GROUP 2

Patient Admission & Present Perfect Tense

1. Septianti Eka Putri 09170000045
2. Evi Tri Wahyuni 09170000060
3. Dwi Dian Nitami 09170000078
4. Balqies Ariana 09170000079
A. Convertation: Welcoming a New Patient
Ahmed has gotten fever for two days. His temperature increases. His parents finally decide to
bring him to hospital. After arriving in the hospitals, his mother his in the admission room to
register Ahmed. After that Ahmed is being examined by a doctor helped by a nurse.

Front Officer : Welcome to Commonwealth Hospital. Can I help you mom?

Mrs. Ali : Yes I’d like to register my son. He has gotten fever for two days. And his
temperature gets higher today.
Front Officer : Has he ever been hospitalized or visited a doctor here?
Mrs. Ali : Never.
Front Officer : Okay, so we need to fill in the admission form for the patient’s medical record.
Mrs. Ali : Sure.
Front Officer : What’s your son’s name?
Mrs. Ali : Ahmed.
Front Officer : When was he born?
Mrs. Ali : June 15, 2000.
Front Officer : Where is your address?
Mrs. Ali : Saint Avenue street, number 4.
Front Officer : May I have your phone number as a parents?
Mrs. Ali : Sure. 08786992.
Front Officer : Okay. So the complaint is fever. Any thing else?
Mrs. Ali : No.
Front Officer : Okay then, so please wait while your son is being examined by our doctor.
Mrs. Ali : Okay.
A. Percakapan: Menyambut Pasien Baru
Ahmed menderita demam selama dua hari. Suhunya meningkat. Orang tuanya akhirnya
memutuskan untuk membawanya ke rumah sakit. Setelah tiba di rumah sakit, ibunya ada di
ruang masuk untuk mendaftarkan Ahmed. Setelah itu Ahmed diperiksa oleh seorang dokter
yang dibantu oleh seorang perawat.

Petugas Depan: Selamat datang di Rumah Sakit Commonwealth. Bisakah saya bantu ibu?
Ibu Ali: Ya, saya ingin mendaftarkan putra saya. Dia menderita demam selama dua hari. Dan
suhunya semakin tinggi hari ini.
Petugas Depan: Pernahkah dia dirawat di rumah sakit atau mengunjungi dokter di sini?
Ibu Ali: Tidak pernah.
Petugas Depan: Oke, jadi kita perlu mengisi formulir masuk untuk rekam medis pasien.
Ibu Ali: Tentu.
Petugas Depan: Siapa nama putra Anda?
Ibu Ali: Ahmed.
Petugas Depan: Kapan dia lahir?
Ibu Ali: 15 Juni 2000.
Petugas Depan: Di mana alamat Anda?
Ibu Ali: Jalan Saint Avenue, nomor 4.
Petugas Depan: Bolehkah saya memiliki nomor telepon Anda sebagai orangtua?
Ibu Ali: Tentu. 08786992.
Petugas Depan: Oke. Jadi keluhannya adalah demam. Ada yang lain?
Ibu Ali: Tidak.
Petugas Depan: Baiklah kalau begitu, mohon tunggu sementara putra Anda sedang diperiksa oleh
dokter kami.
Ibu Ali: Oke.
B. Word Power: Medical Terms
Word Meaning
Abasia Inability to walk
Abatement A reduction or elimination of public health nuisances such as
smoke, loud noise etc.
Abaxial Lying outside the axis of anybody or part
Abdomen The part of the body between the chest and hip region (the front or
anterior portion)
Abdominogenital Relating to abdomen and genital organs

Abdominopelvic Relating to the abdomen and pelvis

Abdominoplasty An operation performed on the abdominal wall for cosmetic

purposes
Abduction Movement of a body part away from the median plane of the body
Aberrant Differing from the normal
Aberration Deviation from the normal pattern
Abetalipoproteinaemia A disorder characterised by an absence of low-density beta-
lipoprotein, presence of acanthocytes in blood, degeneration
of retinal pigments, malabsorption, and neuromuscular
abnormalities

