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History taking-2rd lecture

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The document provides information on conducting patient interviews and history taking. It discusses important concepts like cultural competence, communication skills, questioning techniques, and reviewing different body systems. The goal is to help practitioners understand patients' medical issues in their full psychosocial context in a respectful manner.

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History taking-2rd lecture
Listen to the patient he is telling you the diagnosis (william Osler) HISTORY TAKING
History taking is experientially acquired task…the only way to learn it… is to do it.
Learning objectives • Concepts in communication. • Cultural competence • Basic interview skills. • Patient v/s clinician centered interview. • DO’s and Don’ts of interview
Concepts in communication HISTORY TAKING
• Interviewing is a skill. • Taking medical history can be a challenge. client’s issues • Telescoping: Clients may forget, underreport, or combine separate health events into a single memory,. • Fabricated medical recall that never occurred. • Mental state at time of injury/illness Concepts in Communication
Compassion & Caring – Verbally and non verbally – Body language – Sit down and maintain Social distance – Lean forward, nod , encourage – Take notes maintaining adequate eye contact. – Silent attentiveness.
Communication style • Individual Differences are there. • Gender based styles • Temprament/ personality based styles • Religon, socioeconomic differences, beliefs and behaviours of both therapist and client. • Cultural differences.
Health Illiteracy • The inability to read, understand, and respond to health information • Filling out medical History forms. • Instruction written on medicine bottle. • Read details of exercise form. • minimize the use of medical terminology • Use simple but not demeaning language.
Cultural competence • It be defined as the ability to understand, honor, and respect the beliefs, lifestyles, attitudes, and behaviors of others. • As health care professionals, we must develop a deeper sense of understanding of how ethnicity, language, cultural beliefs, and lifestyles affect the interviewing, screening, and healing process.
Cultural competence • A 25-year-old African American woman who is also a physical therapist came to a physical therapy clinic with severe right knee joint pain. She could not recall any traumatic injury but reported hiking 3 days ago in the Rocky Mountains with her brother. She lives in New York City and just returned yesterday. A general screening examination revealed the following information: • Frequent urination for the last 2 days • Stomach pain (related to stress of visiting family and traveling) • Fatigue (attributed to busy clinic schedule and social activities) • Past medical history: Acute pneumonia, age • Nonsmoker, social drinker (1-3 drinks/week) • What Are the Red/yellow Flag Signs/Symptoms? • How Do You Handle a Case like This? • Young age • African American • With the combination of red flags (change in altitude, increased fatigue, increased urination, and stomach pain) there could be a possible systemic cause, not just life's stressors as attributed by the client. The physical therapist treated the symptoms locally but not aggressively and referred the client immediately to a medical doctor. Result: The client was subsequently diagnosed with sickle cell anemia. Medical treatment was instituted along with client education and a rehab program for local control of symptoms and a preventive strengthening program.
Cultural Competency • Minority Groups • Hindus • Christians • Shias , 12 imam followers or 6 imam followers • Sunnis :various ethnic groups • Courtesy is very important in Asian cultures. Clients may act polite, smiling and nodding, but not really understand the clinician's questions.
Cultural Competency in a Screening Interview • •Wait until the client has finished speaking before interrupting or asking questions • •Allow "wait time" (time gaps) for some cultures . • •Be aware that eye contact, body-space boundaries, even handshaking may differ from culture to culture
Cultural Competency • In some cultures (e.g., Muslim) information about the client's diagnosis and condition are relayed to the head of the household who then makes the decision to share the news with the client or other family members . • sustained direct eye contact may be considered aggressive behavior in some cultures. • Watch the client's body language while listening to him or her speak • Head nodding and smiling do not necessarily mean understanding or agreement;
Cultural competence • Keep comments, instructions, and questions simple and short. • Avoid using medical terms Minority Health's Web site (www.omhrc.gov/clas)." The Council on American-Islamic Relations" or the Muslim American Society. "The APTA offers a wide range of information on cultural competence.
