ppt 6 - history taking
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8/17/2019 Ppt 6 - History Taking
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Basic History Taking
Tim Communication Skill FKUB
8/17/2019 Ppt 6 - History Taking
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Communication + History Taking
Communication : How to ask
(Bagaimana cara bertanya) History taking : Wat wil be
aske! (Apa yang akan
!itanyakan )
8/17/2019 Ppt 6 - History Taking
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8/17/2019 Ppt 6 - History Taking
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Te Structure o$ a Basic e!icalHistory
Basic "n$ormation o$ te #atient
History o$ ,resent "llness (H,")
,ast e!ical History (,H)e!ications
Family History
Social History (inclu!e! smokingbea*ior- alcool- #ysical
acti*ity)
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Basic "n$ormation o$ te#atient
name, age, address, sex, ethnicity, occupation, religion, marital status.
8/17/2019 Ppt 6 - History Taking
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History o$ ,resent "llness(H,")
Start $rom Cie$ Com#laint (CC) atauKeluan Utama
Cie$ Com#laint : why patient here--use patient's own words
One sentence that covers the dominant reason(s) for
hospitalization
Usually a single symptoms, occasionally more than one
complaints eg: chest pain, palpitation, shortness ofreath, an!le swelling etc
"hat rings your here# $ow can % help you# "hat seems to
e the prolem#
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/am#le o$ History ,resent "lnessSeorang 0aki1laki berusia 23 taun
!atang ke U4 !engan mengelusakit ke#alaSakit ke#ala !irasakan se5ak 6 ariyang lalu' Sakit ke#ala !irasakan !i
ke#ala sebela kanan' Sakit!irasakan se#erti !iremas (cekot1cekot)' Sakit menyebar ke bola matasebela kanan- makin lama makinmemberat' Sakit !irasakan terusmenerus- meningkat saat menun!ukatau su5u!' Sakit berkurang saat
#en!erita berbaring'st7'
8/17/2019 Ppt 6 - History Taking
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etails o$ History o$ ,resent "llness
,ysician asks
8uestions to!iscussing te!etails o$ te
cie$com#laint'
8/17/2019 Ppt 6 - History Taking
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History o$ ,resent "llness answers8uestions o$ ''
Wen te#roblem
began- wat an! were tesym#toms are-
wat makeste sym#tomsworse or
better'
8/17/2019 Ppt 6 - History Taking
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History o$ ,resent "llness $or ,ain
Timing (Wen)
0ocation (Were)
.a!iation (9n! out te
#ain ra!iates)Caracter (Wat is it
like)
Se*erity (How ba! is
it),rogressi*ity
;ggra*ating <;lle*iating $actors
8/17/2019 Ppt 6 - History Taking
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;gar u!a iingat untuk ,ain
%osition=site
'e*erity > ow it a?ects !aily work=#ysical acti*ities' Wakes im
u# at nigt- cannot slee#=!o any work'
Relationsi# to anyting or oter bo!ily $unction=#osition'
Ra!iation: were mo*e! toRelie*ing or aggra*ating $actors > any acti*ities or #osition
&uality- nature- caracter > burning sar#- stabbing- crusing@ also
e#lain !e#t o$ #ain > su#er9cial or !ee#'
iming > mo!e o$ onset (abru#t or gra!ual)- #rogression
(continuous or intermittent > i$ intermittent ask $re8uency an!nature')
reatment recei*e! or=an! outcome'
$nset o$ !isease
8/17/2019 Ppt 6 - History Taking
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/am#le :Cie$ Com#laint : a!a nyeri
Timing : !a!a nyeri se5ak 6 5am yang lalu
Wy : !a!a nyeri saat menarik becak
.a!iation : Ayeri men5alar ke lengan kiriCaracter : Ayeri se#erti !itusuk > tusuk
Se*erity : Ayeri !irasakan sangat berat inggakeluar keringat !ingin
,rogressi*ity : !alam 6 5am Ayeri bertamba ebat;ggra*ating an! alle*iating : Ayeri memberat saat
!ibuat ber5alan- nyeri berkurang 5ika !i#akaiberbaring
8/17/2019 Ppt 6 - History Taking
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,ast e!ical History Tis soul! inclu!e any illness (#ast) $or
wic te #atient as recei*e! treatment'
Start by asking te #atient i$ tey a*e any
me!ical #roblems' "$ you recei*e little=nores#onse- te many 8uestions can el#unco*er im#ortant #ast e*ents
"$ #atient recei*e little=no res#onse
Ha*e tey e*er recei*e! me!ical care"$ so- wat #roblems=issues were a!!resse!
Was te care continuous or e#iso!ic
8/17/2019 Ppt 6 - History Taking
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%ast )edical *istory Ha*e tey e*er
un!ergone any#roce!ures- 1
.ays- C;T scans-."s or oters#ecial testing
/*er been
os#italie! "$ so-$or wat
8/17/2019 Ppt 6 - History Taking
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%ast 'urgical *istory(%'*#
Were tey e*er
o#erate! on- e*en asa cil!
