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History Taking Process DX 611 Orthopedics

History Taking Process DX 611 Orthopedics. James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic. Introduction. Make eye contact and shake hands Demonstrate an interest in the patient. A Time to Listen and Learn…. Present time consciousness is essential

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History Taking Process DX 611 Orthopedics

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  1. History Taking ProcessDX 611 Orthopedics James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic

  2. Introduction • Make eye contact and shake hands • Demonstrate an interest in the patient

  3. A Time to Listen and Learn… • Present time consciousness is essential • Be with the patient

  4. First Impression is a Lasting One • Build the doctor/patient relationship • Commence therapeusis

  5. Closed End v. Open End History • Intake forms • Interview

  6. Introductory Materials • Date • Age • Sex • Race/ethnic origin • Birthplace • Occupation

  7. List the Sources of… • Referral • History • Reliability

  8. Main Parts of History • Chief complaint • Present illness • Past health history • Current health status • Family • Psychosocial • Review of systems

  9. History Taking Process • Chief complaint • Present illness • Past history

  10. Comprehensive v. Limited History • Specific complaint • Stiff neck • Muscle strain • Strain • Complicated condition • Obese with diabetes • Loss of weight and fatigue • Poor response to care

  11. Comprehensive History • Medico-legal • Motor vehicle accident • Work related injury

  12. Sequence • Begin with a general question. • Please tell me what brings you into the office?

  13. Sequence • Next, ask direct questions without leading the patient. • Where is the pain? • What does it feel like?

  14. Direct Questions • Does the pain move around? • Show me. Point to the pain.

  15. Graded Response • How long can you play before you get the pain in the back?

  16. Spinal Stenosis • How far can you walk before you have to stop?

  17. Inability to Describe Symptoms • Is your pain burning, aching, sharp, pressure-like, stabbing, shooting, or what?

  18. Avoid ConfusionAsk one question at a time… • You injured your back while lifting a box? • How much did the box weigh?

  19. Avoid Medical Terminology • Use language that the patient can understand. • Try to use their words…

  20. Sensitive Questions • Tobacco • Recreational drugs • Alcohol • Domestic violence • Psychiatric illnesses

  21. Special ChallengesSilence v Overtalkative • Collecting thoughts • Determining trust • Recounting present illnesses • Check non-verbal signs • Give free-reign for 5 minutes • Show interest • Ask questions • Focus discussion • Be polite • Re-evaluate goals

  22. Angry or Hostility • In pain • Not in control • Frightened • Loss of income • Tired of waiting

  23. Accept the Feelings Defuse the Anger • Once the patient calms down, you should continue…

  24. Illiteracy • May have difficulty completing the intake forms

  25. DepressionIdentify and Explore Manifestations • Fatigue • Weight loss • Insomnia • Mysterious aches and pains

  26. Neuro-musculoskeletal History • Onset • Palliative/provocative • Quality of pain • Referred or radiating • Severity of pain • Timing and treatment

  27. Final Questions • Is there anything else that is bothering you?

  28. Final Questions • What do you expect me to do for you?

  29. Acute Condition • Pain is the most outstanding feature • Rubor • Dolar • Tumor • Calor

  30. Chronic Condition • Pain is no longer the most outstanding feature but stiffness, weakness, and/or loss of sensation.

  31. History Taking Exercise • O,P,Q,R,S,T

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