Onset, duration, timing of cc since when gradually or suddenly spontaneous or after some specific events how long it last? how frequent? when your symptoms appear (night / early in the morning / afternoon / after working / while resting) CHIEF COMPLAINTS (yg wajib ditanyakan pada patient setiap satunya) 1. Chest pain 2. Difficulty in breathing 3. Excessive fatigue 4. Collapse / feel like want to collapse 5. Nervousness 6. Swolle
Onset, duration, timing of cc since when gradually or suddenly spontaneous or after some specific events how long it last? how frequent? when your symptoms appear (night / early in the morning / afternoon / after working / while resting) CHIEF COMPLAINTS (yg wajib ditanyakan pada patient setiap satunya) 1. Chest pain 2. Difficulty in breathing 3. Excessive fatigue 4. Collapse / feel like want to collapse 5. Nervousness 6. Swolle
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Onset, duration, timing of cc since when gradually or suddenly spontaneous or after some specific events how long it last? how frequent? when your symptoms appear (night / early in the morning / afternoon / after working / while resting) CHIEF COMPLAINTS (yg wajib ditanyakan pada patient setiap satunya) 1. Chest pain 2. Difficulty in breathing 3. Excessive fatigue 4. Collapse / feel like want to collapse 5. Nervousness 6. Swolle
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online from Scribd
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 identityname, 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??