Lecture overviewDemonstration of History Taking based on symptoms in 3rd semester small class Self learning Evaluation check listOSCE

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 patientEstablish a comfortable rapport with the patientExhibit empathy, tact and compassion, maintaining a professional & ethical code of conductConcisely communicate the history

Chief complainthistoryPhysical examinationtests15105DATA COLLECTIONDifferential diagnosisInitial Problem / DiagnosisIterative hypothesis

Introductory questionsGood relationshipLogical mannerListen carefullyInterrupt appropriatelyNote non-verbal cluesCorrectly interpret

Presenting (principal) symptomHistory of presenting illnessPast historySocial historyoccupation, education, smoking, alcohol, analgesic use, overseas travel, immunisation, marital status, social support, living conditionsFamily historySystems review

History of presenting illnessdetails of current illnesses, details of previous, similar episode, current treatment & drug history, menstrual & reproductive history for women, extend of functional disability

History of presenting illnessCurrent symptomsthe time of onset & duration; the mode of onset; the site & radiation; especially of pain; the character; the severity; aggravating or relieving factors; associated symptomsCurrent treatment & drug historytablets or medicines, colour or size, name & dose, length of use. Treatment for blood pressure, high cholesterol, diabetes, arthritis, anxiety or depression, antibiotics, NSAIDs

Sexual historyurethral discharge, dysuria, vaginal discharge, a genital ulcer, anorectal symptoms, type of sexual practiseAIDSMenstrual historylast menstrual period, age at which menstrual began, regular, menopause, childbearing years

Past historyPast illnessesserious illnesses or operations or admissions to the hospital. Childhood illnesses, obstetric or gynaecological problems. Past treatments, allergies, blood transfusions

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

Occupation & educationwork exposure to dust, chemicals or disease : mine workers asbestosis. Hobies bird fanciers and lung diseaseSocial habitssmoking : how many cigarettes (cigars or pipe), for how many years . alcohol : how much, how often ?

Family history - family disease- genogram

The systems reviewshortness 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 difficultyOnset : 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 associatedPE : Hemoptysis, pleuritic chest pain, DVTPulmonary edema / ACS : Exertional chest pain (CP), PND, orthopnea, and peripheral edema.COPD : Cough, wheeze, and progressively worsening SOBOEPneumonia, other infections : Fever / chills, rigors, increased sputum production, coughAscities : 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 uncontrolledConstitutional symptoms: fever, chills, night sweats, weight loss, anorexia, and asthenia.

Thank you

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