Abeyance A sate of temporary abolition of function

Ability The physical, mental, or legal competence to function
Abiotic Incompatibility with life, without life
Abiotrophy An age-dependent manifestation of genetically determined
trait
Ablastin An antibody that seems to inhibit reproduction of
trypanosome; found in rats
Ablate To remove, or to destroy the function of
Ablution An act of washing or bathing
Abnormal Not normal
Abort To remove the embryo or foetus from the mother’s womb before it is
viable
Abortifacient An agent that produces abortion

Abortigenic Producing abortion

Abortion Removal (spontaneous or induced) of an embryo or foetus from the uterus

before it reaches the stage when it can survive outside the womb
Abrachia Congenital absence of arms
Abrachiocephaly Congenital absence of arms and head

Abscess A collection of pus, usually associated with redness , awelling and pain

Absorption The incorporation or soaking in of substances (solids, liquids, gases, light

or heat) by system
Abstinence To refrain from the use of certain components of diet, alcohol, drugs or
from sexual intercourse
 Abrasion Removal of the superficial layers of skin or mucous membrane,
usually seen as a skin wound

Abuse 1. Misuse or excessive use of anything.

2. Harmful or offensive treatment (physical or sexual) of an
individual

Anterior Toward the front of the body

Bacilus A family of rod-like bacteria causing diseases in man
Bacterid An eruption of pus filled cavities on the palms and soles, as an
allergic reaction to bacterial infection at a distant site
Bacteriolyze To cause the digestion of dissolution of bacteria
Bacterium A single celled microorganism that multiplies by cell division
Balanoplasty Surgical recontruction of glans penis
Balanoposthitis Inflamation of the glans penis and prepuce
Balantidiasis A disiase caused by Balantidium colo; with symptoms of diarrhea,
dysentery, abdominal pain, and weight loss
B. Kekuatan Kata: Ketentuan Medis

Kata Arti

Abasia Ketidakmampuan untuk berjalan

Pengurangan Pengurangan atau penghapusan gangguan kesehatan

masyarakat seperti asap, kebisingan keras dll.

Abaksial Berbaring di luar poros siapa pun atau sebagian

Perut Bagian tubuh antara daerah dada dan pinggul (bagian

depan atau anterior)

Abdominogenital Berkaitan dengan perut dan organ genital

Abdominopelvik Berhubungan dengan perut dan panggul

Abdominoplastik Operasi dilakukan pada dinding perut untuk keperluan

kosmetik

Abduksi Pergerakan bagian tubuh menjauh dari median bidang

tubuh
Aberrant Berbeda dengan normal

Penyimpangan Penyimpangan dari pola normal

Abetalipoproteinaemia Gangguan yang ditandai dengan tidak adanya beta-lipoprotein densitas

rendah, keberadaan acanthocytes dalam darah, degenerasi pigmen retina,
malabsorpsi, dan kelainan neuromuskuler

Abeyance Keadaan penghapusan fungsi sementara

Kemampuan Kompetensi fisik, mental, atau hukum untuk berfungsi

Abiotik Ketidakcocokan dengan kehidupan, tanpa kehidupan

Abiotropi Manifestasi yang bergantung pada usia dari sifat yang ditentukan secara
genetis

Ablastin Antibodi yang tampaknya menghambat reproduksi trypanosome;

ditemukan pada tikus

Ablate Untuk menghapus, atau menghancurkan fungsi

Pembersihan Tindakan mencuci atau mandi

Abnormal Tidak normal

Menggugurkan Untuk mengeluarkan embrio atau janin dari rahim ibu sebelum layak

Abortifacient Agen yang menghasilkan aborsi

Abortigenik Memproduksi aborsi

Abortus Pengangkatan (spontan atau diinduksi) dari embrio atau janin dari rahim
sebelum mencapai tahap ketika dapat bertahan hidup di luar rahim

Abrachia Kelainanan tidak adanya lengan

Abrachiocephaly Kelainan pada tangan dan kepala

Abses Kumpulan nanah, biasanya berhubungan dengan kemerahan,

pembengkakan dan nyeri

Absorpsi Penggabungan atau perendaman zat (padatan, cairan, gas, cahaya atau
panas) oleh sistem

Abstinence Untuk menahan diri dari penggunaan komponen tertentu dari diet,
alkohol, obat-obatan atau dari hubungan seksual
Abrasi Pengangkatan lapisan kulit superfisial atau selaput lendir, biasanya dilihat sebagai luka kulit

Abuse 1. Menyalahgunakan atau menggunakan sesuatu secara berlebihan.