The study of patient begins with history HISTORY TAKING
Qualities of skilled listener • Can hear the vocal inflection • Understand Non verbal clues • Integrate history and physical examination
 Patient complaining of anxiety and he has on first glance bulging eyes and tremors of hyperthyroidism  Examiner would make mental notes to ask for a history of weight loss or family history of thyroid disease and on physical examination would seek confirming signs like rapid pulse and enlarged thyroid
 The patient who moves slowly and stifly, speaks monotonically and softly, and has minimal facial expression & tells you that he has swallowing difficulty.  Examiner would need to ask for other parkinsonian risk factors and physical findings such as tremors, cogwheel rigidity and gait abnormalities.
 I'm beginning to get an idea of the nature of your problem. Let me ask you some other questions. At this point the interviewer may begin to use closed-ended questions (i.e., questions requiring the answer to be "yes" or "no") in order to characterize the symptoms more clearly.
 Open-ended questions  Closed-ended questions  Funnel sequence or technique  Paraphrasing technique
History taking-2rd lecture
 Patient centered interviews  Clinician centered interviews  Combination of both
Questioning skills Relationship building skills  Non-focusing skills: ◦ Silence ◦ Nonverbal encouragement ◦ Neutral utterances  Focusing skills: ◦ Echoing ◦ Open ended requests ◦ Summerising/ ◦ paraphrasing  Emotion seeking skills  Direct inquiry  Indirect inquiry ◦ Self disclosure ◦ Impact of the problem ◦ Patients’ explanatory model  Empathy skills(NURS) ◦ Name ◦ Understand ◦ Respect ◦ support
Step 1: Setting the stage for the interview(30- 60sec) ◦ Welcome the patient ◦ Use patient’s name ◦ Introduce yourself and identify your specific role ◦ Ensure patient readiness and privacy ◦ Remove barriers to communication. ◦ Ensure comfort and put the patient at ease.
 “SALAM/ Good morning(?), Mr. ZAHID(?). I am Dr.ALI, and I will be your doctor today(?). (He may Shakes patient’s hand; positions chair so that he is at the same eye level with the patient(?); closes the door to ensure privacy; and puts the patient at ease with some small talk.) “I hope you had no trouble getting here today(?).”
 Indicate time available  Indicate interviewer’s needs  Obtain list of all issues the patient wants to discuss.(chief complaint)  Summerize and finalize the agenda
 “We have 15 minutes together(?). I will need about 5 minutes to examine you and go over some of your vital signs(?). But before I do that, I’d like to get a list of what you want to talk about today.…(?)  Is there something else? So you’d like to talk about your headache and get some refills; anything else?”….(?)
 State opening question (ok! Tell me about the headache)  Listen attentively for clues to the patient’s personal circumstances…using non focusing questioning skills( remain silent,nodding,lean forward)  Obtain additional data from non-verbal sources (patient’s physical characteristics and appearance)
 “Okay, tell me all about the headache.” (Remains silent while the patient talks; nods head, leans forward, and intermittently says “uh huh” to encourage the patient to keep talking. Listens for at least 30 seconds, or longer if the patient is giving a coherent, nonrepetitive story.)
Help patient to tell his Bio-psycho-social story( symptom, emotional & personal story)  Obtain the patient’s description of his symptoms/problems(good overview of problem in patient’s own words…avoid CCQ like onset? Duration? Severity?)  Develop personal(work) and emotional context(scared) of patient’s story…focus Q and emotion seeking skills  Expand the patient’s story
 Continuing from above, the interviewer focuses on a symptom mentioned by the patient: “You said the headache was really painful….” This invites the patient to expand on the symptom description. Then the interviewer picks up a personal issue mentioned by the patient: “work . . . say more about that….” The interviewer listens for the first opportunity to naturally ask for emotion, “How do you feel about that?” When the patient responds with an emotion (eg, scared), the interviewer NURSes emotion by (1) naming (“scared”), (2) understanding (“I can see how that would be scary.”), (3) respecting (“It’s been a hard time for you.”), and (4) supporting (“Let’s work together to get to the bottom of it.”).  The interviewer then expands on the patient’s story by focusing on another symptom or personal issue previously mentioned by the patient: “You mentioned your son; tell me about him.” The  interviewer continues with cycles of focusing-emotion- seeking-NURS.
