The History Flashcards
What is an example of identifying data?
Name Age Handedness Nationality/race Sex Occupation
What are the 4 general important things you should obtain during history taking?
Identifying data
Source of referral
Source of history
Chief complaint
What are some examples of source of referral?
Another clinician
Insurance carrier
Whomever..
What are some examples of source of history?
How was the history obtained
- patient
- parent
- interpreter
- Reviewed previous medical records
What are the examples for chief complaint?
The chief complaint list should consist of the complaints and/or symptoms that brought the patient into the office
What does opqrst stand for?
Onset Provoking/palliative Quality Radiation Severity Time/frequency
Sharp pain on motion indicates a problem with what structure?
Joint
Constant pain indicates a problem with what structure?
Joint or nerve
Burning and/or hot feeling would be what structure?
Nerve
Sharp pain not on motion is what structure
Nerve
Stabbing or lightening like pain would be what structure?
Nerve
Tingling and/or numbness indicates what structure?
Nerve
Cramping/knot and/or spasm is what structure?
Muscle (bag of worms)
What structure will cause a dull ache?
Muscle (bag of worms)
What structure will cause radiating dull or deep ache?
Referred pain: scleratogenous pain
What structure will cause a deep burning or dull pain?
Bone/ligament
What structure will cause pinpoint pain over paraspinal tissue
Myofascial trigger point
What structure will cause a crawling sensation (formication)?
Myofascial pain
What structure will cause throbbing pain?
Vascular
What structure will cause well localized pain?
Peripheral
What structure will cause diffuse pain?
Central
What types of pain are related to nerves?
Constant (joint or nerve) Burning and/or hot feeling Sharp pain not on motion Stabbing or lightening like pain Tingling and/or numbness
What will nerve pain follow when radiating?
Specific dermatomal pattern
How will muscle pain act when radiating?
Be localized pain and may refer to peripheral areas. Follow a specific pattern called myotomal patterns
Injuries to ligament refer pain into pattern areas called?
Sclerotia patterns
What is the pain scale where a patient marks on a 100mm line to rate their pain?
Visual analog pain scale
What is the Borg pain scale?
(0-10) rating scale 0 is no pain, 10 being worst pain ever
According to the AMA what is the rating for when the signs or symptoms constitute an annoyance but cause no impairment in the performance of a particular activity?
Minimal
According to AMA what is the rating for when the symptoms or signs preclude any activity that precipitates the signs or symptoms?
Marked
According to AMA what is the rating for when the sign or symptoms can be tolerated but would cause some impairment in the performance of an activity that precipitates the symptoms or signs?
Slight
According to AMA what is the rating for when the symptoms and signs would cause marked impairment in the performance of an activity that precipitates the symptoms or signs?
Moderate
According to AMA how often is intermittent pain?
Less than 25% of the time when awake
According to AMA what is frequent pain?
Between 50% and 75% of the time awake
According to AMA how frequent is occasional pain?
Between 25%and 50% of the time awake
According to AMA how often is constant pain?
Between 75% and 100% of the time when awake
What is the benefit of a good examination?
First: determine if lesion in musculoskeletal system is present
Second: determine location of problem
Third: what pathological conditions could cause lesion
Fourth: careful analysis of history and examination to determine which condition is most likely present
What is dermatome pain?
Radiating, sharp,stabbing, and well demarcated. Area of sensation attributed to a particular nerve root level
What is myogenous pain?
Pain referral within muscular or facial tissue
What is scleratogenous pain?
Dull, achy, diffuse and difficult to pinpoint. This is referred pain from somatic structures, cartilage, ligament, joint capsule, or bone
What should you look for during an unofficial inspection of the patient?
Gait and stance
Is eye contact made?
Is clothing appropriate for weather
Color and moisture of skin
What areas should you check with auscultation?
Supra clavicles area
Anterior neck
Temples bilaterally
Eyes and skull (may reveal Bruins within the school)
What might cause a bruit?
Vessel stenosis
External compression
Normal anatomical variant
Where can temperature be taken?
Oral Rectal Axillary Tympanic membrane Temporal