2. Perawatan yang berbahaya atau ofensif (fisik atau seksual) dari seorang individu

Depan Menuju bagian depan tubuh

Bacilus Keluarga bakteri mirip batang yang menyebabkan penyakit pada manusia

Bacterid Erupsi nanah mengisi rongga di telapak tangan dan telapak kaki, sebagai reaksi alergi
terhadap infeksi bakteri di lokasi yang jauh

Bacteriolyze Menyebabkan pencernaan disolusi bakteri

Bacterium Mikroorganisme bersel tunggal yang berkembang biak dengan pembelahan sel

Balanoplasty Rekonstruksi bedah penis kelenjar

Balanoposthitis Peradangan pada kelenjar penis dan preputium

Balantidiasis Penyakit yang disebabkan oleh Balantidium colo; dengan gejala diare, disentri, sakit perut,
dan penurunan berat badan
Banding The process of differential staining of chromosomes of cells to reveal
the characteristic patterns of bands that permit identification of
individual chromosomes and recognition of missing segments

Brain stem The entire unpaired subdivision of the brain, that forms a stalk like
connection
Brain washing Making changes in attitudes and behaviour of a person through various
forms of psychological pressure
Bran A by-product of milling of wheat containing approximately 20% of
complex sugars; usually taken in the form of cereal or special bran
products. Adds fibre to diet

Breast 1. The female organ of milk secretion

2. The pectoral surface of the thorax
Breathing The process of taking air into and out of the lung through the nose
Bronchiectasis Dilation of bronchioles (the internal structures of the lungs) associated
with production of thick sputum
Bronchogram A special X-ray to visualize the lung airways
Brush biopsy Obtained by rubbing the surface of the affected area with a brush to obtain
cells for examination
Burn An injury caused by heart or fire, or any chemical agent like acid or alkali

Bypass To create new flow from one structure to the other through a channel
Caesarean An operation for delivering a child by cutting through the abdomen and the
uterus
Caffeine A subtance obtained from tea or coffee, used as a stimulant
Calcaneus The bone that forms the heel
Cardiomyopathy A diseased heart muscle
Calcification Deposition of calcium salts
Calcinosis A confition characterized by the deposition of calcium salts in various tissues

Cephal/o Head
Chrom Color
Deep Closer to the center of the body
Distal Farther from the point off attachment or point of reference
Derm/o Skin
DOB Death of Birth
Enter/o Intestine
Gastr/o Stomach
Hem/o, Hemat/o Blood
Lateral Toward the side of the body
M/F Male/female
Marital status Widow/widower/married/unmarried
My/o Muscle
Myel/o Spinal cord
Onych/o Nail
Oste/o Bone
Phag Eat or swallow
Phleb/o Vein
Posterior Toward the back of the body
Pulm/o, Lungs
Pulmon/o

Superficial Closer to the surface of the body

Synov/i Synovial fluid, joint, or membrane
Thromb/o Clot
Vas/o Vessel or duct
 Prefix Meaning
A- Without, absence of
Ab- Away from
Ad- Toward, near
Ante- Before
Ec-, Ect/0- Out, outside
End/0 In, within
Mon/o One
Peri- Surrounding
Poly- Many, much
Post- After, behind
Trans- Across, through
Supra- Above
 Suffix Meaning
-algia Pain
-centesis Puncture, tap
-desis Binding, fusion
-ectonomy Excision, surgical removal
-emia Blood
-graphy Act of recording data
-pexy Surgical fixation
-plasty Plastic repair/surgery, recontruction
-sclerosis Hardening
-tripsy Crushing
-uria Urin,urination
C. Useful Expressions
The following are some useful expressions used for asking patient’s information .
To Ask Name What is your name?
What is your complete name?
What is your surname?
May i know your name?

To Ask Age How old are you?

