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HISTORY TAKING IN CARDIAC ADULT PATIENT (cc: chest pain)

I. greet patient VI. General medical history


II. explain the purpose and aim of history taking and 1. PAST HISTORY
take patient agreement (IC) RF : high fever and joint pain
III. see the patient medical record following the sore throat
COPD: prolong cough, breath
IV. take patient identityname, age, marital status,
difficulty, wheezing???
address, occupation
1. FAMILY HISTORY
should observed patient’s attitude, reactions same illness like you
and gesture while been questioned heart problem/lung problem
1. OCCUPATIONAL INJURY
Before you work as …... before this
you work as what????
V. chief complaint 1. NUTRITIONAL STATUS
1. onset, duration, timing of cc Do you well balance meal????
since when What you usually you eat??
gradually or suddenly How many times you eat everyday?
spontaneous or after some specific
events
How long it last? V. HISTORY OF MAJOR RISK FACTOR
How frequent? CAD
when your symptoms appear 1. Smoking???
(night/early in the 2. Have you attend any medical check
morning/afternoon/after up recently and measure your
working/while resting)--setting blood glucose??
1. location 3. Have you ever checked your
Can you show me where you feel pain?? blood cholesterol??
Is it radiate?? Where to?? 4. Blood pressure??
5. Any history of hypertension???
1. intensity and quality 6. Any history of premature coronary
Can you describe how severe your pain arterial disease (any family member
is?? that died in early age due to heart
Is it sharp as pinprick?? problem??)
Is it disturbing your daily life???

CHIEF COMPLAINTS (yg wajib


1. factor precipitate(↑↓)
ditanyakan pada patient setiap
What you had done b4 the symptom
satunya)
appears? 1. chest pain
Do you think it related to your activity? 2. difficulty in breathing
is there anything that make it better/worse 3. excessive fatigue
e.g. weather 4. collapse/ feel like want
to collapse
1. any associated manifestation (tnye 5. nervousness
setiap soalan) 6. swollen at part of wur
Anything that accompany pain??? body
Another complain??

1. previous treatment
Have you seen Dr for your symptoms?
What Dr Say??
Any medication he/she gave you??What??
Is it relieved your pain and symptoms??