9/9 - Patient History Flashcards
why is effective communication so important in the interview process
necessary to obtain clear picture of patient’s sx
what type of questions are preferred? why?
open ended
- allows pt to relay what is important to them
- get real responses
- can have good follow up questions
what is questionnaire a form for
medical hx screening
what is the most critical part of an exam
accurate and thorough pt history
what are 4 reasons why is an accurate and thorough pt hx so important
facilitates decision making process
assists in planning appropriate tests
differentiation b/w MSK and non-MSK conditions
develop effective treatment plan
why is a clear chronological hx of problem important
what’s worked
what hasn’t worked
what are ways to categorize an estimate of the manner of the presenting disorder
severity
irritability
stage
stability
how does the level of irritability impact PT
level of irritability and reactivity influences what we are able to do in physical exam
- pain levels and willingness to move
what helps you decide what tests and measures are most important
what do you need to do to r/i and r/o things
what is the importance of appropriate tests and measures for documenting purposes
to show that the interventions are helpful
- that there is measurable change (esp for some insurances)
what are 10 goals of pt hx
- pt profile
- msk vs non-msk or both
- precise description of sx
- aggravating and easing factors
- CI or precautions to exam/intervention?
- clear chronological hx of problem
- develop dx hypotheses of sx
- estimate manner of presenting disorder
- assess baseline functional level to determine progress
- determine appropriate tests and measures to perform
what conditions are more common in older pts
tendinopathies
what conditions are more common in younger pts
instability
what conditions are more common in females
ACL injuries
what are components to a patient profile
age, sex, race
height and weight
primary language
barriers to learning &learning preferences
why are age, sex, and race important to include on a patient profile
certain conditions are more common
why is primary language an important thing to include in a patient profile
may impact communication and learning
why are barriers to learning and learning preferences important to include in a patient profile
impact future pt education
what are the 3 things included in a social history
- social interactions, activities, support
- family/caregiver resources (support or stress)
- cultural beliefs and behaviors
what do we want to know about a patient’s occupation
current and previous work activities
- type of work
- hours
- conditions
- pace and stress level
- length of time at current job
what about a patient’s occupation can frequently lead to injury
poor workplace ergonomics
what about their functional status do we want to know
current and PLOF
- self care
- home management
- ADLs
rec activities
- hobbies
- exercise
what about growth and development do we want to know about a patient
developmental background
hand / foot dominance
why do we care about hand/foot dominance
if involved extremity is dominant, it may adversely impact prognosis
what about a patient’s living environment do we want to know
home and community characteristics
- set up, stairs, etc.
projected dc destination
what are the 5 things we want to know about the hx of current condition
- chief complaint
- MOI
- pain assessment
- local, referred, radicular - sx behavior
- aggravating, easing factors - current interventions/response
- done on their own, prior PT
why do we want to know about the MOI
can give a lot of info on what tissues are involved
what do we want to ask about the meds the patient might be taking
for current condition?
other conditions?
what do we want to know about a patient’s PMH
review prior hospitalizations
prior surgeries
pre-existing medical conditions
what do we want to know about a patient’s family history
family health risks
how do we interpret pt hx and what are the next steps
formulate 2-3 diagnostic hypotheses
determine most appropriate tests
exam process to r/i or r/o hypotheses
how many diagnostic hypotheses after a patient hx do we want to have? is there an exception this? what do we do if there is a different amt of hypotheses?
2-3
exception: pt is post-op and you know what they are coming for
1 thing - blinders were on
8 things - ask more Qs
