Patient Examination: History

1
Patient Examination History

• Rehab 536

Ellen McGough, PT, M.Ed.
2
The Relative Importance of History
Examination History

• Important component of diagnostic reasoning
• Hypothesis development
• Directs physical examination
• Provides context

3
Stages of the interview
Examination History

• Preparation - chart review
• Greeting patient establishing rapport
• Inviting the patients story
• Establishing agenda for interview
• Generating testing hypotheses about patients
  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
Preparation
Examination History

• Review the referral and medical record
• Identify the medical diagnosis
• Identify referral source
• Identify Precautions

5
General Considerations for the Patient Interview
Examination History

• Introduction
• Review the reason for referral
• Sit or stand at eye level with patient
• Make the patient feel comfortable
• Provide privacy/confidentiality

6
General Considerations Communication
Examination History

• Flexibility in Communication Style

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

7
General ConsiderationsGathering Data
Examination History

• Gather Measurable Data

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

8
Primary Complaint
Examination History

• What is the primary problem or complaint?
• Are there other related problems?

9
ONSET
Examination History

• Sudden or Insidious?
• When?
• Sudden - Date of injury or surgery
• Insidious - Approximate date symptoms
  started.
• How?
• Sudden - Mechanism of injury
• Insidious - Contributing activities

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7 attributes of symptoms
Examination History

• 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
Symptoms LOCATION
Examination History

• 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
Symptoms QUALITY
Examination History

• Severity?
• Sharp? Dull? Throbbing? Aching?
• Pain Rating
• 0-10 scale
• Visual analog Scale

13
Symptoms BEHAVIOR
Examination History

• Constant or intermittent?
• What makes symptoms increase?
• What makes symptoms decrease?
• Frequency of episodes?
• Duration of episodes?

14
Symptoms RECENT BEHAVIOR
Examination History

• 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
Diagnostic Tests
Examination History

• X-rays
• CT Scan
• MRI
• Bone scan
• EMG
• Blood Test
• Myelogram
• Others

16
Previous Care
Examination History

• Hospitalizations
• Therapy
• Previous orthotics or prosthetics
• Chiropractic
• Massage
• Acupuncture

17
Previous Medical History (PMH)
Examination History

• Hospitalizations
• Surgeries
• Medical Conditions
• Injuries
• Previous Episodes

18
Medications
Examination History

• Related to current condition
• Prescription
• Non-prescription
• Meds related to other medical conditions

19
Assistive Devices
Examination History

• Use of the Devices?
• How often?
• In what circumstances?
• Hearing
• Visual
• Ambulation
• Wheelchair
• Railings
• Bath bench

20
Social Situation
Examination History

• Live alone?
• Live with ___
• Apartment or House?
• Steps to entrance?
• Steps inside?
• Daily activities?

21
Occupation/Recreation
Examination History

• Job Requirements
• Recreational activities
• Hobbies
• Adaptations needed

22
Function Prior to Onset
Examination History

• What was your function prior to this incident or
  episode?
• Help Needed?
• Assistive Devices?
• Adaptations needed?

23
Current Function
Examination History

• Walking Distance
• Sitting Tolerance
• Lifting Tolerance
• Sleep pattern
• Assistive Devices
• Help for ADLs

24
Patients Goals
Examination History

• What are your goals?