ASSESSING THE PATIENT

AND TAKING MEDICAL

HISTORY
STEPS FOR TAKING A PATIENT
HISTORY
1. Introductory “small talk”
 Good morning, so how can we help
you today?
 May I help you?
 Well, what can I do for you?
 So, what brings you here today,
Mrs. Smith?
2. Chief Complaint
 Ok, tell me what the problem
is?
 What’s the problem?
 What’s the matter ?
 What did happen to you?
3. History of Present
Condition?
(timing, other symptom,
previous occurrence)
 Have you had similar
problem before?
 Do you have any pains?
- Do your muscles feel stiff in
- When did the problem begin?
 Are you having any other pain or
problem?
 How long did it last?
 Have you ever had a head injury?
 Have you had a fever before?
- How long have your gums been
bleeding?
4. Past medical history
 Are you allergic to any
medication?
 Have you ever had any other
medical problem?
5. Family History
 How’s the rest of the family?
 Has anyone in your family had a
similar problem?
 Is there any heart disease in the
family?
- Have you had any disease in the
family, like diabetes or high
blood pressure?
6. Medication
 Are you taking any medication?
 Have you tried any medication?
 Do you take any drugs / medicines?
- Are you taking any pills or
medicines at the moment?
7. Social History
 Are you a smoker?
 What do you do?
 Do you drink alcoholic?
 Are you a heavy drinker?
 What’s your job?
8. Physical Examination
 Would you lie down, please?
 Can you lift your arm, please?
 Could you stand up please, so I can
measure your height?
- Would you take a sample of your
urine?
Thanks for your
attention….
EXERCISE !
1. Translate the following questions
into Indonesia!
2. Work in pair and make a dialogue
in which the nurse/midwife is
taking a history of the patient and
act it out in front of the class
without looking at your notes!
1. Examining the child
(questioning the parent)
1. Does she sleep at the normal time?
2. Is he/she active like other children?
3. Does she/he have a good appetite?
4. Does she/he eat at the usual times?
5. Does he/she pass wind as a normal?
6. When did his/her first tooth appear?
7. Is his/her toilet normal?
8. Does he/she ever get diarrhea?
9. Does she/he cough a lot?
10. How often do you feed him/her?
11. Does she/he cough a lot?
12. Does he/ she ever bring up his/her food?
13. Has he /she ever had fever?
14. Do you give him/her liquids?
2. Respiratory examination
( Questioning patient )
1.Do you cough a lot?
2. Do you ever get short breath?
3. Do you have any chest pain after
exercise?
4. Is there any pain in your chest
when you cough?
5. Do you wheeze?
6. How is your appetite?
7. Do you sweat at night?
8. Do you smoke?
9. Do you cough when you smell
certain food or other smells?
10. What bring on your cough?
3. Ophthalmological examination
( Questioning the patient )
1. Do your eyes get tired easily?
2. Do your eyes get red easily?
3. Do you ever see double (distorted)
image in front of your eyes?
4. Do you get headache when you’re
reading?
5. Do your eyes itch?
6. Do your eyes water?
7. Are you short-sighted or long-sighted?
8. How long have you had this problem
with your vision?
9. Do your eyeballs feel painful?
10. Do you any discharge from your
eyes?
4. MUSCULOSKETAL EXAMINATION
( Questioning the patient )
1. Does it hurt if you bend your
knee?
2. Do you have any difficulty
moving your arms or legs?
3. Have you had any falls?
4. Do you feel any weakness in your
limbs?
5. Can you bend over and touch your
toes?
6. Can I just have you walk to the
door and back?
7. Does your knee feel tender here?
8. Do your muscle feel stiff in the
morning?