When were you born?
To Ask Address What is your address?
Where do you live?
Your address, please.

To Ask Phone Your phone number, please.

May I know your phone number?
Can I have your phone number?
What is your phone number?
Do you have a mobile phone number?
To Ask Occupation, Tittle,& Education What is your occupation?
Your occupation, please.
Do you have any academic title?
What do you do?
Where do you work?
What is your title?
What is your last educations?
To Ask Marital Status Are you married?
May i know your material status?
To Ask Health Insurance Do you have any health insurance?
Will you use health insurance
To Ask Next Of Kin Who is your next of kin?
May i knowv your next of kin?
To Ask Reason For Contact What brings you in the hospital?
Who sends you to this hospital?
What makes you come to this hospital?
Why do you come to this hospital?
What are cyou suffering for?
What seems to be the trouble?
D. Pratice: Playing a role as a nurse
Work in pairs, prepare nurse-patient interview. One student as a nurse: Ask
the patient to complete the Patient Admission Form.
D. Praktek: Berperan sebagai perawat.
Bekerja berpasangan, mensiapkan wawancara perawat-pasien. Satu siswa
sebagai perawat: Meminta pasien untuk mengisi Formulir Penerimaan Pasien
 Rumah Sakit Commonwealth
5th Avenue, New York City
Patient Admission Form
Patient Details
Full name: ..........................................................................
DOB (Date of birth): .........................................................
Address: ............................................................................
M/F: ..................................................................................
Marital status: ...................................................................
Phone Number: .................................................................
Occupation: .......................................................................
Citizenship: .......................................................................
Religion: ............................................................................
Reason for admission: ........................................................
Past medical history: ..........................................................
Past surgical history: ..........................................................
Medication: ........................................................................
Allergies: ............................................................................
Next of kin: ........................................................................
 Commonwealth Hospital
5th Avenue, Kota New York
Formulir Pendaftaran Pasien
Rincian Pasien
Nama lengkap: ..........................................................................
Tanggal lahir: .................................................................................
Alamat: ............................................................................
M/F: ..................................................................................
Status pernikahan: ...................................................................
Nomor telephone: .................................................................
Pekerjaan: .......................................................................
Kewarganegaraan: .......................................................................
Agama: ............................................................................
Alasan masuk: ........................................................
Riwayat medis sebelumnya: ..........................................................
Riwayat bedah sebelumnya: ..........................................................
Obat: ........................................................................
Alergi: ............................................................................
Dan lain-lain: ........................................................................
E. Practice: Discussion
In small group consist of four students, discuss the following questions! After
discussion in front of the class.
1. How is the process for taking patient history in all hospitals?
2. Do they have similar process?
3. In your opinions, what should a hospital do in taking patient history?
E. Praktek: diskusi
Dalam kelompok kecil yang terdiri dari empat siswa, diskusikan pertanyaan-pertanyaan berikut!
Setelah diskusi maju di depan kelas
1. Bagaimana proses untuk mengambil riwayat pasien di semua rumah sakit?
2. Apakah mereka memiliki proses yang serupa?
3. Menurut pendapat Anda, apa yang harus dilakukan rumah sakit dalam mengambil riwayat
pasien?
F. Language focus: yes/no questions, WH question
1. Yes/no questions
A question in which the answer is yes/no. Yes/no question uses to be, modal, or auxiliary before a subject
of sentence. Look at the following formula!

Positive sentence: To be/modal/auxiliary + subject + verb + (object)

Negative sentence: To be/modal/auxiliary + not + subject + verb + (object)

1) Examples with to be:

a. For nominal sentence
To be + S + adjective/noun/adverb

Is it your book?

Answer: yes it is/ no, it is not
Are you hungry?
Answer: yes, i am/ no, i am not
F. Fokus bahasa: pertanyaan ya/tidak, pertanyaan WH
1. Pertanyaan ya/tidak
Sebuah pertanyaan di mana jawabannya adalah ya / tidak. Pertanyaan ya/tidak menggunakan to be, modal,
atau kata bantu sebelum subjek kalimat. Lihatlah rumus berikut!

