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History Taking ofRespiratory System

Pulmonology Departement

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Activities

Lectureoverview

Demonstration of History Taking

based on symptoms in 3rd semester

small class

Self learning

Evaluation

check list

OSE

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CLINICAL COMPETENCE

3 / 4

Pernah melakukan atau pernah

menerapkan dia!ah "uper#i"i $3% Mampu melakukan "e&ara mandiri $4%

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The successful student should beable to :

Per+orm a &omplete hi"tory +or a gi#enpatient

E"tali"h a &om+ortale rapport !ith thepatient

E0hiit empathy. ta&t and &ompa""ion.maintaining a pro+e""ional - ethi&al &odeo+ &ondu&t

Con&i"ely &ommuni&ate the hi"tory

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Chie+&omplaint

hi"tory Phy"i&al

e0amination te"t"

12

1

2

DATA COLLCT!O"

Di#erentialdia

gnosis Initial Prolem /

Diagno"i"

!terati$ehypoth

esis

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!ntroductory %uestions

ood relation"hip

Logi&al manner

Li"ten &are+ully

Interrupt appropriately

Note non5#eral &lue"

Corre&tly interpret

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&resenting 'principal( symptom

History of presenting illness &ast history

Social history

o&&upation. edu&ation. "moking.al&ohol. analge"i& u"e. o#er"ea" tra#el.immuni"ation. marital "tatu". "o&ial"upport. li#ing &ondition"

)amily history

Systems re$ie*

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History of presenting illness

detail" o+ &urrent illne""e". detail" o+

pre#iou". "imilar epi"ode. &urrenttreatment - drug hi"tory. men"trual -reprodu&ti#e hi"tory +or !omen. e0tendo+ +un&tional di"aility

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History of presenting illness

Current symptom"

the time o+ on"et - duration6 the mode o+on"et6 the "ite - radiation6 e"pe&ially o+pain6 the &hara&ter6 the "e#erity6aggra#ating or relie#ing +a&tor"6 a""o&iated

"ymptom" Current treatment + drug history

talet" or medi&ine". &olour or "i7e. name -

do"e. length o+ u"e, Treatment +or loodpre""ure. high &hole"terol. diaete".arthriti". an0iety or depre""ion. antiioti&".N*AID"

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Se,ual history

urethral di"&harge. dy"uria. #aginaldi"&harge. a genital ul&er. anore&tal"ymptom". type o+ "e0ualpra&ti"e8AID*

-enstrual history

la"t men"trual period. age at !hi&hmen"trual egan. regular. menopau"e.

&hildearing year"

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&ast history

&ast illnesses

"eriou" illne""e" or operation" or admi""ion" tothe ho"pital, Childhood illne""e". o"tetri& orgynae&ologi&al prolem",

Pa"t treatment". allergie". lood tran"+u"ion"

The social + personal history

o&&upation. edu&ation. "moking. al&ohol.analge"i& u"e. o#er"ea" tra#el. immuni"ation.marital "tatu". "o&ial "upport. li#ing &ondition"

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Occupation + education

!ork e0po"ure to du"t. &hemi&al" ordi"ea"e 9 mine !orker" 8a"e"to"i",:oie" 8ird +an&ier" and lung di"ea"e

Social habits

"moking 9 ho! many &igarette" $&igar" orpipe%. +or ho! many year" , al&ohol 9 ho!mu&h. ho! o+ten ;

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)amily history

5+amily di"ea"e

5 genogram

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The systems re$ie*

"hortne"" o+ reath. &ough. &ough up

anything. &oughed up lood. "noreloudly. !hee7ing. +e#er". night "!eat".pneumonia or tuer&ulo"i". &he"t

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Detailed history + e,ploring possibleetiologies of cough :

Chara&ter6 !hat i" the &ough like ;5 &learing o+ the throat 9 E= - po"t na"al drip

