patient examination: history

1. Patient Examination: History Rehab 536

3. 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. Preparation Review the referral and medical record Identify the medical diagnosis Identify referral source Identify Precautions

5. 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. General Considerations: Communication Flexibility in Communication Style:

7. General Considerations:Gathering Data Gather Measurable Data:

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

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

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

14. 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. Diagnostic Tests X-rays CT Scan MRI Bone scan EMG Blood Test Myelogram Others

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

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

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

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

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

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

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

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

24. Patient’s Goals What are your goals?