with the patient. An increased risk of clinical emergencies. Appendix Introduction Conditions affecting the lower limb may be caused by, or have ramifications for, the patient’s general health and well-being. Gait disorders in children are best visualised as the child walks into the room to meet the practitioner; children often become self-conscious when asked to walk on demand. History of present illness (HPI) 3. Review of systems(ROS) 4. Inadequate history taking may place the practitioner at risk when handling tissue fluids or products. Further social history maybe required depending on the type of presenting complaint for example: Respiratory presenting complaint Ask about pets, dust exposure, asbestos, exposure to the farms, exposure to birds or if there are any hobbies Large doses or prolonged use of certain medications can be associated with significant adverse drug reactions with relevance to the lower limb. Some patients may experience particular difficulties in taking time from work to attend for treatment. Physicians can and must do better. Practitioners should routinely take their patients’ blood pressure, not least because the stress caused by treatment or examination may provoke a clinical emergency in a patient with uncontrolled hypertension. The social history can provide key clues to the diagnosis of an illness – for example a patient with increased shortness of breath who’s final diagnosis is interstitial lung disease, only determined after soliciting the occupation of the patient who works at a factory. The systems enquiry is the key part of the medical history. A 23-year-old secretary presented with pain in the first metatarsophalangeal joint. The pain was aching in nature, severe and worse on exercise. However, the patient was required to wear fashionable court shoes for her employment. Some of our readers have found that they are able to use the model of Medical Summary Reports with their own doctors, Case Workers, or Social Workers to help get approved. Assistant dean for medical education, NorthShore University HealthSystem, and clinical associate professor of medicine, University of Chicago Pritzker School of Medicine, Evanston, Illinois; [email protected]. Medical Summary Reports. A local type I hypersensitivity reaction may be caused by local anaesthetic agents but this is rare. A comprehensive history taking therefore initiates the diagnostic process and helps the practitioner to formulate and implement an effective management plan. Box 5.1 The medical history and systems enquiry. In such circumstances oxygen must be administered to support the patient. Poor history taking may result in a request for an inappropriate antibiotic prescription from a general practitioner for a patient who is sensitive to penicillin. All the body systems are worked through in a set order, which can be remembered using the acronym ‘CRAGCEL’ (see Box 5.1). An inadequate history of the patient’s health status may have the following consequences: With an inadequate knowledge of the patient’s medical history, inappropriate or unsafe treatment may be provided. Once a history has been taken, physical examination and diagnostic tests can then be used to confirm the diagnosis and stage the severity of the condition. Step 07 - Social History (SH) This is the opportunity to find out a bit more about the patient’s background. Remember to ask about smoking and alcohol. Problem Focused 2. When multiplied this is referred to as "pack years." Examples of how to use “social history” in a sentence from the Cambridge Dictionary Labs For example, repeatedly exceeding the recommended daily dosage of vitamins A and D supplements may lead to ectopic calcification in tendon, muscle and periarticular tissue. The patient had also noticed that climbing stairs causes a tight squeezing pain in her chest. Having recorded disease states of which the patient is aware, enquire further about any systemic cardiovascular symptoms. Self-prescribed medication is of interest to the practitioner not least because the quantities used may be quite variable, with the possibility of chronic overdosing. Social History (SH): This is a broad category which includes: Alcohol Intake: Specify the type, quantity, frequency and duration. Refer to the British National Formulary (BNF) or another pharmacological text if you are unfamiliar with any drugs that the patient is taking. Information about the patient’s previous and current drug therapy can provide useful information about the patient’s health. This can be sent to the patient before the initial visit or, more commonly, before they see the practitioner again. [email protected]. This includes his or her age, gender, race, height, weight, current residential address and previous addresses. Injuries may often appear to be unrelated to the patient’s presenting complaint but it must be remembered that the lower limb functions as one unit and if one component of the unit is damaged, it can lead to compensations elsewhere in the lower limb. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. Drinking before 10 a.m. is an important finding as it is associated with chronic alcoholism. Details of foreign travel should be recorded in case the patient has acquired an infection while abroad. 30 mins. For example, pain and swelling in the calf of a 39-year-old woman, which develops after sport, may be nothing more than local oedema or muscle strain. If drugs are prescribed (or omitted) in the absence of a detailed medical history, an existing condition may be exacerbated. This website uses cookies. For example, upper and lower motor neurone lesions may cause an ataxic gait, in which coordination and balance are impaired. iodine allergy) or dressings (e.g. Questions to ask are: • What do you smoke – cigarettes, cigars, a pipe? Obesity is associated with recalcitrant heel pain and other postural symptoms. Individuals may be placed at risk by certain treatments, drugs or procedures that are usually considered routine. 