Introduction to History Taking

Lecturer :
dr. Theo Audiyanto, Sp. PD

This teaching material is copyrighted.

No part of this work may be reproduced, including photocopied, without written permission of Universitas Pelita Harapan .
A Good Doctor
✴Professional behavior
✴Skill :
– Communication skill
– (learn to ask, listen and talk)
– Physical examination skill
» (train your senses)
✴Knowledge
✴Good Heart
CLINICAL SKILL
• History Taking
• Physical Examination

Data Gathering
Analysis
Diagnosis
 DATA INPUT
History
Physical
examination
Application :
medical knowledge

Processor Analyzing: OUTPUT:

Clinical critical thinking Working Diagnosis
Smartphone can listen
and speak... it can
communicate !
My doctor don’t want to
listen to me !
and He is just writing not
talking
 Think with your HEAD
Listen listen with your HEART

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

Active listening Partnering

Guided questioning Summarization

Nonverbal communication Transitions

Empathic responses Empowering the patient

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

• Make sure you are talking to right patient

• Introduce your self (as medical student)
• Jotting not writing

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

• Past Medical History

• Other History : Drug history, Family History, Social History, Sexual, etc
 Active Listening
• Chief Complain (keluhan utama)
• Open question
– Clarifying
– Summarizing

What has Happen ?

Listen: carefully and acquired the info

 Get the STORY !

Listen to the STORY... the patient tell

the problem,
YOU established the diagnosis
 Disease

Anamnesa Symptom
Complain

Physical Sign
examination Finding
 Disease story
Physiologic Pathogenesis Pathophysiologic

Normal Anatomy Anatomy Pathology

Clinical Pathology

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 !”