Patient History Flashcards
Examination
Patient history
Physical examination- systems review, tests and measures
Patient history
Types of data that may be generated from a patient or client history
Interview
Review medical record
Combination of both
Patient history demographics
Age
Referral source
Reason
Occupation
Patient history chief complaint
Patient identified problems
Date of injury or diagnosis
Mechanisms of injury
Reason for seeking pt services
Sinss and body chart
SINSS
Severity
Irritability
Nature
Stage
Stability
Severity - SINSS
Intensity of symptoms as related to functional activity
Irritability- SINSS
Time for symptoms to come on and go away
Minimal- tolerates repetitive, sustained activities
Moderate- tolerates brief activities less than 10 min
Maximal - activity not tolerated due to pain or symptoms last greater than 30 min
Nature - SINSS
Musculoskeletal vs non musculoskeletal
Type of pain and symptoms
Reflection of systems review and differential diagnosis
Stage - SINSS
Time frame with symptoms
Acute pain - recent onset 0-3 weeks
Subacute pain- later stage of healing or early chronicity 3-6 weeks
Chronic pain - extended duration past expected recovery greater than 6 weeks
Stability - SINSS
Progressions of patients pain and symptoms over time
Getting better- improving
Staying the same
Becoming worse
SINSS consideration
Does it limit you
Does it make patient worse
Body chart
Shows Key characteristic of pain
- location
- quality
- depth
- frequency
- relationships between areas of symptoms
- clearing all other areas
Location body chart
Documented as P1, P2, P3 with a rating 0/10 scale
Quality body chart
Type of symptoms
Aching, numbness, tingling, burning, stabbing, tightness
Depth of symptoms body chart
Deep or superficial or indescribable
Frequency body chart
Constancy of symptoms
Constant C
intermittent I
variable V
Radicular symptoms
Direct stimulation of a nerve root results in a sharp lancinating pain well localized to dermatome
Visceral referral
Kidney pancreas, cardiac can mimic or masquerade as musculoskeletal pain
Somatic referral
Symptoms that arise from referral of a musculoskeletal structure like a facet joint
Red flags
Information that may suggest serious pathology
Should act as a stop sign and decide who a referral should be made to
Red flag examples
Unexplained weight loss
Severe pain that is unchanged by position or movement
Changes in bowel or bladder function
Recent, persistent, history of fever, chills, night sweat nausea, or vomiting
Symptoms that a wicked patient at night that are not altered by change in position
Uncontrolled diabetes, hypertension, or eating disorders
Suicide, plans or attempts
Undiagnosed fractures
Yellow flags
Factors that increase the risk of poor, prognosis or outcomes
Developing perpetuating, long-term disability
Comorbidities
Continue with interventions and plan of care, but always monitor this
Yellow flags examples
Depression, anxiety, fear avoidance
Controlled diabetes, hypertension, and other comorbidities
Red flag versus yellow flag
Red flag is a serious pathology or psychosocial factors requiring immediate referral includes emergent medical issues like depression
Yellow flag is a non-emergent condition or psychosocial factor which require caution could be monitored while patient is still being treated may hinder prognosis
Cardiopulmonary collection of information
Do you have any heart or lung problems?
Ask about hypertension, irregular heartbeat, chest pain, pacemaker, asthma, shortness of breath
Endocrine collection of information
Do you often experience fatigue?
Common things to ask, include about diabetes, thyroid problems, weight loss, weight gain, fever, chills, sweats
Eyes ears nose and throat collecting information
Do you have any trouble with your eyes, ears, nose, or throat?
Comment to ask about vision problems, hearing problems, allergies, difficulty swallowing
GI GU collection of info
Have you had any changes in your bowel or bladder function?
Common ones ask about include bowel or bladder, incontinence, nausea, vomiting, heartburn acid reflux, constipation, kidney problems
Hematologic lymphatic info collection
Do you have any problems with your circulation?
Common wants to ask about our blood clots, cancer, kidney or liver problems
Integumentary information collection
Do you have any moons are open sores?
Do you have a skin condition such as eczema or psoriasis?
Neurologic info collection
Do you have any numbness or tingling?
Common things to ask our stroke, MS, headaches, epilepsy, dizziness, lightheadedness, also, depression, anxiety, and suicidal thoughts
Musculoskeletal info collection.
Do you have any problems with your bones are muscles
Ask about fractures OA osteoporosis
Social history of patients
Support systems
Home environment
Religious beliefs
Current health behaviors
Drinks
Smoking
Nutrition
Sleep
Physical therapy
Stress level
