2. slide history taking
Post on 08-Jul-2018
220 Views
Preview:
TRANSCRIPT
-
8/19/2019 2. Slide History Taking
1/24
HISTORY TAKING
-
8/19/2019 2. Slide 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
-
8/19/2019 2. Slide History Taking
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($ere2
HOW to START?
-
8/19/2019 2. Slide History Taking
4/24
T$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
-
8/19/2019 2. Slide History Taking
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
-
8/19/2019 2. Slide History Taking
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
-
8/19/2019 2. Slide History Taking
7/24
0 Associated with problem in"
&Heart and lung
hest wall
&Respiratory muscle &An$iety
0 The most !aluable means to establishing theetiology is ta%ing the medical history
0Determine the onset& Acute or #hronic
DYS4N%A
-
8/19/2019 2. Slide History Taking
8/24
CH%ST 4AIN
0 'tiology of chest pain"
& #ardiac origin
& (oncardiac) intrathoracic structure
& Tissues of nec%) thoracic wall) *oints) spine
& Subdiaphragmatic organs
0 Angina pectoris =discomfort in the chest+ ad*acent area
associated with myocardial ischemia
it means tightening (OT ,A(
-
8/19/2019 2. Slide History Taking
9/24
0 Observe t$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$e +ain
0 As% the patient to describe how the
chest pain de!eloped
CH%ST 4AIN
-
8/19/2019 2. Slide History Taking
10/24
SYNCO4%
"ost co--on!, cased b, redced
+erfssion of t$e brain
%tio!o,9
Stoke Ada-
Ot$er cardiac arr$,t-iasSei:re disorders
-
8/19/2019 2. Slide History Taking
11/24
Cardiovasc!ar s,nco+e ; 8ite +ro-+t!,
C!es to differentiate t$e case of s,nco+e
0 4recedein events
0 T,+e of onset
04osition of onset0 4osts,nco+a! c!earin of sensori-
0 Associated events
SYNCO4%
-
8/19/2019 2. Slide History Taking
12/24
4A54ITATION
0 4a!+itation < an n+!easant a(areness of
t$e forcef! or ra+id beatin of t$e $eart
0 C$anes in r$,t-= rate
-
8/19/2019 2. Slide History Taking
13/24
%D%"A
0 Cardiac ede-a is enera!!, s,-etrica!
0 It -a, invo!ve t$i$= enita!= abdo-ina!(a!!
Cases of ede-a
0 Cardiac
0 He+atic
0 Rena!
-
8/19/2019 2. Slide History Taking
14/24
0 Cardiac ede-a
; D,s+nea on exertion
; Often assc. (it$ ort$o+nea or 4ND
0 He+atic
; D,s+nea in fre8ent
0 Rena!; >sa!!, c$ronic
-
8/19/2019 2. Slide History Taking
15/24
HO? TO G%T TH% HISTORY @
-
8/19/2019 2. Slide History Taking
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@
-
8/19/2019 2. Slide History Taking
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
-
8/19/2019 2. Slide History Taking
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?
-
8/19/2019 2. Slide History Taking
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%?
-
8/19/2019 2. Slide History Taking
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$in -ake it better7
(orse
-
8/19/2019 2. Slide History Taking
21/24
. Ti-in onset= dration= fre8enc,2
9 ; Has an, t$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
-
8/19/2019 2. Slide History Taking
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@
-
8/19/2019 2. Slide History Taking
23/24
0 4ersona! +ast $istor,
; R$e-atic fever
; CO4D0 Occ+ationa! $istor,
0 Ntritiona! $istor,
-
8/19/2019 2. Slide History Taking
24/24
Ad!ts s$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,
top related