The Health History Flashcards
What is the purpose of conducting a health history?
- Develop a trusting and supportive relationship
- Gather information
- Offer information
- Retain a record of what happened in a consultation
What does SQIRTN stand for?
S - site Q - quality I - intensity R - any radiations T - timing (pattern) N - neurological signs/symptoms
What are the 5 parts of taking a health history?
1 - SQIRTN 2 - history of presenting complaint (HPC) 3 - past medical history (PMH) 4 - family and psychosocial history 5 - systems' history
What are 5 examples of a RED FLAG in a health history?
- SOB
- Chest pain
- Persistent night pain
- Constant, unremitting pain
- Progressive neurological symptoms
- Unexplained weight loss
- Lack of appetite
Define RED FLAG
A red flag is a sign or a symptom that indicates the possible or probable presence of a serious medical condition that can cause irreversible disability or untimely death unless managed properly.
What is the difference between a SYMPTOM and a SIGN? Provide examples of each.
Symptom = subjective, personal opinions/interpretation of patient (e.g. pain, dizziness, numbness, fatigue)
Sign = objective (measurable and observable), discovered by practitioner, indicators of a problem (e.g. sweating, BP, HR, pallor)
What are the 5 basics of valid consent?
1 - explain what is going to happen and why
2 - explain benefits
3 - explain risks
4 - explain alternatives (including no treatment)
5 - ask for consent and record in clinical history
Define contraindication to treatment.
Medical conditions or clinical signs/symptoms discovered during history taking and/or physical examination which suggest that some manual treatment techniques may not be appropriate.
What is a relative contraindication? Provide examples.
Practitioner can treat the patient, but with caution.
E.g. IVD herniation
age and health status
pregnancy (especially 1st trimester)
severe scoliosis
active inflammatory disease (e.g. rheumatoid arthritis or gout)
patient recently treated by another practitioner
What is an absolute contraindication? Provide examples.
Practitioner should not treat the patient.
E.g. weak bone (e.g. osteoporosis)
neurological dysfunction (e.g. caudal equina syndrome)
vascular insufficiency (especially in head and neck; e.g. peripheral vascular disease, stroke history)
lack of working diagnosis
pain/excessive tissue feedback
non-compliance (consent not given)
What are adverse reactions to treatment? Provide examples of minor and major adverse reactions.
Patients need to be warned before commencing physical examination/treatment. Over half of new patients will experience minor adverse reactions that resolve within 24-72 hours. Major adverse reactions are rare but possible.
E.g’s of minor adverse reactions:
- increased muscle pain
- joint stiffness/soreness
- tiredness/fatigue
E.g’s of major adverse reactions:
- disk herniation
- cauda equina syndrome
- fracture
- joint sprain
- stroke
What are the 5 broad parts to follow when conducting a health history?
1 - SQIRTN
2 - history of presenting complaint; when/how it started, progression, any treatment/investigations, history of similar injury, aggravating/relieving factors
3 - past medical history; previous accidents, hospitalisations, major illnesses, meds
4 - family and psychosocial history; family history, QOL, work, hobbies, stress, alcohol/drugs, diet, other musculoskeletal history
5 - systems history; CV, resp, gastrointestinal, neuro, repro, dermatological, endocrine, dental/opthalmic
Explain the general step-by-step flow of an osteopathy consultation (including points at which referral may be necessary).
Health history -> maybe referral -> PROMs -> informed consent -> examination -> maybe referral -> provision of working diagnosis -> maybe referral -> management plan -> maybe referral -> informed consent -> management -> maybe referral -> review/self-management -> maybe referral
What are the 4 broad parts covered in the new VU Osteopathy Clinic Patient Form? Where is this information stored?
1 - patient information
2 - privacy consent form
3 - health information and demographics
4 - research in health questionnaire (currently partners in health)
Entered into patient management system
