HISTORY TAKING IN

SEXUALLY TRNSMITTED
INFECTIONS

REPRODUCTIVE SYSTEM
PADJADJARAN UNIVERSITY
WHAT IS THE ESSENTIAL COMPONENTS IN
THE “DIAGNOSIS” of STI?

 History taking
 Genital/Venereological Examination
 Laboratory Examination
HISTORY TAKING ?
• WHAT FOR ?
. . . To collect data ~ the causes :
 sign & symptoms predisposing factors & risk factors
 Complication
 Etc.

• HOW ?
BY ASKING to THE PATIENTS, THE MEDICAL TERMS of the
information about,
 sign & symptoms ~ the causes
 predisposing factors & risk factors
 Complication, etc.

TO THE LANGUAGE THAT THE PATIENTS UNDERSTAND

HISTORY TAKING
• What are the requirements ?
– Need background knowledge of diseases.
– Need trust : patient – physician.
– Empathy
– Communications skill : focus question & gather
information
• 80% of accurate diagnostic can be revealed
by retrieving appropriate data.
HOW THE “STI PATIEN” FEEL ABOUT
THEIR CONDITIONS?

• Embarrassed
• Emotionally disturbed
– To show the genital
– Done a multiple sexual behaviour
– Afraid of being suffered a cancer or STI
WHAT SHOULD WE DO TO OBTAIN A
TRUTHFUL & ACCURATE HISTORY ?

• Explain what you are doing.

• Privacy, confidentially, comfortable.
• Non-judgmental & respectful.
• Speaking :
 The language is understandable &
reassuring
 Utilizese term used by patient or say in
vernacular
 HOW TO DO IT

• INITIATING THE SESSION

• GATHERING INFORMATION
• PROVIDING STRUCTURE FOR THE
CONSULTATION
• BUILDING RELATIONSHIP
FACILITATING PATIENT INVOLVEMENT
• CLOSING THE SESSION
INITIATING THE SESSION

ESTABLISH INITIAL RAPPORT

• Greet patient, obtain patient name
• Introduce your self
• Demonstrate respect and interest; attend to
patient physical comfort
• Give the patient an adequate explanation
about history taking : PRIVATE QUESTION
• Explain the goal or expected result of history
taking
INITIATING THE SESSION

In Dr. Hasan Sadikin Hospital : “5 S”

SENYUM
SAPA
SALAM
SOPAN
SANTUN
INITIATING THE SESSION

IDENTIFYING THE REASON FOR THE

CONSULTATION : chief complain
• Vaginal discharge : gonorrhoeae, nongonorrhoeae,
trichomoniasis, candidosis, bacterial vaginosis ?
• Urethral discharge, dysuria, urinary
frequency : gonorrhoeae, nongonorrhoeae ?
• Sore around the genital or anus : syphilis,
chancroid ?

• Warts
• Any swellings : orchitis as a complication of urethtritis ?
GATHERING INFORMATION

“Description” of chief complain ~ CAUSES

: vaginal discharge
• Amount, color, consistency?
• Abnormal odor?
• Blood stain?
• Using antiseptic or other in the genital
• Contraception
• Pregnancy : first day of the last menstrual cycle
GATHERING INFORMATION

INCUBATION PERIOD :
• Length of time of the symptoms
• Last sexual contact
GATHERING INFORMATION

RISK FACTORS
 SEXUAL HISTORY :
• Number of sexual partner
• Type of sexual behavior practice : orogenital,
anogenital ?
• Regular or casual sexual partner
• Condom use & consistently use
HIV RISK ASSESSMENT
• INJECTING DRUG USER (IDU)
• SEXUAL PARTNER : gay, bisexual, IDU
GATHERING INFORMATION
 OTHER SYMPTOMS RELATED TO :
• Complications
• Mixed infections

 MEDICATION & ALLERGY

• CURRENT MEDICATIONS
• HISTORY OF ALLERGIC REACTIONS
CLOSING THE SESSION

• SUMMARIZING
• ASK THE PATIENT IF SHE HAS ANY
QUESTIONS OR OTHER ITEMS TO
DISCUSS
• EXPLAIN THE NEXT STEP