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HISTORY TAKING&VITAL SIGN

Dewi Kartikawati


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Importance of HistoryTaking

Obtaining an accurate history is the

critical first step in determining theetiology of a patient's problem.

A large percentage of the time )70%),you will actually be able make adiagnosis based on the history alone.


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How to take a history?

The sense of what constitutes importantdata will grow exponentially in future asyou learn about the pathophysiology ofdisease

You are already in possession of the toolsthat will enable you to obtain a goodhistory.

An ability to listen and ask common-sense

questions that help define the nature of aparticular problem.

A vast and sophisticated fund ofknowledge not needed to successfully

interview a patient.


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Introduce yourself.Note never forget patient namesCreat patient appropriately in a friendly relaxed way.Confidentiality and respect patient privacy.

GeneralApproach

Try to see things from patient point of view. Understandpatient underneath mental status, anxiety, irritation ordepression.Always exhibit neutral position.

Listening

Questioning: simple/clear/avoid medical terms/open, leading,interrupting, direct questions and summarizing.


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Taking the history &Recording: Always record personal details:

name,

age,address,

sex,

ethnicity,

occupation,

religion,

marital status,

Record date of examination


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Complete History Taking

Chief complaint

History of present illness

Past medical history Systemic enquiry

Family history

Drug history

Social history


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Methods of Examination

Inspection

Palpation

LightDeep

Percussion

Flatness, dullness, resonance,hiperresonance, tymphany

Ausculatation

Pitch, intensity, duration, quality


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CHIEF COMPLAINT


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Chief Complaint

The main reason push the patient (pt) toseek for visiting a physician or for help

Usually a single symptoms, occasionallymore than one complaints ex: chest pain,palpitation, shortness of breath, ankleswelling etc

The patient describe the problem in theirown words.

It should be recorded in pts own words.

What brings your here? How can I helpyou? What seems to be the problem?


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Chief Complaint

Cheif Complaint (CC)

Short/specific in one clear sentencecommunicating present/major problem/issue.

Timing fever for last two weeks or sincemonday

Recurrent recurring episode of abdominalpain/cough

Any major disease important e.g. DM, asthma,HT, pregnancy, IHD:

Note: CC should be put in patient language.


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History of Present Illness


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History of Present Illness -Tips

Elaborate on the chief complaint in detail

Ask relevant associated symptoms

Have differential diagnosis in mind

Lead the conversation and thoughts

Decide and weight the importance ofminor complaints


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Sequential presentationAlways relay story in days before admission e.g. 1 week

before the admission, the patient fell while gardening and cuthis foot with a stone.Narrate in details By that evening, the foot became swollenand patient was unable to walk. Next day patient attendedKhorshid hospital and they gave him some oral antibiotics.He doesnt know the name. There is no effect on hiscondition and two days prior to admission, the foot continued

to swell and started to discharge pus. There is high fever andrigors with nausea and vomiting.

History of Presenting Complaint (HPC)

In details of symptomatic presentationIf patient has more than one symptom, like chest pain,swollen legs and vomiting, take each symptom individuallyand follow it through fully mentioning significant negatives aswell. E.g the pain was central crushing pain radiating to left

jaw while mowing the lawn. It lasted for less than 5 minutes

and was relieved by taking rest. No associated symptoms withpain/never had this pain before/no relation with food/he is

In details of present problem with- time of onset/ mode ofevolution/ any investigation;treatment &outcome/any

associated symptoms.


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History of Present Illness

- Tips Avoid medical terminology and make use

of a descriptive language that is familiar

to them Ask OPQRST for each symptom


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ain (OPQRST)

Position/si

te

Severity how it affects daily work/physical activities.Wakes him up at night, cannot sleep/do any work.

Relationship to anything or other bodily

function/position.Radiation: where moved toRelieving or aggravating factors any activities or

position

Quality, nature, character burning sharp, stabbing,crushing; also explain depth of pain superficial ordeep.

Timing mode of onset (abrupt or gradual),progression (continuous or intermittent ifintermittent ask frequency and nature.)Treatment received or/and outcome.

Onset of

disease

Are there any associated symptoms?


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Past Medical Illness


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Past Medical History

Start by asking the patient if they haveany medical problems

Heart Attack/DM/Asthma/HT/RHD,

TB/Jaundice :E.g. if diabetic- mentiontime of diagnosis/currentmedication/clinic check up

Past surgical/operation history

E.g. time/place/ and what type of operation.Note any blood transfusion and bloodgrouping.

History of trauma/accidents

E.g. time/place/ and what type of accident


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Drug History


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Drug History

Drug History (DH)

Always use generic name or put trade

name in brackets with dosage, timingand how long. Example: Ranitidine 150mg BD PO

Note: do not forget to mentionVitamins/Traditional medicine


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Family History


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Family History

Any familial disease/running in familiese.g. breast cancer, DM, schizophrenia,Developmental delay, asthma, albinism


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Social History


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Social History

Smoking history - amount, duration andtype. A strong risk factor for IHD

Drinking history - amount, duration and

type. Cause cardiomyopathy,vasodilatation

Occupation, social and education

background, ADL, family social supportand financial situation


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Other Relevant History

Gyane/Obstetric history if female

Immunization if small child

Note: Look for the child health card.

