Taking History

7/30/2019 Taking History

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TAKING HISTORY


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Flu is a respiratory infection caused by a number of viruses. The

viruses pass through the air and enter your body through your nose

or mouth. Between 5% and 20% of people in the U.S. get the flu

each year. The flu can be serious or even deadly for elderly people,newborn babies and people with certain chronic illnesses.

Symptoms of the flu come on suddenly and are worse than those of the

common cold. They may include :

Body or muscle aches

Chills Cough

Fever

Headache

Sore throat

Is it a cold or the flu? Colds rarely cause a fever or headaches. Flualmost never causes an upset stomach. And "stomach flu" isn't

really flu at all, but gastroenteritis.

The main way to keep from getting the flu is to get a yearly flu vaccine.

If you get the flu, your health care provider may prescribe medicine

to help your body fight the infection and lessen symptoms.

National Institute of Allergy and Infectious Diseases

FluAlso called: Grippe, Influenza
http://www.nlm.nih.gov/medlineplus/commoncold.htmlhttp://www.nlm.nih.gov/medlineplus/gastroenteritis.htmlhttp://www.nlm.nih.gov/medlineplus/gastroenteritis.htmlhttp://www.nlm.nih.gov/medlineplus/commoncold.html


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QUESTIONS

1. What is flu?

2. What is other name of flu?

3. How do the viruses work?

4. Who are the victims?5. What are the symptoms of the flu?


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TRANSLATION

Translate the passage above


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USEFUL EXPRESSIONS

To ask the chief complaint:

What brings you in today?

Tell me what has been going on!

What seems to be the problem?

What are your complaints?To ask present illness:

What is wrong?

Where is it wrong? When did it start going wrong?

How did it go wrong?


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Practice these following Questions!

Close-ended Questions

Do you have diarrhea everyday? Do you have any allergies?

Do you drink alcohol?

Does it stay in one place or does radiate anywhereelse?

Does it affect your sleep?

Are your bowels movements regular? Is the pain continues or does it come and go?

Have you noticed any blood in your stool?

Have you taken any medicine for the pain?


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Open-ended Questions

WH-questions

What seems to be the problem?

What makes it better?

What makes it worse?

Where does it hurt? When did you feel the pain?

Why do you scratch it?

Which part of your chest/abdomen/head is

affected? How many loose stools do you have a day?

How much sleep do you get?

How is your appetite?


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INTERVIEW

There are some elements of the comprehensiveHistory:

The Opening

It is important to begin each medical interviewwith a patient-centered approach.

The Chief Complaint

History of Present Illness Past Medical History


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PART 1: The Opening (Identifying the data)

Nurse : Good morning, Mr. Gunawan.

Patient :Good morning, nurse.

Nurse :Im Nurse Halida and I would like to have an interview with you.

Patient :Yes. Be my guest.

Nurse : Well, Sir. What is your full name?

Patient : My full name is Anggodo Gunawan

Nurse :Alright. How do you spell your first name?Patient : A-N-G-G-O-D-O.

Nurse :How old are you?

Patient :Im 40 years old.

Nurse :Are you married?

Patient :Yes, I am.

Nurse :What is your occupation?

Patient :Im a businessman.


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PART 2Asking for the Chief complaint

Nurse :Well, sir. Tell me whats wrong with you?

Patient :I got a terrible pain in my stomach lastnight. I couldnt get back to sleep nor walk around.

Nurse :And was it just last night?

Patient :Yes, it was.


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PART 3

History of the Present Illness

Nurse :And could you explain a little bit about the pain?Patient :Its getting bad and went away and went back

Nurse :And when did it happen last light?

Patient :It was around 8 or 9 pm

Nurse :And could you point to me where the pain is?

Patient :Its just here, under the rib cage.

Nurse :Did you take any medicine?

Patient :I took an aspirin at two oclock but it did not work

and panadol at five oclock but it didnt work either.

Nurse :Did you have other symptoms that it got along with the

pain?

Patient :I had a little bit nausea.


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PART 4History of the Past Illness

Nurse :And about your past medical history, didyou have any ongoing issues, diabetes, any issues

with your lung, heart?

Patient :No. I didnt

Nurse :Had you had any surgery in the past?Patient :Yes, I had a fracture ankle surgery

because of playing football. I had asthma when I

was in elementary school but I havent got it so far

unless the wheezy cough.Nurse :Are you carrying on medication, herbal

medicine?

Patient :No, I am not.


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Pair work

Work on pair, find a situation and make

a simple dialog about history taking.

Note: You can take the case from thereading part above.


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After doing the interview with

your friend in a dialog

practice, write some simple

sentences about the case as a

brief conclusion.

Documents

Taking History