 Summerize patient centered HPI (review the list of patient’s symptoms, personal and emotional story in 2-3 sentences…you have headache that get worse at work and u r worried about losing your job)  Check accuracy  Ask patient whether it is ok to ask more specific questions.
 “You are having headaches that get worse at work and you are worried about losing your job—is that right? Is it okay if I ask you some more specific questions about the headaches?”
 Patient centered interview gives you psychosocial information  Clinician centered interview helps u to make diagnosis(e.g. symptom characteristics, family, social history )
 The clinician takes charge of the interaction to acquire specific details not provided already by the patient , usually to diagnose disease or to fill in the routine database.  Close ended questions  Open ended questions
 7 cardinal features: 1. Onset and chronology 2. Position and radiation 3. Quality 4. Quantification 5. Related symptoms 6. Setting factors 7. Transforming factors Mneumonic OPQQRST
 History of presenting illness  Inquire about symptoms in the same body system(focused review of systems)…absence of dyspnea in patient with chest pain weighs against the diagnosis of pulmonary embolism.  Ask about other relevant symptoms…ask for GI bleed in RA patient with fatigue.
HISTORY TAKINGHISTORY TAKING Medical conditions Hospitalisations Serious illnesses / injuries Operations
HISTORY TAKING Current medications: • Prescribed • Over-the-counter • Name • Dose • Frequency Recreational drugs
Common medications side effects • Skin reactions, non-inflammatory joint pain (antibiotics) • Muscle weakness/cramping (diuretics) • Muscle hyperactivity (caffeine and medications with caffeine) • Back and/or shoulder pain (NSAIDs;retroperitoneal bleeding) • Hip pain from femoral head necrosis (corticosteroids) • Gait disturbances (Thorazine/tranquilizers) • Movement disorders (anticholinergics, antipsychotics, antidepressants) • Hormonal contraceptives (elevated blood pressure)
Risk Factors for NSAID Gastropathy Back, shoulder, neck, or scapular pain in any client taking NSAIDs in the presence of the following risk factors for NSAID-induced gastropathy raises a red flag of suspicion: • Age (65 years and older) • History of peptic ulcer disease, GI disease, or rheumatoid arthritis • Tobacco or alcohol use • NSAIDs combined with oral corticosteroid use • NSAIDs combined with SSRIs • Chronic use of NSAIDs (duration: .3 months or more) • Higher doses of NSAIDs, including the use of more than one NSAID (dual or duplicate use) • Concomitant infection with Helicobacter pylori (under investigation! • Use of acid suppressants (e.g., HA-receptor antagonists, antacids);
Is Your Client at Risk for NSAID- lnduced Gastropathy? • A g e in years x 2 = • History of NSAID symptomse.g., upper abdminal pain , bloating , nausea,heart burn, loss of appetit,vomiting + 50 points • A R A class; add 0, 10, 20 or 30 based on class • t N S A I D dose (fraction of maximum recommended) x 15 • If currently using prednisone add 40 points • TOTAL SCORE: Risk/year = [Total score - 100] / 40 • Range: 0-5
American Rheumatism Association (ARA) Functional Class • +0 points for class 1 (normal) • +10 points for ARA class 2 (adequate) • +20 points for ARA class 3 (limited) • +30 points for class 4 (unable) ARA Criteria for Classification of Functional Status in Rheumatoid Arthritis: • Class 1 Completely able to perform usual ADLs (self-care, vocational, avocational) • Class 2 Able to perform usual self-care and vocational activities, but limited in avocational activities • Class 3 Able to perform usual self-care activities, but limited in vocational and avocational activities • Class 4 Limited in ability to perform usual self-care, vocational, and avocational activities
Case study: • A 66-year-old woman with a history of rheumatoid arthritis (class 3) has been referred to physical therapy after three metacarpal-phalangeal (MCP) joint replacements. Although her doctor has recommended maximum dosage of ibuprofen (800 mg tid; 2400 mg), she is really only taking 1600/day. She says this is all she needs to control her symptoms. She was taking prednisone before the surgery, but tapered herself off and has not resumed its use. • She has been hospitalized 3 times in the past 6 years for gastrointestinal (GI) problems related to NSAID use, but does not have any apparent GI symptoms at this time. Use the following model to calculate her risk for serious problems with NSAID use:
HISTORY TAKING Anyone in family had similar problem? Any serious illnesses in the family?
