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HISTORY TAKING

References
1. Heart Disease.
A Textbook of Cardiovascular Medicine
6th Ed Braunwald
2. Batess .Guide to physical examination
and history taking 8th Ed

HOW to START?
Greet client respectfully and with kindness
Introduce yourself
Explain about history taking
and the goal of history taking
Identify the patients data ( described elsewhere)

CHIEF COMPLAINT(S)
The one or more symptoms or concerns
causing the patient to seek care
Give the opportunity to relate their
experiences and complaints in their own
way

The most frequent problem(s)

Dyspnea & Excessive fatigue


Chest pain
Syncope/ collapse
Palpitation
Edema

DYSPNEA
Dyspnea = abnormally uncomfortable
awareness of breathing
One of the principal symptom of cardiac and
pulmonary disorders
It occurs at rest or at a low level activity

DYSPNEA
Associated with problem in:
Heart and lung
Chest wall
Respiratory muscle
Anxiety

The most valuable means to establishing the


etiology is taking the medical history
Determine the onset. Acute or Chronic

CHEST PAIN
Etiology of chest pain:
Cardiac origin
Noncardiac, intrathoracic structure
Tissues of neck, thoracic wall, joints, spine
Subdiaphragmatic organs
Angina pectoris =
discomfort in the chest/ adjacent area
associated with myocardial ischemia
it means tightening NOT PAIN

CHEST PAIN
Ask the patient to describe how the
chest pain developed

Observe the patients gesture


Clenching the fist in front of the sternum
(Levines sign) is a strong of an ischemic
origin of the pain

SYNCOPE
Most commonly caused by reduced
perfussion of the brain
Etiology:
Stoke Adam
Other cardiac arrhytmias
Seizure disorders

SYNCOPE
Cardiovascular syncope - quite promptly
Clues to differentiate the cause of syncope
Precedeing events
Type of onset
Position of onset
Postsyncopal clearing of sensorium
Associated events

PALPITATION
Palpitation = an unpleasant awareness of
the forceful or rapid beating of the heart
Changes in rhytm, rate

EDEMA
Cardiac edema is generally symetrical
It may involve thigh, genital, abdominal
wall
Causes of edema
Cardiac
Hepatic
Renal

Cardiac edema
- Dyspnea on exertion
- Often assc. with orthopnea or PND
Hepatic
- Dyspnea in frequent
Renal
- Usually chronic

HOW TO GET THE HISTORY ?

CHIEF COMPLAINT(S)
Give the opportunity to relate their
experiences and complaints in their own
way
Q: How can I help you?
What can I do for you?
What concerns bring you here today
Which one you are most concerned about?

PRESENT ILLNESS
Describe how each symptom developed
1. Onset and chronology of chief complaint
2. Location
3. Quality and intensity
4. Factors that precipitate, aggravate or alleviate
5. Timing ( onset, duration, frequency)
6. Setting in which the symptoms occur
7. Any associated manifestation(s)
8. History of previous treatment and its responses
(name, dose, frequency of the drug(s)

1. Onset and chronology of chief complaint


Q: When did you feel it?
How was it happen?
When was it happened
When was the last time you feel it
2. Location
Q: Show me where you get the pain?
Does it radiates?
Where is it?

3. Quality,quantity and intensity


Q: - Tell me about your pain
- How worst is it?
- Is it sharp like a pinprick, or does it
ache?
- Do you get short of breath climbing
stairs?
- Was it affected your ability to work?

4. Factors that precipitate, aggravate or


alleviate
Q: - What have you done before you
feel it?
- What helps make it better?
- What make it worse?
- Does anything make it better/
worse

5. Timing ( onset, duration, frequency)


Q: - Has any thing like this happened
to you before?
- How long did it last
- How often does it come
6. Setting in which the symptoms occur
- Personal activities
- Environmental factors
- Emotional reactions
Other circumstances that may have
contributed to the illness

7. Any associated manifestation(s)


Q: Have you noticed anything else that
accompanies it
8. History of previous treatment and its
responses (name, dose, frequency of
the drug(s)
Q: Have you seen the doctor before?
What kind of medicine did you
take?

Personal past history


- Rheumatic fever
- COPD
Occupational history
Nutritional history

Adults should be routinely questioned about


the presence of the major risk factor for
CAD
Cigarette smoking
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Family history

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