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Patient Examination: History

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

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  1. Patient Examination: History Rehab 536 Ellen McGough, PT, M.Ed.

  2. Examination: History The Relative Importance of History • Important component of diagnostic reasoning • Hypothesis development • Directs physical examination • Provides context

  3. 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

  4. Examination: History Preparation • Review the referral and medical record • Identify the medical diagnosis • Identify referral source • Identify Precautions

  5. 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

  6. 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

  7. Examination: History General Considerations:Gathering Data Gather Measurable Data: • Distances • Duration of Activity • Time/function • Number of falls

  8. Examination: History Primary Complaint What is the primary problem or complaint? Are there other related problems?

  9. 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

  10. 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

  11. 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

  12. Examination: History Symptoms: QUALITY Severity? Sharp? Dull? Throbbing? Aching? Pain Rating 0-10 scale Visual analog Scale

  13. Examination: History Symptoms: BEHAVIOR Constant or intermittent? What makes symptoms increase? What makes symptoms decrease? Frequency of episodes? Duration of episodes?

  14. 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?)

  15. Examination: History Diagnostic Tests X-rays CT Scan MRI Bone scan EMG Blood Test Myelogram Others

  16. Examination: History Previous Care Hospitalizations Therapy Previous orthotics or prosthetics Chiropractic Massage Acupuncture

  17. Examination: History Previous Medical History (PMH) Hospitalizations Surgeries Medical Conditions Injuries Previous Episodes

  18. Examination: History Medications Related to current condition Prescription Non-prescription Meds related to other medical conditions

  19. Examination: History Assistive Devices Use of the Devices? How often? In what circumstances? Hearing Visual Ambulation Wheelchair Railings Bath bench

  20. Examination: History Social Situation Live alone? Live with ___ Apartment or House? Steps to entrance? Steps inside? Daily activities?

  21. Examination: History Occupation/Recreation Job Requirements Recreational activities Hobbies Adaptations needed

  22. Examination: History Function Prior to Onset What was your function prior to this incident or episode? Help Needed? Assistive Devices? Adaptations needed?

  23. Examination: History Current Function Walking Distance Sitting Tolerance Lifting Tolerance Sleep pattern Assistive Devices Help for ADLs

  24. Examination: History Patient’s Goals What are your goals?

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