HISTORY TAKING • Current smoker? • Past smoker? • How many years? • Cigarettes/ roll-ups / cigars? • How many per day? • Who lives at home – partner? Children? • Stairs at home? • Need help with housework, shopping, cooking? • Do you drink alcohol? • What? Wine? Beer? • How much? • Calculate units/week
 Have you had any fractures or dislocations to your bones or joints?  • Have you been injured in a road traffic accident?  • Have you injured your head? • Have you been in a fight or assault?
Couple of questions for each body system e.g: • Fits, faints, funny turns • Headaches • Vision problems • Shortness of Breath (SOB) • Cough – blood (red flag) • Chest pain • “Heart fluttering” (palpitations) • Ankle swelling • Change in bowel habits – blood (red flag) • Nausea or vomiting • Weight loss – red flag • Change in waterworks • Blood in urine • Menstrual problems • Joint or muscle pain • Skin rashes • Lumps or bumps HISTORY TAKING
 Fill in the HPI  Past medical history  Social history  Family history  Drug history  Review of systems
History taking-2rd lecture
History taking-2rd lecture
History taking-2rd lecture
 Human aging is best characterized as the progressive constriction of each organ system's homeostatic reserve.  "homeostenosis," begins in the third decade and is gradual, linear, and variable among individuals.  Acute confusion , Depression, Falling, Incontinence ,Syncope
 A past medical history of prostate cancer in a 55-year-old man with sciatica of unknown cause should raise the suspicions of the therapist.
 Guillain-Barre syndrome, Any age; history of infection/alcoholism  Multiple sclerosis; 15-50  Rotator cuff degeneration 30+  Spinal stenosis, Men > women 60+  Tietze's syndrome, Before 40, including children  Costochondritis , Women > men 40+  Neurogenic claudication 40-60+
 AIDS/HIV Men > women; 20-49  Burger's disease; Men > women; 20-40 (smokers)  Abdominal aortic aneurysm (hypertensive); Men > women ;40-70  Cancer  Breast cancer; Women > men 45-70 (peak incidence)  Hodgkin's disease; Men > women ;20-40, 50-60  Osteoid osteoma (benign); Men > women; 10-20  Pancreatic carcinoma; Men > women; 50-70  Skin cancer Men = women Rarely before puberty  Gallstones Women > men; 40+  Gout Men > women; 40-59  Gynecologic conditions Women 20-45 (peak incidence)
Male Gender ◦ the presentation of joint pain accompanied by (or a recent history of) skin lesions in an otherwise healthy, young adult raises the suspicion of a sexually transmitted infection (STI). ◦ Osteoporosis ◦ Mortality double after fracture Female gender ◦ hip fracture is equal to her combined risk of developing breast, uterine, and ovarian cancer. ◦ Women of age 26-49 more prone to mental illness.
 When a 55-yearold woman with a significant family of heart disease comes to the therapist with shoulder, upper back, or jaw pain, it will be necessary to take the time and screen for possible cardiovascular involvement.  For women, gender-linked protection against coronary artery disease ends with menopause. At age 45 years, one in nine women develops heart disease. By age 65 years, this statistic changes to one in three women
Clinical Presentation: A 45-year-old obese english woman presents with midthoracic pain that radiates to the interscapular area on the right.  What are risk factors???  If the client had a primary pain pattern with gastrointestinal symptoms, she would have gone to see a medical doctor first.  Physical therapists see clients with referred pain patterns, often before the disease has progressed enough to be accompanied by visceral signs and symptoms. They may come to us from a physician or directly.
 Watch for specific risk factors. In this case, look for the five Fs associated with gallstones:  fat,  fair,  forty (or older),  female, and  fertile .
 When the disease advances, gastrointestinal distress may be reported. This is why it is always important to ask clients if they are having any symptoms of any kind anywhere else in the body.  The report of recurrent nausea, flatulence, and food intolerances points to the gastrointestinal system and a need for medical attention.
HISTORY TAKING THANK YOU

More Related Content

History taking-2rd lecture

  • 2. Listen to the patient he is telling you the diagnosis (william Osler) HISTORY TAKING
  • 3. History taking is experientially acquired task…the only way to learn it… is to do it.
