HISTORY TAKING OF RESPIRATORY SYSTEM 2003.ppt

 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 ation tests 15 10 5 DATA COLLECTION D i f f e r e n t i a l d i a g n o s i s Initial Problem / Diagnosis I t e r a t i v e h y p o t h e s i s 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 practise→AIDS  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