Kalimat positif: To be/modal/kata bantu + subyek + kata kerja + (objek)

Kalimat negatif: To be/modal/kata bantu + tidak + subjek + kata kerja + (objek)

1) Contoh menggunakan to be:

a. Untuk kalimat nominal
To be + S + kata sifat/kata benda/kata keterangan

Is it your book?

Answer: yes it is/ no, it is not
Are you hungry?
Answer: yes, i am/ no, i am not
b. For continuous tenses
To be + S + Ving

Are you reading a book?

Answer: yes, i’m/ no, i’m not
Was she studying last night at 8?
Answer: yes, she was/ no, she wasn’t
c. For passive voice

To be + S + V3 + O

Is the prescription given to you?

Answer: yes, it is/ no, it isn’t
Are the dishes washed?
Answer: yes, they are/ no, they are not
2) Examples with do/ does/ did:
Doesn’t he live in London?
Answer: yes, he does/ no he doesn’t
Do you like coffee?
Answer: yes, I do/ no, I don’t
Did eat any spicy food?
Answer: yes, she did/ no, she didn’t
3) Examples with modals:
Can you open your mouth, please?
Answer: yes, I can/ no, I can’t
Will you attend the seminar?
Answer: yes, I will/ no, I won’t
May I have your phone number?
Answer: yes, you may/ no, you may not
Must I take all the medicine?
Answer: yes, you must/ no, you mustn’t
Could you please take a glass of water for me?
Answer: yes, I could/ no, I couldn’t
4) Examples with have/ has/ had
Have/ has/ had + S + V3
Have you examined the patient?
Answer: yes, I have/ no, I haven’t
Has he been weel?
Answer: yes, he has/ no, he hasn’t
Another example for Language focus: yes/no questions, WH question
• For nominal sentence (To be + S + adjective/noun/adverb)
1. Am I beautifull?
Answer: yes you are/ no, you are not.
2. Are you study?
Answer: yes, I am/ no, I am not.
• For continuous tenses (To be + S + Ving)
1. Is he playing a ball?
Answer: yes, he is/ no, he is not.
2. Was he watching movie last week?
Answer: yes, he was/ no, he wasn’t
• For passive voice
1. Are the patient checked by the doctor?
Answer: yes, they are/no, they are not
2. Is she taken a medicine?
Answer: yes, she is/ no, isn’t she.
Examples with do/does/did
1. Does she wear a urine cateter?
Answer: yes, she does/ no, she doesn’t.
2. Do we went to the hospital?
Answer: yes, we do/ no, we don’t
3. Did you love me?
Answer: yes I did/ no, I didn’t
• Examples with modals:
1. Can I touch your head, please?
Answer: yes, you can/ no, you can’t
2. Will we went together?
Answer: yes, we will/ no, we won’t
3. May I know your address?
Answer: yes, you may/no, you may not.
4. Must I pay these foods?
Answer: Yes you must/ no, you mustn’t
5. Could we tell his family?
Answer: yes, we could/ no, we couldn’t
• Examples with have/has/had
1. Have you controled the blood?
Answer: yes, I have/ No, I haven’t
2. Has she gone?
Answer: yes, he has/ no, he hasn’t
2. WH Questions
is a question intiated with wh-question and the answer is more informative and clear
• What: apa
 Who: siapa
 Whom: siapa
 Where: dimana/kemana
 When: kapan
 Why: kenapa
 How: bagaimana
1) Asking a subject
Who/what + verb +(object)
Examples:
 Who accompanies you?
 What happens?

2) Asking object/complement/adverb
QW + auxiliary + V1
Examples:
 What do you feel?
 Why are you so pale?
 When will the exhibition end?
 Where is the emergency room?
 Which one do you want?
 Whom did you call?
 Whose soes are these?
G. Practice Grammar Focus
Translate the following sentences into English!
1. Apa yang anda rasakan?
2. Apakah anda pernah datang kemari?
3. Dimana apotek terdekat?
4. Siapa yang memeriksamu?
5. Bisakah kau menunjukkan lukanya?
6. Sudah berapa lama kamu batuk?
7. Apakah kamu merasa pusing?
8. Berapa jenis obat yang dokter beri?
9. Apakah aku harus kembali lagi menemui dokter lagi?
10. Kenapa kamu sedih?
G. Practice Grammar Focus
Translate the following sentences into English!
1. What do you feel?
2. Have you ever come?
3. Where is the nearest pharmacy?
4. Who examined you?
5. Can you show the wound?
6. How long have you been coughing?
7. Are you feeling dizzy?
8. How many types of drugs the doctor gave?
9. Do I have to go back to see the doctor again?
10. Why are you sad?
H. Reading Exercise
Physician Referral Letter In Indonesia is known as Surat Rujukan. A patient with physician
referral letter comes to a hospital with various reason. Read the following example of the
letter

