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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
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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
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