AbouT Patient History
A patient history is taken from the patient as part of the interview portion of the examination (collecting data about the patient). This part of the examination assists the therapist in generating a preliminary hypothesis or hypotheses related to the physical therapy diagnosis of the patient. This hypothesis generation allows the therapist to pursue tests and measures related to that hypothesis and develop a diagnosis in a more organized, sequenced manner.
The patient history section of the evaluation can include several questions directed towards the patient problem. These questions usually start out as a general question, and become more focused as the patient interview progresses.
What questions are asked in the interview?
Note--these are just a starting point. Other questions may be generated to more fully discover the patient problem.
General questions
Rationale: Discover why the patient is seeking physical therapy care.
Example:
What brings you to physical therapy today?
Why did your physician (doctor) send you to physical therapy?
What problem did you want me to address today?
What daily activities are difficult for you because of your problem?
Assess Pain
Rationale: establish chronicity of pain, pain location, activity restriction, and guide towards further physical therapy special tests. A pain description can help to generate a hypothesis about the patient problem based upon its quality, location, and severity.
Tools needed:
Visual Analog Scale--a visual analog scale helps the therapist to quantify pain at its best, worst, and what the pain is right now. An example is located in the image below.
The patient history section of the evaluation can include several questions directed towards the patient problem. These questions usually start out as a general question, and become more focused as the patient interview progresses.
What questions are asked in the interview?
Note--these are just a starting point. Other questions may be generated to more fully discover the patient problem.
General questions
Rationale: Discover why the patient is seeking physical therapy care.
Example:
What brings you to physical therapy today?
Why did your physician (doctor) send you to physical therapy?
What problem did you want me to address today?
What daily activities are difficult for you because of your problem?
Assess Pain
Rationale: establish chronicity of pain, pain location, activity restriction, and guide towards further physical therapy special tests. A pain description can help to generate a hypothesis about the patient problem based upon its quality, location, and severity.
Tools needed:
Visual Analog Scale--a visual analog scale helps the therapist to quantify pain at its best, worst, and what the pain is right now. An example is located in the image below.
Body schematic diagram--a body schematic diagram helps the therapist identify the exact location or locations of pain and if the pain is localized, diffuse, acute, or chronic in nature. An example is located below.
Questions to ask:
When did your pain start?
Describe the pain to me.
How does the pain make you feel?
How long have you had this pain?
What does the pain prevent you from doing?
What makes the pain better or worse?
What causes the pain?
What have you tried to do to alleviate your pain? Did it help?
Can also refer to the following OPQRST (Onset, Provokes, Quality, Radiation, Severity, Time)
Review of Systems
Assess Circulatory/Cardiac Status
Questions to ask: (establish risks to circulatory status either peripherally or centrally)
Do you have a history of vascular disease or have you been told you have poor circulation?
Do you have a history of atherosclerosis?
Do you have a history of problems with your heart?
Do you have a history of high blood pressure?
Are you a diabetic?
Do you have any sort of altered sensation in the your legs (numbness, tingling, burning)?
Have you been told you have peripheral neuropathy?
Assess Neurologic Status
Questions to ask: (establish neurologic involvement)
Do you have any numbness?
Do you have any tingling?
Have you had any headaches followed by weakness?
Have you had any trouble with your speech or swallowing?
Have you had any changes in vision?
Have you had any weakness, unsteadiness, stiffness, or feeling clumsy?
Do your symptoms change with the weather?
Have you had any time where you have passed out?
Do you feel dizzy or lightheaded?
Have you had any changes in your mood (feeling depressed, tearful, agitated)?
Have your symptoms been associated with nausea or vomiting?
Do you have diabetes?
Have you had a loss of the ability to move?
Have you had a loss of sensation anywhere?
Have you had a change in bowel or bladder habits?
Do you have headaches?
Do you have seizures?
Assess for Musculoskeletal Involvement
Questions to ask: (establish problems with muscles, articulations, or bones)
General pain questions as above.