5 ra""y &ough $hard - metalli&% 9 &ondition"that narro! the tra&hea or laryn0

5 'arking &ough $like a "eal% 9 &roup

5 :a&king &ough 9 pharyngiti".tra&heoron&hiti". early pneumonia

5 !hooping &ough 9 pertu"i"5 any "putum produ&tion ; I+ "o. !hat &ollor -ho! mu&h $ mu&u". lood. pu". pink +roth% ;

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On"et6 ho! did it "tart $"udden #er"u"gradual% ;

Inten"ity9 at !hat time o+ day i" your&ough at it" !or"t ; Doe" it keep youa!ake at night $a"thma and &hroni&ron&hiti" may e a""o&iated !ithno&turnal or morning &ough ;

Duration9 ho! long ha" it een going on$a&ute #er"u" &hroni& #er"u" paro0y"mal

#er"u" "ea"onal #er"u" perrenial; I+&ough i" &hroni&. ho! ha" it &hangedre&ently ; I" it getting etter. !or"e or"taying the "ame ;

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E#ent a""o&iated 9

5 Pneumonia 9 +e#er. &hill". rigor".in&rea"ed "putum produ&tion

5 >=TI 9 malai"e. "ore throat. rhinotthe.myalgia. heada&he. ear pain

5 tra&heiti" 9 retro"ternal pain like a hotpoker

5 T' / malignan&y 9 hemopty"i".

&o"titutional "ymptom"

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Detailed history + e,ploring possibleetiologies of dyspnea :

Chara&ter 9 de"&rie the nature o+ yourreathing di?&ulty

On"et9 ho! did the *O' "tart $ "udden #"

gradual% ;, @hat !ere you doing !henyou e&ame *O' ;

Inten"ity9 ho! "e#ere i" your *O' rightno!. on a "&ale o+ 1 to 1 !ith 1 eing

mild and 1 eing the !or"t ; :a" itgotten !or"e ;

Duration9 ho! long ha#e you een *O';

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reBuen&y9 :a" thi" e#er happened to youe+ore ; I+ "o. ho! o+ten doe" it happen ;@hen !a" the la"t time you e&ame *O' ;

Palliati#e +a&tor" 9 I" there anything thatmake" your *O' etter ; i+ "o. !hat ;

Pro#o&ati#e +a&tor" 9 I" there anything that

make"your *O' !or"e ; I+ "o. !hat ; E0ertion ;

Po"ition $"itting up #er"u"lying do!n%;

E0po"ure to &old air ; In+e&tion ;

Allergie"

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reBuen&y9 :a" thi" e#er happened to youe+ore ; I+ "o. ho! o+ten doe" it happen ;@hen !a" the la"t time you e&ame *O' ;

Palliati#e +a&tor" 9 I" there anything thatmake" your *O' etter ; i+ "o. !hat ;

Pro#o&ati#e +a&tor" 9 I" there anything that

make"your *O' !or"e ; I+ "o. !hat ; E0ertion ;

Po"ition $"itting up #er"u"lying do!n%;

E0po"ure to &old air ; In+e&tion ;

Allergie"

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E#en a""o&iated

PE 9 :emopty"i". pleuriti& &he"t pain. D)T

Pulmonary edema / AC* 9 E0ertional &he"tpain $CP%. PND. orthopnea. and peripheraledema,

COPD 9 Cough. !hee7e. and progre""i#ely!or"ening *O'OE

Pneumonia. other in+e&tion" 9 e#er / &hill".rigor". in&rea"ed "putum produ&tion.

&ough A"&itie" 9 Adominal di"ten"ion

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An0iety $diagno"i" o+ e0&lu"ion% 9Lightheadedne"". diaphore"i". tremling.

&hoking "en"ation. palpitation". numne""or tongling in hand"/+eet. &he"t pain.nau"ea. adominal pain.deper"onali7ation/dereali7ation. u"he" or

&hill". real o+ dying. +ear o+ going &ra7y ordoing "omething un&ontrolled

Con"titutional "ymptom"9 +e#er. &hill".night "!eat". !eight lo"". anore0ia. anda"thenia,

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Thank you