Wat year !i! tisoccur
Were tere anycom#lications
"$ tey !on&t know tename o$ te o#eration-
try !etermine wy it
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8/17/2019 Ppt 6 - History Taking
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Current )edications- %rescription and.on/%rescription
e!ication ose ;mount Fre8uency
8/17/2019 Ppt 6 - History Taking
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Allergies0Reactions
"!enti$y tes#eci9creaction tat
occurre! witeacme!ication'
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Allergies0Reactions
Ha*e teye#erience! any
a!*erse reactions tome!ications
wat te eact natureo$ te reaction
;na#ylais isabsolutecontrain!ication ;ras !oes not raise
te same le*el o$concern'
8/17/2019 Ppt 6 - History Taking
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1amily *istory "n #articular- you
are searcing $oreritable illnessesamong 9rst orsecon! !egreerelati*es'
/am#le : Heart!isease-congenitalabnormalities-Stroke- iabeteselitus
8/17/2019 Ppt 6 - History Taking
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'ocial *istory
;lcool "ntake
Cigarette smoking %ter rug Use
arital Status
Seual History
Work History
%ter 7' tra*el
8/17/2019 Ppt 6 - History Taking
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'mo2ing *istory
Ha*e tey e*ersmoke! cigarettes
"$ so- ow many#acks #er !ay an!$or ow manyyears
Filtere! or non9ltere! cigarette
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Alcohol o tey !rink alcool
"$ so- ow muc #er!ay an! wat ty#e o$!rink
/ncourage tem to beas s#eci9c as #ossible'
"$ tey !on&t !rink on a!aily basis- ow muc
!o tey consume o*era week or mont
8/17/2019 Ppt 6 - History Taking
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3or20*obbies0$ther Wat sort o$ work
!oes te #atient !o Ha*e tey always
!one te same ting
o tey en5oy it "$ retire!- wat !o tey
!o to stay busy ;ny obbies
,artici#ation in s#ortsor oter #ysicalacti*ity
Were are tey $romoriginally
8/17/2019 Ppt 6 - History Taking
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.e*iew o$ Systems (.%S)
&haracterize patient's overall health status
eview systemssymptoms from head to toe
'ystem Revie4
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'ystem Revie4
Respiratory 'ystem•Coug(#ro!ucti*e=!ry)•S#utum (colour- amount-smell)•Haemo#tysis
•Cest #ain•S%B=ys#noea• Tacy#noea•Hoarseness•Weeing
Cardiovascular•Cest #ain•,aroysmal Aocturnal ys#noea
•%rto#noea•Sort %$ Breat(S%B)•Coug=s#utum (#inkis=$rankbloo!)•Swelling o$ ankle(S%;)•,al#itations•Cyanosis
5astrointestinal0Alimentary•;##etite (anoreia=weigtcange)•iet•Aausea=*omiting
•.egurgitation=eartburn=Datulence•iEculty in swallowing•;b!ominal #ain=!istension•Cange o$ bowel abit•Haematemesis- melaena-
aematocagia• aun!ice
5eneral•Weakness•Fatigue
•;noreia•Cange o$ weigt•Fe*er•0um#s•Aigt sweats
' t R i
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'ystem Revie46rinary 'ystem•Fre8uency•ysuria
•Urgency•Hesitancy• Terminal !ribbling•Aocturia•Back=loin #ain•"ncontinence
•Caracter o$ urine:color=amount (#olyuria) <timing•Fe*er
.ervous 'ystem•Gisual=Smell=Taste=Hearing=S#ee
c #roblem•Hea! ace•Fits=Faints=Black outs=loss o$consciousness(0%C)•uscleweakness=numbness=#aralysis•;bnormal sensation• Tremor•Cange o$ bea*iour or #syce
5enital system•,ain= !iscom$ort= itcing•iscarge
•Unusual blee!ing•Seual istory•enstrual istory > menarce=0,= !uration < amount o$ cycle=Contrace#tion•%bstetric istory > ,ara=
gra*i!a=abortion
)usculos2eletal 'ystem•,ain > muscle- bone- 5oint•Swelling
•Weakness=mo*ement•e$ormities•4ait
8/17/2019 Ppt 6 - History Taking
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'aat 7oass - )ema2ai '$A%
'ub5ecti*e: ow #atient $eels=tinks about im' How
!oes e look' "nclu!es ,C an! generala##earance=con!ition o$ #atient
$b5ecti*e > rele*ant #oints o$ #atient com#laints=*ital
sings- #ysical eamination=!aily weigt-Dui!
balance-!iet=laboratory in*estigation an! inter#retatio
%lan > about management- treatment- $urter
in*estigation- $ollow u# an! reabilitation
Assessment > a!!ress eac acti*e #roblem a$ter
making a #roblem list' ake !i?erential !iagnosis'
Calgary Cambri!ge
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Calgary1Cambri!geCommunication o!el (CC%4)
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Tank you
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