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
examin
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tests
15
10
5
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 practiseAIDS
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