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    Assesing The Patient and Taking Medical History

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    Siti Khofifah
    The document outlines the steps for taking a patient's medical history, including: 1) Introductory questions, 2) Chief complaint, 3) History of present condition, 4) Past medical history, 5) Family history, 6) Medication, 7) Social history, and 8) Physical examination. It provides examples of questions to ask patients under each step, such as asking about allergies, previous medical issues, family health history, current medications, smoking, and conducting a physical exam. The document concludes by asking readers to practice translating medical history questions into another language and role playing a nurse taking a patient history.

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    Assesing The Patient and Taking Medical History

    Uploaded by

    Siti Khofifah
    83 views21 pages
    The document outlines the steps for taking a patient's medical history, including: 1) Introductory questions, 2) Chief complaint, 3) History of present condition, 4) Past medical history, 5) Family history, 6) Medication, 7) Social history, and 8) Physical examination. It provides examples of questions to ask patients under each step, such as asking about allergies, previous medical issues, family health history, current medications, smoking, and conducting a physical exam. The document concludes by asking readers to practice translating medical history questions into another language and role playing a nurse taking a patient history.

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    ASSESING THE PATIENT AND TAKING MEDICAL HISTORY.pptx

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    The document outlines the steps for taking a patient's medical history, including: 1) Introductory questions, 2) Chief complaint, 3) History of present condition, 4) Past medical history, 5) Family history, 6) Medication, 7) Social history, and 8) Physical examination. It provides examples of questions to ask patients under each step, such as asking about allergies, previous medical issues, family health history, current medications, smoking, and conducting a physical exam. The document concludes by asking readers to practice translating medical history questions into another language and role playing a nurse taking a patient history.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    83 views21 pages

    Assesing The Patient and Taking Medical History

    Uploaded by

    Siti Khofifah
    The document outlines the steps for taking a patient's medical history, including: 1) Introductory questions, 2) Chief complaint, 3) History of present condition, 4) Past medical history, 5) Family history, 6) Medication, 7) Social history, and 8) Physical examination. It provides examples of questions to ask patients under each step, such as asking about allergies, previous medical issues, family health history, current medications, smoking, and conducting a physical exam. The document concludes by asking readers to practice translating medical history questions into another language and role playing a nurse taking a patient history.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    ASSESING 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
    - 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
    6. Medication
     Are you taking any medication?
     Have you tried any
    medication?
     Do you take any drugs?
    - 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 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. Any pain in your chest
    when you cough?
    5. Do you wheeze?
    6.How is your appetite?
    7.Do 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
    6. Do your eyes water?
    7. Are 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?

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