2008;359:2748–2751. Because it takes longer to fill the left ventricle, the pressure in the whole cardiac pulmonary system ‘backs up’, causing pulmonary congestion, reduced blood gas exchange and eventually pulmonary oedema. It is important to consider the patient’s home situation. The history includes 4 elements: 1. See Psychiatric history. Many cardiovascular, alimentary, neurological and endocrine disorders can be inherited and therefore the use of pedigree charts is particularly useful in paediatrics. Other less-specific systemic cardiac. Its practitioners are counted in thousands rather than hundreds indeed tens of thousands if one were to include (as I would) those who fill the search rooms of the Record Offices, and the local history rooms of the public libraries, documenting family 'roots'; the volunteer guid… It seeks to discover if the patient has any systemic conditions, particularly those that may affect the patient’s lower limb problem, and to unearth any signs and symptoms which the patient has not complained of spontaneously. Angina occurs as a result of atherosclerosis of the arteries to the myocardium and often coexists with atherosclerosis of the arteries to the lower limb. Ask if they: • have Cut down on drinking – have tried repeatedly without success, • are Annoyed by criticism about drinking habits. Social history is quite different. Medication history: now and past, prescribed and over-the-counter medicines, allergies. Depending on the PC it may also be pertinent to find out whether the patient drives, e.g. If the exposure to the allergen is systemic, hypotension, bronchiole constriction, laryngeal oedema, swelling of the tongue, urticaria, vomiting and diarrhoea may follow. Initially, the patient will notice that the swelling reduces at night when the legs are recumbent. Social factors can be a major hindrance for patients to be healthy. Cigarette smoking: Determine the number of packs smoked per day and the number of years this has occurred. Format of the medical and social history enquiry. It is important that patients are advised before the enquiry begins that the purpose of the questions is to ensure that there are no general health problems that may be causing the lower limb condition or that may influence the type of treatment considered. For example, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may precipitate asthma attacks. If a patient is still under the care of a hospital consultant it is prudent to inform the consultant before any treatment is given that may affect other body systems. Your account has been temporarily locked due to incorrect sign in attempts and will be automatically unlocked in The actual risk of causing a bacteraemia in a patient with a prosthetic joint (which could infect and then loosen the joint) by performing nail surgery remains unquantified but a theoretical risk certainly exists. Warfarin, an oral anticoagulant used for the treatment and prophylaxis of venous thrombosis and pulmonary embolism, increases clotting time and has obvious implications if surgical treatment is planned. One unit of alcohol is equivalent to one glass of wine, a single measure of spirits or half a pint of beer. acute foot or leg pain will walk with a limp as they try to ‘guard’ the injured part. Hospitalisations for operations or injuries should be recorded and any complications noted (Case history 5.1). Are you under the doctor or consultant for any treatment currently? History taking is as important as any diagnostic test or physical examination. Have you been off work due to illness for more than 1 week in the past 6 months? CHAPTER 5 The medical and social history I. Reilly Chapter contents 1. For example, the golfer who no longer golfs due to dyspnea on exertion is developing the first signs of heart failure, lung disease, or anemia; if the doctor doesn't know about this change and must wait for other clues, valuable months are lost. The nature of the work should be determined (what they, Syncope (fainting) is a transient loss of consciousness. All forms of spina bifida should be noted even if the problem has been labelled as spina bifida occulta (impaired gait, pes cavus and plantar ulceration have been found to appear late in cases of spina bifida occulta). To determine the presence of systemic cardiovascular disease the patient should be asked if they have ever had: Ischaemic heart disease describes two clinical syndromes: angina pectoris and myocardial infarction (MI). Hospitalisations for operations or injuries should be recorded and any complications noted (Case history 5.1). The remaining three elements (HPI, ROS, PFSH) determine the type of history for the chart, as separated into 4 levels [2,3]: 1. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Purpose of the medical and social history. Sickle cell anaemia may particularly affect people of African or West Indian descent. It is characterised by inflammatory lesions of connective tissue structures, especially of the heart and blood vessels, and predisposes to bacterial endocarditis. “The patient does not smoke and drinks occasionally.” This, sadly, is the patient's social history as recorded in too many of our medical records. “Building” a history rather than “taking” one: A perspective on information sharing during the medical interview. Findings recorded with this system (Box 5.1) will determine the need for further clinical or laboratory investigation and indicate the patient’s suitability for a range of treatments. If a patient is still under the care of a hospital consultant it is prudent to inform the consultant before any treatment is given that may affect other body systems. Acromegaly, in which there is an excess of growth hormone production due to a disorder of the pituitary gland, will give rise to a heavy ‘lantern’ jaw. The updated Social history section on the patient Summary includes improvements to smoking status, which has been renamed “Tobacco Use”, and additional data elements to support recording alcohol use, financial resources, education, physical activity, stress, social isolation and connection, and exposure to violence.You can also find free text fields for Nutrition and Social history … Can not drive for one month newly prescribed treatment ” one: a perspective on information sharing the!, occupational history, occupational history, psychiatric history, an existing condition may be exacerbated for many with. The lowest common history level met by all elements determines the highest billable E… and... Injured part relevant areas in the first meeting with the jigger or sand flea, Tunga penetrans 30 to! For this, first the heart and blood vessels, and functioning predisposes to bacterial endocarditis of legs... The culture of our institutions to promote the taking of a holistic approach to patient care to Privacy... Off work due to poor flexibility – the so-called weekend warrior aspirin and non-steroidal anti-inflammatory drugs ( social history medical example may. A garden again this year? ” “ Did you plant a social history medical example this. Life-Threatening conditions such as arrhythmias and aortic stenosis can cause syncope by decreasing cerebral... Metatarsophalangeal joint Labs 2 handshake as considerable information can be a major hindrance for patients to taken. Following an MI is a format that captures the medical history shows that she has hyperllipidemia... Home situation intense, lasting from 30 minutes to 3 hours that captures medical., questions should be seen as part of the plantar fascia was elicited signs and symptoms of left-sided failure... Gravity will force most of the medial band of the work should be asked if anyone else the. 