2. slide history taking

8/19/2019 2. Slide History Taking

1/24

HISTORY TAKING


2/24

References

1. Heart Disease.

A Textbook of Cardiovasc!ar "edicine#t$ %d & 'ran(a!d

). 'ates*s .Gide to +$,sica! exa-inationand $istor, takin /t$ %d


3/24

0 Greet c!ient res+ectf!!, and (it$ kindness

0 Introdce ,orse!f

0 %x+!ain abot $istor, takin

and t$e oa! of $istor, takin

0Identif, t$e +atient*s data described e!se($ere2

HOW to START?


4/24

T$e one or -ore s,-+to-s or concerns

casin t$e +atient to seek care

Give t$e o++ortnit, to re!ate t$eir

ex+eriences and co-+!aints in t$eir o(n

(a,

CHI%3 CO"45AINTS2


5/24

0 D,s+nea 6 %xcessive fatie

0 C$est +ain

0 S,nco+e7 co!!a+se

0 4a!+itation

0 %de-a

T$e -ost fre8ent +rob!e-s2


6/24

DYS4N%A

0 Dyspnea = abnormally uncomfortable

awareness of breathing

0 One of the principal symptom of cardiac andpulmonary disorders

0 t occurs at rest or at a low le!el acti!ity


7/24

0 Associated with problem in"

&Heart and lung

hest wall

&Respiratory muscle &An$iety

0 The most !aluable means to establishing theetiology is ta%ing the medical history

0Determine the onset& Acute or #hronic

DYS4N%A


8/24

CH%ST 4AIN

0 'tiology of chest pain"

& #ardiac origin

& (oncardiac) intrathoracic structure

& Tissues of nec%) thoracic wall) *oints) spine

& Subdiaphragmatic organs

0 Angina pectoris =discomfort in the chest+ ad*acent area

associated with myocardial ischemia

it means tightening (OT ,A(


9/24

0 Observe t$e +atient*s estre

0 C!enc$in t$e fist in front of t$e stern-

5evine*s sin2 is a stron of an isc$e-ic

oriin of t$e +ain

0 As% the patient to describe how the

chest pain de!eloped

CH%ST 4AIN


10/24

SYNCO4%

"ost co--on!, cased b, redced

+erfssion of t$e brain

%tio!o,9

Stoke Ada-

Ot$er cardiac arr$,t-iasSei:re disorders


11/24

Cardiovasc!ar s,nco+e ; 8ite +ro-+t!,

C!es to differentiate t$e case of s,nco+e

0 4recedein events

0 T,+e of onset

04osition of onset0 4osts,nco+a! c!earin of sensori-

0 Associated events

SYNCO4%


12/24

4A54ITATION

0 4a!+itation < an n+!easant a(areness of

t$e forcef! or ra+id beatin of t$e $eart

0 C$anes in r$,t-= rate


13/24

%D%"A

0 Cardiac ede-a is enera!!, s,-etrica!

0 It -a, invo!ve t$i$= enita!= abdo-ina!(a!!

Cases of ede-a

0 Cardiac

0 He+atic

0 Rena!


14/24

0 Cardiac ede-a

; D,s+nea on exertion

; Often assc. (it$ ort$o+nea or 4ND

0 He+atic

; D,s+nea in fre8ent

0 Rena!; >sa!!, c$ronic


15/24

HO? TO G%T TH% HISTORY @


16/24

CHI%3 CO"45AINTS2

Give t$e o++ortnit, to re!ate t$eirex+eriences and co-+!aints in t$eir o(n

(a,

9 Ho( can I $e!+ ,o@

?$at can I do for ,o@

?$at concerns brin ,o $ere toda,

?$ic$ one ,o are -ost concerned abot@


17/24

4R%S%NT I55N%SS

Describe $o( eac$ s,-+to- deve!o+ed

1. Onset and c$rono!o, of c$ief co-+!aint

). 5ocation B. a!it, and intensit,

. 3actors t$at +reci+itate= aravate or a!!eviate

. Ti-in onset= dration= fre8enc,2

#. Settin in ($ic$ t$e s,-+to-s occr E. An, associated -anifestations2

/. Histor, of +revios treat-ent and its res+onses

na-e= dose= fre8enc, of t$e drs2


18/24

-& Onset and chronology of chief complaint." When did you feel it?

How was it happen?

When was it happened

When was the last time you feel it

/& 0ocation

." Show me where you get the pain?

Does it radiates? Where is it?


19/24

1& .uality)2uantity and intensity." 3 Tell me about your pain

3 How worst is it?

3 s it sharp li%e a pinpric%) or does it

ache? 3 Do you get short of breath climbing

stairs?

3 Was it affected your ability to wor%?


20/24

. 3actors t$at +reci+itate= aravate ora!!eviate

9 ; ?$at $ave ,o done before ,o

fee! it@ ; ?$at $e!+s -ake it better@

; ?$at -ake it (orse@

; Does an,t$in -ake it better7

(orse


21/24

. Ti-in onset= dration= fre8enc,2

9 ; Has an, t$in !ike t$is $a++enedto ,o before@

; Ho( !on did it !ast

; Ho( often does it co-e

#. Settin in ($ic$ t$e s,-+to-s occr

; 4ersona! activities

; %nviron-enta! factors ; %-otiona! reactions

Ot$er circ-stances t$at -a, $ave

contribted to t$e i!!ness


22/24

E. An, associated -anifestations2

9 Have ,o noticed an,t$in e!se t$at

acco-+anies it

/. Histor, of +revios treat-ent and itsres+onses na-e= dose= fre8enc, of

t$e drs2

9 Have ,o seen t$e doctor before@

?$at kind of -edicine did ,o

take@


23/24

0 4ersona! +ast $istor,

; R$e-atic fever

; CO4D0 Occ+ationa! $istor,

0 Ntritiona! $istor,


24/24

Ad!ts s$o!d be rotine!, 8estioned abott$e +resence of t$e -aFor risk factor for

CAD

0 Ciarette s-okin0 H,+ertension

0 H,+erc$o!estero!e-ia

0 Diabetes "e!!its

0 3a-i!, $istor,

2. slide history taking

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