Basic History

Taking

Tim Communication Skill FKUB

Importance of History
Taking
Obtaining

an accurate history is the

critical first step in determining
the etiology of a patient's problem.
A large percentage of the time )
82%), you will actually be able make
a diagnosis based on the history
alone.

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

Onset of disease
Position/site
Quality, nature, character burning sharp, stabbing, crushing; also
explain depth of pain superficial or deep.

Relationship to anything or other bodily function/position.

Radiation: where moved to
Relieving or aggravating factors any activities or position
Severity how it affects daily work/physical activities. Wakes him
up at night, cannot sleep/do any work.

Timing mode of onset (abrupt or gradual), progression

(continuous or intermittent if intermittent ask frequency and
nature.)

Treatment received or/and outcome.

Agar Mudah Diingat untuk Pain

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, XRays, 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

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

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
General
Weakness
Fatigue
Anorexia
Change of weight
Fever
Lumps
Night sweats
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,
haematochezia
Jaundice

Cardiovascular
Chest pain
Paroxysmal Nocturnal Dyspnoea
Orthopnoea
Short Of Breath(SOB)
Cough/sputum (pinkish/frank
blood)
Swelling of ankle(SOA)
Palpitations
Cyanosis
Respiratory System
Cough(productive/dry)
Sputum (colour, amount,
smell)
Haemoptysis
Chest pain
SOB/Dyspnoea
Tachypnoea
Hoarseness
Wheezing

System Review
Urinary System
Frequency
Dysuria
Urgency
Hesitancy
Terminal dribbling
Nocturia
Back/low pain
Incontinence
Character of urine:color/
amount (polyuria) &
timing
Fever system
Genital
Pain/ discomfort/ itching
Discharge
Unusual bleeding
Sexual history
Menstrual history menarche/
LMP/ duration & amount of cycle/
Contraception
Obstetric history Para/
gravida/abortion

Nervous System
Visual/Smell/Taste/Hearing/Spee
ch problem
Head ache
Fits/Faints/Black outs/loss of
consciousness(LOC)
Muscle
weakness/numbness/paralysis
Abnormal sensation
Tremor
Change of behaviour or psyche
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

Assessment address each active problem after

making a problem list. Make differential diagnosis.

Plan about management, treatment, further

investigation, follow up and rehabilitation

Any QUESTIONS ?