Transcript

 Lecture

 overview
 Demonstration of History Taking
 based on symptoms in 3rd semester
 small class
 Self learning
 Evaluation
 check list
OSCE



 Pernah melakukan atau pernah
menerapkan dibawah supervisi (3)
 Mampu melakukan secara mandiri (4)

 To address the symptoms of ......
 To review the anatomy & pathophysiology,
differential diagnosis, pathogenesis,
complication, guidelines for evaluating .......
 To review the etiology, pathogenesis,
differential diagnosis, diagnosis of ........

 Perform a complete history for a given
patient
 Establish a comfortable rapport with the
patient
 Exhibit empathy, tact and compassion,
maintaining a professional & ethical code
of conduct
 Concisely communicate the history
Chief
complaint
history
Physical
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DATA COLLECTION
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Initial Problem / Diagnosis
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Introductory questions
 Good relationship
 Logical manner
 Listen carefully
 Interrupt appropriately
 Note non-verbal clues
 Correctly interpret
 Presenting (principal) symptom
 History of presenting illness
 Past history
 Social history
occupation, education, smoking,
alcohol, analgesic use, overseas travel,
immunisation, marital status, social
support, living conditions
 Family history
 Systems review
 History of presenting illness
details of current illnesses, details of
previous, similar episode, current
treatment & drug history, menstrual &
reproductive history for women, extend
of functional disability
History of presenting illness
 Current symptoms
the time of onset & duration; the mode of
onset; the site & radiation; especially of
pain; the character; the severity;
aggravating or relieving factors; associated
symptoms
 Current treatment & drug history
tablets or medicines, colour or size, name &
dose, length of use. Treatment for blood
pressure, high cholesterol, diabetes, arthritis,
anxiety or depression, antibiotics, NSAIDs

 Sexual history
urethral discharge, dysuria, vaginal
discharge, a genital ulcer, anorectal
symptoms, type of sexual practise→AIDS
 Menstrual history
last menstrual period, age at which
menstrual began, regular, menopause,
childbearing years

Past history
 Past illnesses
serious illnesses or operations or admissions to
the hospital. Childhood illnesses, obstetric or
gynaecological problems.
 Past treatments, allergies, blood transfusions

The social & personal history
occupation, education, smoking, alcohol,
analgesic use, overseas travel, immunisation,
marital status, social support, living conditions



 Occupation & education
work exposure to dust, chemicals or disease
: mine workers →asbestosis. Hobies →bird
fanciers and lung disease
 Social habits
smoking : how many cigarettes (cigars or
pipe), for how many years . alcohol : how
much, how often ?
 Family history
- family disease
- genogram
 The systems review
shortness of breath, cough, cough up
anything, coughed up blood, snore
loudly, wheezing, fevers, night sweats,
pneumonia or tuberculosis, chest X-ray,
 Character ; what is the cough like ?
- clearing of the throat : GER & post nasal
drip
- brassy cough (hard & metallic) : conditions
that narrow the trachea or larynx
- Barking cough (like a seal) : croup
- Hacking cough : pharyngitis,
tracheobronchitis, early pneumonia
- whooping cough : pertusis
- any sputum production ? If so, what collor
& how much ( mucus, blood, pus, pink
froth) ?

 Onset ; how did it start (sudden versus
gradual) ?
 Intensity : at what time of day is your cough
at its worst ? Does it keep you awake at
night (asthma and chronic bronchitis may
be associated with nocturnal or morning
cough ?
 Duration : how long has it been going on
(acute versus chronic versus paroxysmal
versus seasonal versus perrenial0? If cough is
chronic, how has it changed recently ? Is it
getting better, worse or staying the same ?



 Event associated :
- Pneumonia : fever, chills, rigors,
increased sputum production
- URTI : malaise, sore throat, rhinotthe,
myalgia, headache, ear pain
- tracheitis : retrosternal pain like a hot
poker
- TB / malignancy : hemoptysis,
costitutional symptoms
 Character : describe the nature of your
breathing difficulty
 Onset : how did the SOB start ( sudden vs
gradual) ?. What were you doing when you
became SOB ?
 Intensity : how severe is your SOB right now,
on a scale of 1 to 10 with 1 being mild and
10 being the worst ? Has it gotten worse ?
 Duration : how long have you been SOB?


 Frequency : Has this ever happened to you
before ? If so, how often does it happen ?
When was the last time you became SOB ?
 Palliative factors : Is there anything that
makes your SOB better ? if so, what ?
 Provocative factors : Is there anything that
makesyour SOB worse ? If so, what ?
 Exertion ?
 Position (sitting up versuslying down)?
 Exposure to cold air ?
 Infection ?
 Allergies

 Frequency : Has this ever happened to you
before ? If so, how often does it happen ?
When was the last time you became SOB ?
 Palliative factors : Is there anything that
makes your SOB better ? if so, what ?
 Provocative factors : Is there anything that
makesyour SOB worse ? If so, what ?
 Exertion ?
 Position (sitting up versuslying down)?
 Exposure to cold air ?
 Infection ?
 Allergies

 Even associated
› PE : Hemoptysis, pleuritic chest pain, DVT
› Pulmonary edema / ACS : Exertional chest
pain (CP), PND, orthopnea, and peripheral
edema.
› COPD : Cough, wheeze, and progressively
worsening SOBOE
› Pneumonia, other infections : Fever / chills,
rigors, increased sputum production, cough
› Ascities : Abdominal distension
› Anxiety (diagnosis of exclusion) :
Lightheadedness, diaphoresis, trembling,
choking sensation, palpitations, numbness or
tongling in hands/feet, chest pain, nausea,
abdominal pain,
depersonalization/derealization, flushes or
chills, real of dying, fear of going crazy or
doing something uncontrolled
› Constitutional symptoms: fever, chills, night
sweats, weight loss, anorexia, and asthenia.
Thank you