Vol.2-Ch.4 "History Taking"

Question 1

What is the foundation to providing food care to PTs that you have never met before?

Answer 1

The ability to elicit a good history

Question 2

What is another term for a “list of causes” to explain a PTs signs and symptoms?

Answer 2

Differential field diagnosis

Question 3

What are some general things you should always document from the beginning (if possible)? (5)

Answer 3

• Date/Time
• Age
• Sex
• Race
• Birthplace or occupation (if relevant)

Question 4

What is the “Primary Problem”?

Answer 4

The medical cause of the chief complaint

Question 5

What is the chief complaint?

Answer 5

The reason the PT requested help

Question 6

What is the difference between the chief complaint and the primary problem?

Answer 6

The chief complaint is the reason the PT requested help in the first place, where as the primary problem is the underlying medical issue the caused the chief complaint

Question 7

How should you record your PTs chief complaint? What if they are unconscious?

Answer 7

Always record in the PTs own words if possible, if unconscious use a bystander or family members words describing what happened

Question 8

What does OPQRST-ASPN stand for?

Answer 8

Onset (immediate? overtime? where? when? activity?)
Provocation (what makes the pain worse?better?)
Quality (describe pain)
Radiation/Region (where? boundries? referred?)
Severity (how bad 1-10)
Time (beginning? come-and-go? duration? last time?)

Associated Symptoms (symptoms that go along with other diagnosis typically that can help affirm your suspected field diagnosis)

Pertinent Negatives (symptoms that typically go along with other diagnosis typically but are ABSENT in PT description)

Question 9

What to areas of the body are the most common producers of referred pain?

Answer 9

Chest and abdomen

Question 10

What does SAMPLE stand for?

Answer 10

Signs/Symptoms
Allergies
Medications
Past medical history
Last oral intake (time, food)
Events leading up to incident

Question 11

What are some things that you should ask about during the Past Medical History questioning? (5)

Answer 11

• General health
• Adult/Childhood diseases
• Psychiatric Illnesses
• Recent accident or injuries
• Surgeries or hospitalizations

Question 12

What are some type of questions you can ask in a NON-Emergency setting?

Answer 12

• Family medical history
• Home/daily life
• Alcohol, drugs, tobacco
• Diet, exercise, sleep

Question 13

What are the CAGE questions and what are they used for?

Answer 13

1. ever felt the need to Cut down on your drinking?
2. ever felt Annoyed by criiticism of your drinking?
3. ever had Guilty feelings about your drinking?
4. ever drank first think in the morning as an Eye opener?

(Cut down, Annoyed, Guilty, Eye opener)

If a PT answeres 2 or more of these as yes they may be an alcoholic

Question 14

What is and why would you do a Review of the Body Systems?

Answer 14

• They are a series of questions to identify problems you PT has not yet mentioned after your first line of questioning
• It is a system-by-system list of questions that ask more specific questions about systems related to or directly about the effected system

Question 15

What does HEENT stand for?

Answer 15

Head
Ears
Eyes
Nose
Throat

Question 16

What does GPAL stand for and why is it used?

Answer 16

It is used to document a PTs history of pregnancy

• Gravida (How many times pregant?)
• Para (How many viable births?)
• Abortions (How many abortions/miscarriages?)
• Living (How many living children?)