Dear dr. Joko Pranata

ANYTOWN FACILITY is pleased to announce its recent acquistion of the ultra premiun
ACUSON Sequoia™ C512 echocRDIOGRAPHY SYSTEM FOR OUR Cardiology
Department.
The Sequoia C512 system will provide us with maximized diagnostic information and
increased exam efficiency through significantly advanced acoustic imaging. Using
proprietary transmit and receive ultrasound technology, Siemens has elevated the
perfornabce of the Sequoia ultrasound platform by combining new system architecture and
transducer technologies. As a result, we have a better instrument to evaluate all of our
patients with.
Our Sequoia system supports all routine applications for adults, pediatric and neonatal cardiology as well as
cardiovascular imaging. Additionally, we are able to perform a breadth of imaging capabilities imcluding
transthoracic, transesophageal, stress echo, intracardiac, intraoperative and 3D cardiography, as well as routine and
investigational contras agent imaging, vascular and abdominal imaging
And, with the new syngo® Arterial Health Package. We can evaluate cardiac risk factors and quantify cardiovascular
age with automatedintima-media thickness measurements. Additionally, the new mitral valve assessment applications
allows for a rappid 3D/4D evalution of mitral valve morphology and pathology.
Finally, with the DIMAQ™ integrated ultrasound workstation completely embeded into the platform’s architecture,
we can digitally capture a complete patient study, including demographics, statis images, dynamic clips,
measurements and calculations, and then store in the native DICOM file format for instant access and review on the
system
We invite you to contact us at 000.000.0000 (contact phone) with any questions you might have regarding our new
imaging capabilities with the Sequoia C512 system. In addition, we welcome an opportunity to personally
demonstrate the system’s diagnostic imaging capabilities for you.

