Chapter 2 Case History (page 8)

Question 1

To be assessed in the ___________: presence of thyroid disease, diabetes, metabolic disturbances, changes in thirst, hunger and perspiration.

Answer 1

Endocrine System

Question 2

To be included in the assessment of the _________________: presence of discharge, pain, sores; female – presence of dysmenorrhea, menopause, pregnancy and complications, miscarriages, endometriosis, fibroids and cysts, pelvic inflammatory disease.

Answer 2

Reproductive system

Question 3

To be included in the assessment of the _________________: palpation of swollen, hard or painful superficial lymph nodes, edema (pitting and non-pitting).

Answer 3

Lymphatic system

Question 4

To be included in the assessment of the _________________: presence of swallowing difficulties, esophageal reflux (heartburn), appetite changes, nausea, vomiting, indigestion, constipation, diarrhea, abdominal pain, gas, haemorrhoids, liver and gallbladder disease; assessment of palpable abdominal or gans for pain, tenderness, discomfort and immobility.

Answer 4

Gastrointestinal system

Question 5

To be included in the assessment of the _________________: presence of increased or decreased frequency, infections, incontinence, kidney stones.

Answer 5

Urinary system

Question 6

To be included in the assessment of the _________________: presence of chronic cough, asthma, bronchitis, emphysema, pneumonia, tuberculosis, breathing difficulty (dyspnea), observation and assessment of breathing.

Answer 6

Respiratory system

Question 7

To be included in the assessment of the _________________: presence of varicose veins, thrombophlebitis, poor circulation, heat or cold intolerance, edema, slow healing time, heart conditions; assessment of blood pressure, pulse rate and rhythm; special tests.

Answer 7

Circulatory system

Question 8

To be included in the assessment of the _________________: observation and assessment of skin integrity, rashes, lumps/lesions, dryness, scars, redness, temperature, hair and nail changes.

Answer 8

Integumentary system

Question 9

General Body Systems review usually include _____________, ____________, ____________, and ______.

Answer 9

Normal weight

Recent weight changes

Constitutional signs

Pain

Question 10

Health history information must be requested from the client to identify indications and/or
contraindications to treatment. Information requested must include, at the minimum:

Answer 10

• Date on which health history was taken or updated
• General health status
• Client name, address, date of birth, telephone number, occupation, source of referral
• Name and address of primary care physician
• Current involvement in treatment with other health care practitioner(s)
• Current medication(s) and condition(s) they are -treating
• Timing and nature of injuries or accidents
• Timing and nature of surgical procedures
• History of massage therapy
• Primary complaint
• Location and nature of soft tissue and/or joint discomfort
• Vision or hearing loss/ loss of sensation
• Possible cardiovascular insufficiency
• Possible respiratory insufficiency
• Allergies or hypers ensitivity reactions
• Diabetes, cancer, epileps y, skin conditions
• Arthritis, family history of arthritis
• Presence of infectious conditions
• Pregnanc y, gynaecological conditions
• Other diagnosed diseases or medical conditions
• Presence of internal pins, wires, artificial joints or special equipment
• History of headaches or migraines