Introduction To History Taking: Lecturer: Dr. Theo Audiyanto, Sp. PD
Introduction To History Taking: Lecturer: Dr. Theo Audiyanto, Sp. PD
Introduction To History Taking: Lecturer: Dr. Theo Audiyanto, Sp. PD
Lecturer :
dr. Theo Audiyanto, Sp. PD
Data Gathering
Analysis
Diagnosis
DATA INPUT
History
Physical
examination
Application :
medical knowledge
Listen
Listen
Emphatic
Compassion
Are YOU Ready to LEARN ??
Clinical skill
Introduction to
HISTORY taking
Faculty of Medicine
Introduction
• History: every patient has history
• Something that happened has a story
• Patient has problem, they seek for a help
• Find out what is wrong !
Effective Communication
• Patient Satisfaction
• Doctor Satisfaction
• Doctor-Patient agreement on Goal
• Positive support, Empathy
• Clear Information
• Godly Compassion
Technique of Skill Interviewing
Validation
Reassurance
Bickley. Bates’ Guide to Physical Examination and History taking 10 ed. 2009
BASIC : stage of consultation
• Begining
• Active Listening
• Systematic enquiry
• Information gathering
• Context
• (understand a whole person)
• Sharing Information
Holistic
Begining
Communication :
Verbal
Non Verbal
GREETING !
Patient identity
Rapport building
What is the problem ?
What is WRONG ?
What is IT ?
Various Complain...
Various Sign...
Clinical History
• Presenting Complain
– Chief complain Present medical history
– Main symptom
• Associated symptom
• Systematic Review
Anamnesa Symptom
Complain
Physical Sign
examination Finding
Disease story
Physiologic Pathogenesis Pathophysiologic
Onset
Outcome
Etiology
Can the Doctor understand
?
Characteristic Time Additional
Trigger And Relieve
Quality Quantity
Chief Complain
• The major complain that bring patient to
seek for medical help
Description
SOCRATES
SOCRATES
• Site
• Onset
• Characteristic
• Radiation
• Associated Symptom
• Timing (Duration, Course, Pattern)
• Exacerbating and relieving
• Severity
FIFE
Feelings
Idea
Functioning
Expectation
Talking
• Speak Clearly and audibly
• Do not use Jargon
• Do not use unnecessarily emotive words
Thank You !!
Thank You AGAIN
“Practice make perfect !”