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Patient Examination: History Rehab 536 Ellen McGough, PT, M.Ed. Examination: History The Relative Importance of History Important component of diagnostic reasoning Hypothesis development Directs physical examination Provides context Examination: History Stages of the interview

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patient examination history

Patient Examination: History

Rehab 536

Ellen McGough, PT, M.Ed.

the relative importance of history

Examination: History

The Relative Importance of History
  • Important component of diagnostic reasoning
  • Hypothesis development
  • Directs physical examination
  • Provides context
stages of the interview

Examination: History

Stages of the interview
  • Preparation - chart review
  • Greeting patient & establishing rapport
  • Inviting the patient’s story
  • Establishing agenda for interview
  • Generating & testing hypotheses about patient’s problem
  • Establish a shared understanding of the problem(s)
  • Negotiating a plan
  • Closing the interview

Bickley L.S., Bates guide to Physical Examination and History Taking, 1999

preparation

Examination: History

Preparation
  • Review the referral and medical record
  • Identify the medical diagnosis
  • Identify referral source
  • Identify Precautions
general considerations for the patient interview

Examination: History

General Considerations for the Patient Interview:
  • Introduction
  • Review the reason for referral
  • Sit or stand at eye level with patient
  • Make the patient feel comfortable
  • Provide privacy/confidentiality
general considerations communication

Examination: History

General Considerations: Communication

Flexibility in Communication Style:

  • Follow the general format
  • Listen for RED FLAGS
  • Be prepared to ask more questions
  • Open Vs. Closed ended Questions
general considerations gathering data

Examination: History

General Considerations:Gathering Data

Gather Measurable Data:

  • Distances
  • Duration of Activity
  • Time/function
  • Number of falls
primary complaint

Examination: History

Primary Complaint

What is the primary problem or complaint?

Are there other related problems?

onset

Examination: History

ONSET

Sudden or Insidious?

When?

Sudden - Date of injury or surgery

Insidious - Approximate date symptoms started.

How?

Sudden - Mechanism of injury

Insidious - Contributing activities

7 attributes of symptoms

Examination: History

7 attributes of symptoms
  • Location: Where is it? Does it radiate?
  • Quality: What is it like?
  • Quantity & Severity: How bad is it?
  • Timing: When did (does) it start? How long does it last? How often does it come?
  • Setting in which it occurs: contributing circumstances, environmental factors, activities, emotional reactions
  • Factors that make it better or worse
  • Associated manifestations

Bickley L.S., Bates guide to Physical Examination and History Taking, 1999

symptoms location

Examination: History

Symptoms: LOCATION

Where is the pain?

Point to the area of pain.

Has the pain changed locations?

Does it spread to different areas?

  • Draw the pattern on a body chart
symptoms quality

Examination: History

Symptoms: QUALITY

Severity?

Sharp? Dull? Throbbing? Aching?

Pain Rating

0-10 scale

Visual analog Scale

symptoms behavior

Examination: History

Symptoms: BEHAVIOR

Constant or intermittent?

What makes symptoms increase?

What makes symptoms decrease?

Frequency of episodes?

Duration of episodes?

symptoms recent behavior

Examination: History

Symptoms: RECENT BEHAVIOR

Are the symptoms getting better?

Are the symptoms getting worse?

Are the symptoms staying the same?

Frequency of episodes? (less often/more often?)

Duration of episodes? (shorter/longer?)

diagnostic tests

Examination: History

Diagnostic Tests

X-rays

CT Scan

MRI

Bone scan

EMG

Blood Test

Myelogram

Others

previous care

Examination: History

Previous Care

Hospitalizations

Therapy

Previous orthotics or prosthetics

Chiropractic

Massage

Acupuncture

previous medical history pmh

Examination: History

Previous Medical History (PMH)

Hospitalizations

Surgeries

Medical Conditions

Injuries

Previous Episodes

medications

Examination: History

Medications

Related to current condition

Prescription

Non-prescription

Meds related to other medical conditions

assistive devices

Examination: History

Assistive Devices

Use of the Devices?

How often?

In what circumstances?

Hearing

Visual

Ambulation

Wheelchair

Railings

Bath bench

social situation

Examination: History

Social Situation

Live alone?

Live with ___

Apartment or House?

Steps to entrance?

Steps inside?

Daily activities?

occupation recreation

Examination: History

Occupation/Recreation

Job Requirements

Recreational activities

Hobbies

Adaptations needed

function prior to onset

Examination: History

Function Prior to Onset

What was your function prior to this incident or episode?

Help Needed?

Assistive Devices?

Adaptations needed?

current function

Examination: History

Current Function

Walking Distance

Sitting Tolerance

Lifting Tolerance

Sleep pattern

Assistive Devices

Help for ADLs