Basic History

Taking
Tim Communication Skill FKUB
Communication + History
Taking

Communication : How to ask
(Bagaimana cara bertanya)
History taking : What wil be asked
(Apa yang akan ditanyakan )
Importance of History Taking
Obtaining an accurate history is the
critical first step in determining the
etiology of a patient's problem.
Relative Contribution of history, physical
examination and investigations to final diagnosis
(Lloyd & Bor,2004)
Dx made on history
alone
Dx changed after
investigations
Dx changed after
physical examinations
82 %
The Structure of a Medical
History
Basic Information of the patient
History of Present Illness (HPI)
Past Medical History (PMH)
Medications
Family History
Social History
Review of Body Systems

Basic Information of the patient
name,
age,
address,
sex,
ethnicity,
occupation,
religion,
marital status.
History of Present Illness (HPI)
Start from Chief Complaint (CC) atau
Keluhan Utama
Chief Complaint :
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
of breath, ankle swelling etc
What brings your here? How can I help you? What
seems to be the problem?


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 kepala
dirasakan 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.

Details of History of Present
Illness

Physician asks
questions to
discussing the
details of the
chief complaint.
History of Present Illness answers
questions of ..
When the
problem began,
what and where
the symptoms
are, what makes
the symptoms
worse or better.
History of Present Illness for
Pain
Timing (When)
Location (Where)
Radiation (find out
the pain radiates)
Character (What is
it like?)
Severity (How bad
is it?)
Progressivity
Aggravating &
Alleviating factors

Agar Mudah Diingat untuk Pain (OPQRST)
Position/site
Severity how it affects daily work/physical activities. Wakes him up at
night, cannot sleep/do any work.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors any activities or position
Quality, nature, character burning sharp, stabbing, crushing; also explain
depth of pain superficial or deep.
Timing mode of onset (abrupt or gradual), progression (continuous or
intermittent if intermittent ask frequency and nature.)
Treatment received or/and outcome.
Onset of disease
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 ditusuk tusuk
Severity : Nyeri dirasakan sangat berat hingga
keluar keringat dingin
Progressivity : dalam 1 jam Nyeri bertambah
hebat
Aggravating and alleviating : Nyeri memberat
saat dibuat berjalan, nyeri berkurang jika dipakai
berbaring





Past Medical History
This should include any illness (past) for
which the patient has received treatment.
Start by asking the patient if they have
any medical problems. If you receive
little/no response, the many questions
can 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?



Past Medical History
Have they ever
undergone any
procedures, X-Rays,
CAT scans, MRIs or
other special testing?
Ever been
hospitalized? If so, for
what?
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.
Medications (MEDS)
Includes all currently
prescribed
medications ,
traditional medicine
(jamu)
Dosage and
frequency should be
noted.

Current Medications: Prescription and Non-
Prescription
Medication Dose Amount Frequency
Allergies/Reactions

Identify the
specific reaction
that occurred
with each
medication.
Allergies/Reactions
Have they experienced
any adverse reactions to
medications?
what the exact nature of
the reaction?
Anaphylaxis is absolute
contraindication A rash
does not raise the same
level of concern.
Family History
In particular, you are
searching for
heritable illnesses
among first or second
degree relatives.
Example : Heart
disease,congenital
abnormalities, Stroke,
Diabetes Melitus

Social History
Alcohol Intake
Cigarette smoking
Other Drug Use
Marital Status
Sexual History
Work History
Other . travel

Smoking History
Have they ever
smoked cigarettes?
If so, how many
packs per day and for
how many years?
Filtered or non filtered
cigarette ?
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?
Work/Hobbies/Other
What sort of work does
the patient do?
Have they always done
the same thing?
Do they enjoy it?
If retired, what do they do
to stay busy?
Any hobbies?
Participation in sports or
other physical activity?
Where are they from
originally?
Review of Systems (ROS)

Characterize patient's overall health status

Review systems/symptoms from head to toe
System Review
Respiratory System
Cough(productive/dry)
Sputum (colour, amount,
smell)
Haemoptysis
Chest pain
SOB/Dyspnoea
Tachypnoea
Hoarseness
Wheezing
Cardiovascular
Chest pain
Paroxysmal Nocturnal Dyspnoea
Orthopnoea
Short 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 swallowing
Abdominal pain/distension
Change of bowel habit
Haematemesis, melaena,
haematochagia
Jaundice
General
Weakness
Fatigue
Anorexia
Change of weight
Fever
Lumps
Night sweats
System Review
Urinary System
Frequency
Dysuria
Urgency
Hesitancy
Terminal dribbling
Nocturia
Back/loin pain
Incontinence
Character of urine:color/
amount (polyuria) & timing
Fever
Nervous System
Visual/Smell/Taste/Hearing/Speech
problem
Head ache
Fits/Faints/Black outs/loss of
consciousness(LOC)
Muscle
weakness/numbness/paralysis
Abnormal sensation
Tremor
Change of behaviour or psyche
Genital system
Pain/ discomfort/ itching
Discharge
Unusual bleeding
Sexual history
Menstrual history menarche/ LMP/
duration & amount of cycle/
Contraception
Obstetric history Para/
gravida/abortion
Musculoskeletal System
Pain muscle, bone, joint
Swelling
Weakness/movement
Deformities
Gait
Saat Koass : Memakai SOAP
Subjective: how patient feels/thinks about him. How does he
look. Includes PC and general appearance/condition of patient
Objective relevant points of patient complaints/vital sings,
physical examination/daily weight,fluid balance,diet/laboratory
investigation and interpretation
Plan about management, treatment, further investigation,
follow up and rehabilitation
Assessment address each active problem after making a
problem list. Make differential diagnosis.
Put it all together : The Structure of
Interview
Calgary-Cambridge
Communication Model (CCOG)
Thank you