HISTORY TAKING

HISTORY TAKING

A. MEDICINE

1. HAEMOPTYSIS

CS: Male,50 years old. Complain of coughing out blood.

HOPI

· Frequency – is it recurrent?

· Quantity and appearance

o Amount: ½ teaspoon?

o Fresh blood?

o Any blood streak+clear sputum

o Blood clot in sputum?

· Associated symptoms

o SOB?

o Chest pain? (ask for pleuritic pain, central?)

o Fever?

§ Chills and rigor?

§ Low grade or high?

§ Night sweats?

· TB history

o Any TB in the past? On treatment(complete)?

o Contact with people having TB?

o Closed contact with TB pt?

Systemic Review

· Any loss of weight or appetite?

· Ask for signs of anemia (tiredness, diziness, gidiness)

· Calf pain?

Past Medical History

· Any childhood infection?

· History of any chronic illness?(DM, HT)

· History of valvular damage?

· Admitted/investigated?(Any xray, sputum examination,bronchoscope,any blood transfusion?)

Drug History

· On drugs? (anticoagulant)

Social History

· Chronic smoker?

· History of travel overseas/crowded places?

2. INTERMITTENT CLAUDICATION

CS: Male, 50 years. Complain of old pain at the right leg while walking for the pass 1 month.

HOPI

· Site of pain? (Right calf?)

· What brought on the pain? (Onset)

· Nature of pain?

· Radiate to buttock? (Gluteal claudication)

· Duration: last for?

· Relief at rest?

· Do you have swelling on calf?

· Claudication distance (how long were the pt able to walk before he experience the pain?(100m?2km?)

· Severity: Impact on job?

Risk Factors

· DM(on treatment?)

· HPT (on treatment?)

· Chronic smoker?

· History of coronary heart disease?

· Previous stroke?Chest pain? TIA?

· Any investigation done?(doppler's ultrasound?) Medication given?

· Family history?

3. MIGRAINE

CS: Female, 16 years old. Complain of frequent headache.

HOPI

· Site of pain

o Unilateral? Bilateral? Temporal side? Frontal?

· Experience since?

· Nature of the pain (throbbing)

· Duration? (minutes? Hours?)

· Intensity (scale out of 10, 1 is least pain 10 is the worse)

· Associated symptoms

o Nausea, vomiting (relief after vommiting?)

o Aura(mood changes, flashes of light, fortification spectrum-zig zag lines)

o Neck stiffness

· Aggravating factors

o Noise, lights(photophobia) stress, menstrual cycle

o Food(cheese,chocolate, red wine, OCP)

· Relieving

o Dark room and quiet, medication-what?

· Any trauma

· Infection

Family history

· Family members who also had migrain?

Drug History

· Contraceptive?

Social History

· Occupation? Is it stress?

· Smoking? Alcohol?

· Is the headache investigated?? (CT? MRI?)

4. WHEEZING

CS: Male, 18 years old. Complain of wheezing

HOPI

· First time having the problem? Since when?

· Progression

· Duration: How long? Any particular time?

· Severity: how long it lasts

· Aggravating factors/worsen?

o Smoke, at night, drugs, food, weather, dust(ask any carpets or plush toys at home)pets, excess exercise,eczema/skin rash, any allergy to drugs, stress, eating seafood:worse?

· Relieving factors?

o Inhaler(blue:short acting, brown-long acting: how frequent? How many puffs? Nebulizer? Any admission to the hospital?)

o Getting better when taking it?

Systemic Review

· Chest pain? (describe it.. Tightness of the chest?)

· Any dry cough?

Past Medical History

· Any life threatening episodes(emergency admitted)? Any nebulizer/ventilator given?

Family History

· Any family history of astma?

Social History

· Chronic smoker?

· Occupation? (factory worker)

· Exposure to insecticides

5. SHORTNESS OF BREATH

CS: Male,45 years old. Complain shortness of breath

HOPI

· Duration?

· First time?

· Worsening?

· Associated symptoms

o Cough?

o Chest pain?

o Wheezing?

o Palpation?

· Any sputum production?

o Mucoid/pus purulent/foul smelling

o Hemoptysis

o Amount

· Early morning cough?

· Paroxysmal Nocturnal dyspnea?

· Aggravating factor

o Changes of weather, environmental pollution:smoke/haze

· Relieving factor

o Inhaler, nebulizer(any admission)

Systemic Review

· Recent loss of weight, loss of appetite

· Leg swelling?

Past Medical History

· Past history of TB?

· History of DM?

· Admission for life, threatening episodes

Social History

· Smoking?

· Occupational history?

6. ACUTE CHEST PAIN

CS: Male, 40 years old. Complain of chest pain for 1 hour duration

HOPI

· Site: central

· Onset: sudden

· Nature of pain: crushing pain

· Radiation: left arm, neck and jaw

· Associated symptoms:

o Profuse sweating, nausea, vomiting, coughing

· Duration: more than 20 minutes

· Intensity: grade 1-10

· Relieving factors

o No relieving factor, not relieved by nitrates

· Frequency

o Is this first episode? Ask whether first time admitted? Intensity compared to previous episode.

o If 2nd episode, ask about nitrates/GTN.

Risk Factors

· Atherosclerosis

· Hypertension

· Diabetes Mellitus

· Hyperlipidaemia

· Chronic smoking

· Significant family history(first degree family):-M<55,f<65

· Sedentary lifestyle

B. SURGERY

1. JAUNDICE

CS: male, 20 years old. Complain of yellow discoloration of the skin for 1 week

HOPI

· Duration?

