6. history taking.pptx

8/10/2019 6. History Taking.pptx

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Basic HistoryTaking

Tim Communication Skill FKUB


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Communication + History

Taking

Communication : How to ask

(Bagaimanacara bertanya)History taking : What wil be asked

(Apayang akan ditanyakan )


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Importance of History Taking

Obtaining an accurate history is the

critical first stepin determining the

etiologyof a patient's problem.

Relative Contribution of history, physicalexamination and investigations to final diagnosis

(Lloyd & Bor,2004)

Dx made on historyalone

Dx changed afterinvestigations

Dx changed afterphysical examinations

82 %


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The Structure of a Medical

History

Basic Information of the patient

History of Present Illness (HPI)

Past Medical History (PMH)Medications

Family HistorySocial History

Review of Body Systems


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Basic Information of the patient

name,

age,

address,

sex,

ethnicity,

occupation,

religion,

marital status.


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History of Present Illness (HPI)

Start from Chief Complaint (CC) atau

Keluhan Utama

Chief Complaint : whypatienthere--use patient's own words

One sentence that covers the dominant reason(s) for

hospitalization

Usually a single symptoms, occasionally more thanone complaints eg: chest pain, palpitation, shortness

of breath, ankle swelling etc

What brings your here? How can I help you? What

seems to be the problem?


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Example of History Present

Ilness

Seorang Laki-laki berusia 50 tahun datang ke UGD

dengan mengeluh sakit kepala

Sakit kepala dirasakan sejak 1 hari yang lalu. Sakit kepaladirasakan di kepala sebelah kanan. Sakit dirasakan seperti

diremas (cekot-cekot). Sakit menyebar ke bola mata

sebelah kanan, makin lama makin memberat. Sakit

dirasakan terus menerus, meningkat saat menunduk atau

sujud. Sakit berkurang saat penderita berbaring.Dst.


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Details of History of Present

Illness

Physician asks

questions todiscussing the

details of the

chief complaint.


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History of Present Illness answers

questions of ..

Whenthe

problem began,

whatand wherethe symptoms

are, what makes

the symptomsworseor better.


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History of Present Illness for

Pain

Timing (When)

Location (Where)

Radiation (find out

the pain radiates)Character (What is

it like?)

Severity (How badis it?)

Progressivity

Aggravating &

Alleviating factors


11/30Agar Mudah Diingat untuk Pain (OPQRST)

Position/site

Severityhow it affects daily work/physical activities. Wakes him up atnight, cannot sleep/do any work.

Relationship to anything or other bodily function/position.

Radiation: where moved to

Relieving or aggravating factorsany activities or position

Quality, nature, characterburning sharp, stabbing, crushing; also explaindepth of painsuperficial or deep.

Timingmode of onset (abrupt or gradual), progression (continuous orintermittentif intermittent ask frequency and nature.)

Treatment received or/and outcome.

Onset of disease


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Example :

Chief Complaint : Dada nyeri

Timing: dada nyeri sejak 1 jam yang lalu

Why: dada nyeri saat menarik becak

Radiation: Nyeri menjalar ke lengan kiri Character: Nyeri seperti ditusuktusuk

Severity: Nyeri dirasakan sangat berat hinggakeluar keringat dingin

Progressivity : dalam 1 jam Nyeri bertambahhebat

Aggravating and alleviating: Nyeri memberatsaat dibuat berjalan, nyeri berkurang jika dipakaiberbaring


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Past Medical History

This should include any illness (past)forwhich the patient has received treatment.

Start by asking the patient if they have

any medical problems. If you receivelittle/no response, the many questionscan help uncover important past events

If patient receive little/no response

Have they ever received medical care? If so, what problems/issues were

addressed?

Was the care continuous or episodic?


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Past Medical History

Have they ever

undergone any

procedures, X-Rays,

CAT scans, MRIs orother special testing?

Ever been

hospitalized? If so, for

what?