Do you have osteoarthritis?
Do you have rheumatoid arthritis?
Do you have osteoporosis?
Do your symptoms change with movement? How?
Do you feel pain or stiffness in your joints? Which ones?
Do you have swelling in any of your joints?
Do you ever hear your joints clicking or popping?
Have you had any injuries recently? What happened?
Is there anything that you have done that helps the pain?
Have you noticed any change in your muscles or joints?
Is it difficult to move your body part?
What things are difficult for you to do?
Does your joint ever feel like it is going to give way?
Assess for Systemic Involvement
See also: meded.ucsd.edu/clinicalmed/ros.htm
Questions to ask: (establish problems with organs or organ systems)
Does the pain change with movement? (if no may be systemic)
Does the pain wake you up at night?
Do you ever feel short of breath (lung)?
Does it hurt to breathe in or out?
Do you ever feel dizzy?
Do you ever feel fluttering in your chest?
Do you have any swelling anywhere?
Do you have night sweats?
Does the pain ever get better or worse?
Has a doctor ever told you that you have cancer/problems with lung/problems with heart/problems with kidney?
Do you have diabetes?
Do you have high blood pressure?
Have you had any unplanned weight loss or gain?
Have you felt more tired than usual?
Have you felt weak all over?
Have you had any fevers?
Have you had a loss of sensation anywhere?
Have you had a loss of the ability to move?
Have you had a change in bowel or bladder habits?
Have you had any altered sensation anywhere?
Has your skin changed color?
Have you felt coldness in your toes/arms/legs/fingers?
Have you noticed any changes in your skin?
Have you had any changes in your health recently?
Have you had any cost pain?
Have you had a history of stroke?
Are you pregnant?
Have you had any changes in your appetite?
Red Flag Answers and their possible causes: (https://dcp.psc.gov/osg/therapist/documents/COA06_Feda.pdf)
Nausea/Vomiting: GI system, pregnancy, cancer, medication side effects
Fever/chills/sweats: many common ailments to include: flu, occult infection, or cancer
Unexplained weight change: 5% over a 4 week period
Variety of ailments to include: GI disorders, diabetes, hyperthyroidism, adrenal insufficiency, common infections, malignancies, and depression
Numbness and tingling: Indicative of nerve irritation or compression, may also indicate
malignancy
Syncope: Sudden but temporary loss of consciousness, Associated with inadequate blood flow to the brain
Difficulty swallowing: Neurologic disorder, tumor, fracture, pericarditis
Changes in bowel or bladder function
-Urinary retention or complete inability to retain = cauda equina
– Increased frequency/dysuria = urogenital dysfunction
– Blood in stool = dark could indicate GI bleed, bright red is likely external i.e. hemorrhoid
– Blood in urine = infection, urogenital dysfunction
Dizziness/lightheadedness
– Medication side effects, hypoglycemia, cardiovascular dysfunction, BPPV
Dyspnea/SOB/Upper respiratory infection
– Indicative of cardiovascular or pulmonary disease
Urinary tract infection
– Can cause increased urinary frequency, blood in urine, also may develop into kidney infection and may present as low back pain due to referral or actual infection proceeding to that region
– Osteomyelitis may result in deep, dull, central LBP can start with a UTI
Allergies/Ulcers/Kidney Disease Allergies/Ulcers/Kidney Disease
-Kidney disease may present as flank pain Kidney disease may present as flank pain
Ulcers may present as mid-thoracic pain* Ulcers may present as mid-thoracic pain*
Sexually transmitted diseases:
– i.e. painful urination and inflamed joints should raise awareness in a sexually active individual
individual
– Gonorrhea can spread through the bloodstream and inflame joints – immediate
referral required
– Chlamydia can present as back pain
Abdominal pain:
-Abdominal pain may indicate a visceral origin
References
http://www.nature.com/nrrheum/journal/v4/n1/full/ncprheum0673.html
https://dcp.psc.gov/osg/therapist/documents/COA06_Feda.pdf
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