· Getting worse?

· Tea colour urine? Pale colour stool? Change in bowel habit?

· Anemic?(lethargic, tired..etc)

· Any bruises/itchiness?

· Git symptoms

o Any mass?

o Pain at rhc?

· Associated symptoms

o Nausea? Vommiting?

o Fever (low grade? High? Chills and rigor?)

o Weight loss? Loss of appetite?

Past medical history

· Hepaitis, Cholecystitis

Surgical history

· Cholengitis or gall stone removal?

Family history

· Any family members experience the same thing or gotten sick

Drug history

· Oral contraceptives

· Drugs? Antibiotic? PCM? Anti Tb?

Social history

· Occupation: health care professional(needle prick), gardener/farmer:leptospira

· Eat seafood? Iv drugs usage? promiscuity? tatooing? alcoholic?

· Distaste for cigarettes? (if previously he is a chronic smoker..)

· Leptospirosis(any trips to those area affected)

· Mushroom poisoning

2. THYROID

HOPI

· Mass

o Site

o Size (larger/shrunken)

o Tenderness

o Mobility

o Since when?

· Any hoarseness of voice, dysphagia?

· GI - Loss of weight despite increase in appetite

· CNS - Restless, easily feel irritated/emotionally disturbed

· Insomnia?

· Profuse sweating/heat intolerance

· CVS - Palpation

· Any muscle weakness(usually prox), difficult in doing activities(comb hair, etc)

Menstrual history

· oligomenorrhea

Past surgical history

· Surgery at the neck?

Drugs History

· Drug for heart(amiodarone-drug induced thyrotoxicosis)

Family history

· Any with same problem?

3. BREAST LUMP

HOPI

· Site: upper inner/upper outer/lower inner/lower outer

· Duration: when discover first lump

· Size: how big:10 cent, enlarge/shrink? Shape?

· Consistency: soft, firm, hard, regular/irregular, nodular?

· Pain: painful/painless

· Mobility

· Any nipple discharge? What color?, Any skin changes? any lymph node in axilla?

Menstrual History

· Menarche and menapause-when?

· When get first child/breastfeeding-how long?, why stop?(if abrupt)

· Take any oral contraceptives/ hormone replacement theraphy?

Family History

· Any Ca history?

Social History

· Smoking? Fatty diet? Exposure to radiation, sunbathing?

· Any investigation done before, mammogram?

4. ULCER/LUMP

HOPI

· Onset - how notice?, is is first time?, getting worse?

· Site & size(change in size?)

· Change in character (color, discharge)

· Painful/tender?

· Severity? - movement affected?

· Any history trauma?

· Muscle weakness/Numbness?

Past medical history

· Any chronic illness – DM, HT

Drugs History

· In any drugs(DM)

· Compliance?

Family history

· History of Ca

· Family history of DM

5. BENIGN PROSTATIC HYPERPLASIA

HOPI

· Dysuria

o Onset

o Site of pain

o Duration

o Getting worse

o Nature of pain

o Relieving factor

· Sign of BPH

o Weak urinary stream

o Prolonged emptying of the bladder

o Abdominal straining

o Hesitancy

o Irregular need to urinate

o Incomplete bladder emptying

o Post-urination dribble

o Frequent urination

o Nocturia (need to urinate during the night)

o Urgency

o Incontinence (involuntary leakage of urine)

o Problems in ejaculation

· Any fever(rule out UTI)

· Hematuria

· Passing stone in urine

Past Medical & Surgical History

· History of kidney disease(renal stones?)

SpecIfic CVS examination

Inspection(undreess patient to the waist,inspect carefully for 10 scnd),lying 45 degree

Comment on:

1. Chest wall movement with each respiration
2. symmetrically or not
3. chest wall deformity
4. surgical scar
5. silated veins
6. skin discolouration
7. visible pulsation
8. Pecardial bulge
   

Palpation

1. Apex beat( mitral area)
2. Cari apex beat from inferior lateral region,dy biasa beloow nipple skit
3. If x jumpa,roll pateint over left side
4. LOcate apex beat (tunjuk kat examiner kiraan ribs)
5. Access character of :Tapping, Heaving(forceful,sustained,undisplaced impulse "pressure overload due to aortic stenosis/ LV hypertrophy),Thrusting (forceful,unsustainedd,undislace impulse->aortic regurgitation/enlargmnt in mitral),Thrill( palpable murmur)
6. Palpate using palm for: parasternal heave(fro rt ventricular & left atrial hypertrophy),thrill at mitral ,aortic and pulmonary area.suggestd for any stenosis

Auscultation

1. Mitral area->using bell,listen for pan systolic murmurs suggested mitral stenosis
2. using diapghrm->trace up from mitral area to axillae suggested mitral regurgitation
3. Tricuspid area-> serach for pansystolic murmurs( ask patient to breath in ,hold and breath out)
4. Pulmonary area nad aortic area->listen for ejection systolic murmurs for aortic and pulmonary stenosis
   
5. listen kt lt n rt carotid area sugested for ejaction systolic murmur radiate to carotid area,
6. sit the pateint up and listen at 3 area again. This time ask patient to breath in,breath out and hold.

1. Impapable apex beat due tu:
   

• obesity
• pleural & pericardial effusion
• COPD
• Dextocardia(rasa kr sbelah kanan)