Travel and sexual history if suspected STI orinfectious disease

Note:

If small child, obtain the history from the care

giver. Make sure; talk to right care giver. If some one does not talk to your language, get

an interpreter(neutral not family friend ormember also familiar with both language). Ask

simple & straight question but do not go for yesor no answer.


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System Review (SR)

This is a guide not to miss anything

Any significant finding should be moved to HPCdepending upon where you think it belongs.

Do not forget to ask associated symptoms of PC with theSystem involved

When giving verbal reports, say no significant finding on

systems review to show you did it. However when writingup patient notes, you should record the systems review sothat the relieving doctors know what system you covered.

System Review


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System Review

Respiratory SystemCough(productive/dry)Sputum (colour, amount, smell)HaemoptysisChest pain

SOB/DyspnoeaTachypnoeaHoarsenessWheezing

CardiovascularChest painParoxysmal Nocturnal Dyspnoea

OrthopnoeaShort Of Breath(SOB)Cough/sputum (pinkish/frank blood)Swelling of ankle(SOA)PalpitationsCyanosis

Gastrointestinal/AlimentaryAppetite (anorexia/weight change)DietNausea/vomitingRegurgitation/heart burn/flatulenceDifficulty in swallowingAbdominal pain/distensionChange of bowel habitHaematemesis, melaena, haematochagiaJaundice

GeneralWeaknessFatigue

AnorexiaChange of weightFeverLumpsNight sweats

S t R i


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System Review

Urinary SystemFrequencyDysuriaUrgencyHesitancyTerminal dribblingNocturiaBack/loin painIncontinence

Character of urine:color/ amount(polyuria) & timingFever

Nervous SystemVisual/Smell/Taste/Hearing/SpeechproblemHead acheFits/Faints/Black outs/loss ofconsciousness(LOC)Muscle weakness/numbness/paralysisAbnormal sensationTremor

Change of behaviour or psyche

Genital systemPain/ discomfort/ itchingDischargeUnusual bleedingSexual historyMenstrual history menarche/ LMP/ duration &amount of cycle/ ContraceptionObstetric history Para/ gravida/abortion

Musculoskeletal SystemPain muscle, bone, jointSwelling

Weakness/movementDeformitiesGait


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SOAP

Subjective: how patient feels/thinks about him. How does h

look. Includes PC and general appearance/condition ofpatient

Objective relevant points of patient complaints/vital singsphysical examination/daily weight,fluid

balance,diet/laboratory investigation and interpretation

Plan about management, treatment, further investigation,follow up and rehabilitation

Assessment address each active problem after making aproblem list. Make differential diagnosis.


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QUESTION ?


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Vitals Sign


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Where are we going?

What are vital signs?

How do you take them?

So, whats normal?


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What are the vitals

They provide information about thestatus of a patient

Breating (Respirations)

Pulse

Temperature

Blood Pressure


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Counting Respirations

Respiration is one inhalation andexhalation.

Determined by counting for 30 sec, and

multiplying by 2.

A hand on the stomach/chest may help


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Normal Respirations

Adult 12-20/min

Child 15-30/min

Infant 25-50/min


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Respiration Quality

Normal

Shallow (low tidal volume)

LaboredUse of accessory muscles

Flaring

Tripod Breating Noisy breathing


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Pulse

Determined by counting for 30 sec andmultiplying by 2.

Irregular pulse counted for 60 sec.

Provides information about heart, bloodvolume and perfusion.

Taken at a pulse point

Dont use your thumb


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Pulse Quality

Normal

Bounding

WeakThready

Regular/Irregular


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Common Pulse Points

Central Pulses

Carotid

Femoral

Peripheral Pulses

Radial

Brachial (children under 1)

Posterior Tibial, Dorsalis Pedis


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Normal Pulse Rate

Adult 60-80/min

Child 80-120/min

Infant 120-150/min


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Skin

Color

Pink (Normal)

Pale

Cyanotic (Oxygen problems)

Red (CO or heat problems)

Yellow (Jaundice)

Temperature

Warm (Normal)

Hot

Cool

Cold

ConditionDry (Normal)

Moist


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Practice

Get pulse andrespirations fromat least twopeople

Try to get pulsefrom carotid,

radial, andbrachial pulsepoints


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Blood Pressure

Taken withmanual orautomatic BP cuff

Can be taken byauscultation orpalpation


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Key Terms

Systolic

Pressure when

heart is pumping Diastolic

Pressure whenheart is at rest


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One last note on Vitals

First set of vitals is the baseline, you areinterested in changes

On not sick patients, repeat every 15

minutes On sick patients, repeat every 5 minutes

Treat patient, not the vital signs or the

equipment


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Normal Blood Pressure

Male

Systolic = 100+age until 50

Diastolic =60-90

Female

Systolic=90+age until 50

Diastolic = 50-80


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Practice

Get BP from twopeople

Try at least twotechniques forobtaining BP

Auscultation,

Palpation, orAutomatic Cuff


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QUESTION?

history taking a

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