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Past Surgical History (PSH)

Were they ever operated

on, even as a child?

What year did this

occur?

Were there any

complications?

If they don't know the

name of the operation, try

determine why it was

performed.


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Medications (MEDS)

Includes all currently

prescribed

medications ,

traditional medicine

(jamu)

Dosage andfrequency should be

noted.


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Current Medications: Prescription and Non-

Prescription

Medication Dose Amount Frequency


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Allergies/Reactions

Identify thespecific reaction

that occurred

with each

medication.


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Allergies/Reactions

Have they experienced

any adverse reactions to

medications?

what the exact nature of

the reaction?

Anaphylaxisis absolute

contraindication A rashdoes not raise the same

level of concern.


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Family History

In particular, you aresearching forheritable illnessesamong first or seconddegree relatives.

Example : Heartdisease,congenitalabnormalities, Stroke,Diabetes Melitus


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Social History

Alcohol Intake

Cigarette smoking Other Drug Use

Marital Status

Sexual History

Work History

Other . travel


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Smoking History

Have they eversmoked cigarettes?

If so, how manypacks per day and forhow many years?

Filtered or non filteredcigarette ?


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Alcohol

Do they drink alcohol?

If so, how much per day

and what type of drink?

Encourage them to be as

specific as possible.

If they don't drink on a

daily basis, how much do

they consume over a

week or month?


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Work/Hobbies/Other

What sort of work doesthe patient do?

Have they always donethe same thing?

Do they enjoy it? If retired, what do they do

to stay busy?

Any hobbies?

Participation in sports orother physical activity?

Where are they fromoriginally?


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Review of Systems (ROS)

Characterize patient's overall health status

Review systems/symptoms from head to toe

System Review


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System Review

Respiratory System

Cough(productive/dry)

Sputum (colour, amount,

smell)

Haemoptysis

Chest painSOB/Dyspnoea

Tachypnoea

Hoarseness

Wheezing

Cardiovascular

Chest pain

Paroxysmal Nocturnal Dyspnoea

OrthopnoeaShort Of Breath(SOB)

Cough/sputum (pinkish/frank blood)

Swelling of ankle(SOA)

Palpitations

Cyanosis

Gastrointestinal/Alimentary

Appetite (anorexia/weight change)

Diet

Nausea/vomiting

Regurgitation/heart burn/flatulence

Difficulty in swallowingAbdominal pain/distension

Change of bowel habit

Haematemesis, melaena,

haematochagia

Jaundice

General

Weakness

Fatigue

AnorexiaChange of weight

Fever

Lumps

Night sweats

S t R i


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System ReviewUrinary System

Frequency

Dysuria

UrgencyHesitancy

Terminal dribbling

Nocturia

Back/loin pain

Incontinence

Character of urine:color/amount (polyuria) & timing

Fever

Nervous System

Visual/Smell/Taste/Hearing/Speech

problemHead ache

Fits/Faints/Black outs/loss of

consciousness(LOC)

Muscle

weakness/numbness/paralysis

Abnormal sensationTremor

Change of behaviour or psyche

Genital system

Pain/ discomfort/ itching

Discharge

Unusual bleedingSexual history

Menstrual historymenarche/ LMP/

duration & amount of cycle/

Contraception

Obstetric historyPara/

gravida/abortion

Musculoskeletal System

Painmuscle, bone, joint

Swelling

Weakness/movementDeformities

Gait


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Saat Koass : Memakai SOAP

Subjective: how patient feels/thinks about him. How does he

look. Includes PC and general appearance/condition of patien

Objectiverelevant points of patient complaints/vital sings,physical examination/daily weight,fluid balance,diet/laboratory

investigation and interpretation

Planabout management, treatment, further investigation,follow up and rehabilitation

Assessmentaddress each active problem after making aproblem list. Make differential diagnosis.

Calgary Cambridge


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Calgary-Cambridge

Communication Model (CCOG)


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Thank you

6. history taking.pptx

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