Sincerely,

Albert White
ANYTOWN FACILITY
Answer the following question!
1. Why is the letter issued?
2. Who issues the letter?
3. Why is the letter addressed to dr. Joko Pranata?
Excercises c. Have d. Has been
1. She ..... Just opened her book. 4. We have .... This major since last night
a. Has been b. Has a. Learned b. Learn
c. Have d. Had c. Learning d. Learns
2. Mr. Irwan has ...... In that company for ten years. 5. Has your sister …. A new car?
a. Work b. Works
c. Worked d. Working
3. ....... It been any rain this August?
a. Has b. Had
5. Has your sister …. A new car?
a. Buy c. Bought
b. Buying d. Buyed
6. We …. To Singapore many times
a. Have c. Has
b. Have been d. Has been
7. The children have …. Eaten their breakfast.
a. Since c. Yet
b. Been d. Just
8. Mr. Efendi …. In Bali for a week.
c. Been c. Has
9. ..... it your pen?
a. Are c. Is
b. Has d. Am
10. She .... checked by the Doctor last week
a. Was c. Do
b. Would d. Can
Answer to exercise section
1. She ..... Just opened her book.
a. Has been b. Has
c. Have d. Had
2. Mr. Irwan has ...... In that company for ten years.
a. Work b. Works
c. Worked d. Working
3. ....... It been any rain this August?
a. Has b. Had
c. Have d. Has been
4. We have .... This major since last night
a. Learned b. Learn
c. Learning d. Learns
5. Has your sister …. A new car?
a. Buy c. Bought
b. Buying d. Buyed
6. We …. To Singapore many times
a. Have c. Has
b. Have been d. Has been
7. The children have …. Eaten their breakfast.
a. Since c. Yet
b. Been d. Just
8. Mr. Efendi …. In Bali for a week.
c. Been c. Has
d. Having d. Has been
9. ..... it your pen?
a. Are c. Is
b. Has d. Am
10. She .... checked by the Doctor last week
a. Was c. Do
b. Would d. Can
Answer To Practice: Discussion
1. Procedure steps:
• Step 01
Introduce yourself, identify your patient and gain consent to speak with them. Should you wish to take notes as you
proceed, ask the patients permission to do so.
• Step 02 - Presenting Complaint (PC)
This is what the patient tells you is wrong, for example: chest pain.
• Step 03 - History of Presenting Complaint (HPC)
Gain as much information you can about the specific complaint.
Sticking with chest pain as an example you should ask:
Site: Where exactly is the pain?
Onset: When did it start, was it constant/intermittent, gradual/ sudden?
Character: What is the pain like e.g. sharp, burning, tight?
Radiation: Does it radiate/move anywhere?
Associations: Is there anything else associated with the pain, e.g. sweating, vomiting.
Time course: Does it follow any time pattern, how long did it last?
Exacerbating / relieving factors: Does anything make it better or worse?
Severity: How severe is the pain, consider using the 1-10 scale?
• Step 04 - Past Medical History (PMH)
Gather information about a patients other medical problems (if any).
• Step 05 - Drug History (DH)
Find out what medications the patient is taking, including dosage and how often they are taking them,
for example: once-a-day, twice-a-day, etc.
At this point it is a good idea to find out if the patient has any allergies.
• Step 06 - Family History (FH)
Gather some information about the patients family history, e.g diabetes or cardiac history. Find out if
there are any genetic conditions within the family, for example: polycystic kidney disease.
• Step 07 - Social History (SH)
This is the opportunity to find out a bit more about the patient’s background. Remember to ask about
smoking and alcohol. Depending on the PC it may also be pertinent to find out whether the patient
drives, e.g. following an MI patient cannot drive for one month. You should also ask the patient if they
use any illegal substances, for example: cannabis, cocaine, etc. Also find out who lives with the patient.
You may find that they are the carer for an elderly parent or a child and your duty would be to ensure
that they are not neglected should your patient be admitted/remain in hospital.
• Step 08 - Review of Systems (ROS)
Gather a short amount of information regarding the other systems in the body that are not covered in your HPC.
The above example involves the CVS so you would focus on the others.
These are the main systems you should cover:
• CVS
• Respiratory
• GI
• Neurology
• Genitourinary/renal
• Musculoskeletal
• Psychiatry
• Step 09 - Summary of History
Complete your history by reviewing what the patient has told you. Repeat back the important points so that the
patient can correct you if there are any misunderstandings or errors.
You should also address what the patient thinks is wrong with them and what they are expecting/hoping for
from the consultation. A useful acronym for this is ICE [I]deas, [C]oncerns and [E]xpectations.
• Step 10 - Patient Questions / Feedback
During or after taking their history, the patient may have questions that they want to ask you. It is very
important that you don’t give them any false information. As such, unless you are absolutely sure of the
answer it is best to say that you will ask your seniors about this or that you will go away and get them
more information (e.g. leaflets) about what they are asking. These questions aren’t necessarily there to
test your knowledge, just that you won’t try and 'blag it'.
• Step 11
When you are happy that you have all of the information you require, and the patient has asked any
questions that they may have, you must thank them for their time and say that one of the doctors looking
after them will be coming to see them soon.

2. In every hospital, they had a different procedure, but sometimes the form for patient history had in
common
3. The hospital must do in taking patient history is to have a doctor with good consultation skills, a room
layout to allow good eye contact, and open-ended questions.
Answer the following question!
1. Why is the letter issued?
Answer: because Albert White wants to introduce that ANYTOWN FACILITY is pleased to announce its
recent acquistion of the ultra premiun ACUSON Sequoia™ C512 echocRDIOGRAPHY SYSTEM
FOR OUR Cardiology Department.
2. Who issues the letter?
Answer: Albert White
3. Why is the letter addressed to dr. Joko Pranata?
Answer: because Albert White wants invite dr. Joko to contact him for buy the ultra premium acuson for his
patient