Test 1: Module 2 (Patient History/Systems Review)

Question 1

Definition of patient history

Answer 1

Definition 1: A patient history is a compilation of information obtained from the patient
about the disease process and related information pertinent for the problem to be treated

Definition 2: the history is a systematic gathering of data, both from the past and the
present-related to why the patient is seeking the services of the physical therapist

Question 2

Purpose of patient history

Answer 2

A history along with the review of systems are important components of the (differential) diagnostic decision-making process: treat, refer, or refer and treat

Question 3

INTERVIEWING TECHNIQUES

Answer 3

Open-ended questions - requires more than yes/no, prompts for detailed answers

Closed-ended questions – answers only with yes/no

Funnel sequence – Starts with broad open-ended questions and gradually become more specific

Paraphrasing technique - repeating what someone has said without adding any personal thoughts or questions.

Probing/Follow-up questions - Probing questions are often open-ended and start with “what,” “how,” or “why” to encourage more detail.

Question 4

Open-ended questions

Answer 4

requires more than yes/no, prompts for detailed answers

Question 5

Closed-ended questions

Answer 5

answers only with yes/no

Question 6

Funnel sequence

Answer 6

Starts with broad open-ended questions and gradually become more specific

Question 7

Paraphrasing technique

Answer 7

repeating what someone has said without adding any personal thoughts or questions.

Question 8

Probing/Follow-up questions

Answer 8

Probing questions are often open-ended and start with “what,” “how,” or “why” to encourage more detail.

Question 9

CORE INTERVIEW SEQUENCE

Answer 9

1. Review the referral (if applicable)
2. Review available medical record information (if applicable)
3. Review intake form (if applicable)
4. Introduce yourself to the patient, include professional designation, referral received, process of the examination
   
   • My name is __________ _____________. I am a student physical therapist…
   • Explain to the pt why they were referred for physical therapy and explain the process of the examination: History,
     ROS, tests and measures, discussion of goals and POC
5. Begin history taking…

Question 10

General Demographics

Answer 10

Age

Gender (pronouns*)

Marital status or living with partner?
- Do they they live alone?

Race/ethnicity

Primary language

Occupation (present and past)

Question 11

Chief Complaint (c/c)

Answer 11

“What brings you to PT today?”

Pain and symptom assessment
- Location
- Quality and or Intensity
* “Type” of pain
- Behavior
- Changes in pain

Question 12

PAIN DESCRIPTION/QUALITY (Vascular)

Answer 12

Throbbing
Pounding
Pulsing
Burning

Question 13

PAIN DESCRIPTION/QUALITY (Neurogenic)

Answer 13

Sharp
Crushing
Pinching
Burning
Hot/Searing
Itchy/Stinging
Jumping/Shooting/Electrical

Question 14

PAIN DESCRIPTION/QUALITY (Musculoskeletal)

Answer 14

Aching
Sore
Heavy
Dull
Cramping
Deep

Question 15

PAIN DESCRIPTION/QUALITY (Emotional)

Answer 15

Tiring
Miserable
Vicious
Agonizing
Dreadful
Torturing
Annoying
Exhausting

Question 16

FUNCTIONAL STATUS

Answer 16

Living environment
- House (single-story, 2-story,
steps or stairs?)
- Apartment (What floor, stairs,
or elevator?)
- Has caregiver/family help

Current and prior health/fitness status
- Independent or needs help?
- Use of assistive devices

Current and prior work status
- Currently working or retired?

Question 17

SOCIAL FUNCTION

Answer 17

Behavioral health risks
- Smoking, alcohol, drugs?
- Exercise and physical activity
(hobbies)

Cultural beliefs and behaviors

Family and social support

Question 18

Definition of systems review

Answer 18

A systems review is a brief or limited examination of:

1) the anatomical and physiological status of the
cardiovascular/pulmonary, integumentary, musculoskeletal, neuromuscular systems

2) examination of communication ability, affect, cognition, language,
learning style and learning needs of the patient.

A systems review will provide an overview of the
movement system.

Question 19

PURPOSE OF SYSTEMS REVIEW

Answer 19

To look beyond the CC or “primary problem”

To provide an overview of the “whole person”

To determine if consultation or referral is indicated

To guide PT in selecting tests and measures
- “What should I do next?”

Question 20

CARDIOVASCULAR AND PULMONARY SYSTEM

Answer 20

1. *Heart rate / Pulse rate
2. *Blood pressure
3. *Respiratory rate
4. Edema
   
   • Pitting (cutaneous)
   • Non-pitting
5. *Oxygen saturation (SpO2)

(Maybe *Temperature)

Question 21

INTEGUMENTARY

Answer 21

1. Scars
2. Skin color (pallor, redness, cyanosis, hemosiderin, jaundice)
3. Integrity (wound, ulcers, moles)

Question 22

The ABCDE method for wound review

Answer 22

Asymmetry

Borders

Color

Diameter

Evolution

Question 23

MUSCULOSKELETAL

Answer 23

1. Height
2. Weight
3. Gross ROM
4. Gross Strength
5. Gross Symmetry (posture)

Question 24

NEUROLOGICAL / NEUROMUSCULAR

Answer 24

1. Gross coordinated movements
    Balance
    Locomotion
    Transfers and transitions
2. Motor function
    Movement pattern
    Fine movement (fingers/hand)
    Reflexes
3. Sensation
    Touch
    Pain/temperature

Question 25

MENTAL STATUS

Answer 25

Alertness
- Awake, lethargic, stuporous,
comatose

Orientation (x4)
- person, place, time, situation

Attention, Memory, Higher Cognitive Functions
- general recall test, counting,
abstract thought

Visuospatial Examination
- perceptual ability, ability to
manipulate spatial
orientation