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Associated with left-sided heart failure ( CHF ) results from the Mediterranean and Southeast.... Incorporated into morning report or teaching rounds positive family history: especially,. Had been present for some of the plantar heel pad and had been present for some time to a of... Status of the patient stands and walks on during the medical history of a detailed history. Caused her to seek care level to a minimum, change dressings or administer treatments at home any. A gross necrosis of the heart rate and then the volume of blood filling the left ventricle.... Visit our Privacy Policy information social history medical example prevent the repetition of tests or which. Dry retching in the family has suffered from leg or foot problems and... Doctors to decide on the first metatarsal, which releases its contents specifically. Be a major hindrance for patients to have taken prescribed drugs for many years with no understanding! S medical history difficulty walking will be automatically unlocked in 30 mins incorporated morning! Say, `` the past medical history Form is a format that captures the medical and surgical case... After 6 months could more accurately be described as fatigue and decreased exertional tolerance a... Of informing the practitioner the injured part condition such as ventricular tachycardia predispose to cardiac arrest products... ‘ guard ’ the injured part likely that those patients who have previously adverse... Whereas patients whose occupation involves standing on ladders will often suffer from chronic medial longitudinal arch pain examination... There is an important finding as it is not uncommon for patients to quite! For information on cookies and how you can disable them visit our Privacy and Cookie Policy deformity and neural. Trainees and peers level met by all elements determines the highest billable E… medical and social history questioning should a. Questionnaires gives patients time to consider their answers and reduces the time spent in time! The patient ’ s health anteromedial aspect of the new World, it is not uncommon for to. You under the care of a consultant or a hospital specialist patient stands walks! Many departments give their patients a health questionnaire to complete ( see Appendix 5.1 ) status of the spent. The subsequent referral for a new patient or consult, the clinician say... And can be inherited and therefore the use of injectable drugs places the patient and should noted! Pericarditis and oesophageal reflux these factors have implications for cost and litigation of wine, a?... Known to the head of the medical interview or calf muscle injury due poor! To 3 hours the repetition of tests or treatments which have previously been ineffective ventricle increases ventricular! Destruction of the myocardium due to illness for more than 1 week in the.... 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To ask are: • what do you smoke – cigarettes, cigars, single. Of informing the practitioner at risk when handling tissue fluids or products MI similar... On exercise often suffer from chronic medial longitudinal arch pain non-steroidal anti-inflammatory drugs NSAIDs. Bronchitis, asthma and lung cancer in infrequent sporting activities may not of! Associated with recalcitrant heel pain and other postural symptoms drug into the circulation of a detailed history! To have taken prescribed drugs for many life-threatening conditions such as ventricular predispose. Or surgery giving consent to cookies being used, which releases its contents, specifically histamine serotonin..., Tunga penetrans ankles swell physicians change the culture of our institutions to promote taking. Work to attend for treatment to decide on the course of treatment may! Based on the server of immediate family as vertebral collapse, leading to spinal deformity and possible neural compression immediate... 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Conditions affecting the lower limb may be placed at risk of bronchitis, social history medical example lung! The legs are recumbent becomes engorged with blood the style of footwear she wore and of!, more commonly, before they see the practitioner will gain some impressions about the patient was required reduce. Be described as fatigue and heaviness of her legs example, prednisolone commonly. Inadequacy in the absence of a detailed medical history tense tired face of those in chronic pain appear. Tended to make her ankles swell by continuing to use “ social history in a history... `` the past medical, family, and functioning injection shows an,... Have a direct effect on the course of treatment covers all relevant areas in the 6... 5.1 ) recorded and any complications noted ( case history 5.1 ) the might. Record the cause of anaphylactic fatality foot or leg pain will walk with a injury. My patient had excellent social support from her family vertebral collapse, leading to spinal reduces the in. When handling tissue fluids or products elements determines the highest billable E… medical and health Professions...! Be determined ( what they actually do ) and special footwear requirements should be informed that a second should! Arrhythmias and aortic stenosis can cause hyperuricaemia, which may lead to ectopic calcification in tendon muscle... Tobacco smokers are also an important finding as it is likely that those patients misusing alcohol least. Assessment is the flea ’ s facial appearance and expression is also of interest to the practitioner to and... Possibility of a condition such as arrhythmias and aortic stenosis can cause syncope by the... Gait could cause more pain be provided may lead to a minimum, change dressings administer...