  • 4. Learning objectives • Concepts in communication. • Cultural competence • Basic interview skills. • Patient v/s clinician centered interview. • DO’s and Don’ts of interview
  • 6. • Interviewing is a skill. • Taking medical history can be a challenge. client’s issues • Telescoping: Clients may forget, underreport, or combine separate health events into a single memory,. • Fabricated medical recall that never occurred. • Mental state at time of injury/illness Concepts in Communication
  • 7. Compassion & Caring – Verbally and non verbally – Body language – Sit down and maintain Social distance – Lean forward, nod , encourage – Take notes maintaining adequate eye contact. – Silent attentiveness.
  • 8. Communication style • Individual Differences are there. • Gender based styles • Temprament/ personality based styles • Religon, socioeconomic differences, beliefs and behaviours of both therapist and client. • Cultural differences.
  • 9. Health Illiteracy • The inability to read, understand, and respond to health information • Filling out medical History forms. • Instruction written on medicine bottle. • Read details of exercise form. • minimize the use of medical terminology • Use simple but not demeaning language.
  • 10. Cultural competence • It be defined as the ability to understand, honor, and respect the beliefs, lifestyles, attitudes, and behaviors of others. • As health care professionals, we must develop a deeper sense of understanding of how ethnicity, language, cultural beliefs, and lifestyles affect the interviewing, screening, and healing process.
  • 11. Cultural competence • A 25-year-old African American woman who is also a physical therapist came to a physical therapy clinic with severe right knee joint pain. She could not recall any traumatic injury but reported hiking 3 days ago in the Rocky Mountains with her brother. She lives in New York City and just returned yesterday. A general screening examination revealed the following information: • Frequent urination for the last 2 days • Stomach pain (related to stress of visiting family and traveling) • Fatigue (attributed to busy clinic schedule and social activities) • Past medical history: Acute pneumonia, age • Nonsmoker, social drinker (1-3 drinks/week) • What Are the Red/yellow Flag Signs/Symptoms? • How Do You Handle a Case like This? • Young age • African American • With the combination of red flags (change in altitude, increased fatigue, increased urination, and stomach pain) there could be a possible systemic cause, not just life's stressors as attributed by the client. The physical therapist treated the symptoms locally but not aggressively and referred the client immediately to a medical doctor. Result: The client was subsequently diagnosed with sickle cell anemia. Medical treatment was instituted along with client education and a rehab program for local control of symptoms and a preventive strengthening program.
  • 12. Cultural Competency • Minority Groups • Hindus • Christians • Shias , 12 imam followers or 6 imam followers • Sunnis :various ethnic groups • Courtesy is very important in Asian cultures. Clients may act polite, smiling and nodding, but not really understand the clinician's questions.
  • 13. Cultural Competency in a Screening Interview • •Wait until the client has finished speaking before interrupting or asking questions • •Allow "wait time" (time gaps) for some cultures . • •Be aware that eye contact, body-space boundaries, even handshaking may differ from culture to culture
  • 14. Cultural Competency • In some cultures (e.g., Muslim) information about the client's diagnosis and condition are relayed to the head of the household who then makes the decision to share the news with the client or other family members . • sustained direct eye contact may be considered aggressive behavior in some cultures. • Watch the client's body language while listening to him or her speak • Head nodding and smiling do not necessarily mean understanding or agreement;
  • 15. Cultural competence • Keep comments, instructions, and questions simple and short. • Avoid using medical terms Minority Health's Web site (www.omhrc.gov/clas)." The Council on American-Islamic Relations" or the Muslim American Society. "The APTA offers a wide range of information on cultural competence.
  • 16. The study of patient begins with history HISTORY TAKING
  • 17. Qualities of skilled listener • Can hear the vocal inflection • Understand Non verbal clues • Integrate history and physical examination
  • 18.  Patient complaining of anxiety and he has on first glance bulging eyes and tremors of hyperthyroidism  Examiner would make mental notes to ask for a history of weight loss or family history of thyroid disease and on physical examination would seek confirming signs like rapid pulse and enlarged thyroid
  • 19.  The patient who moves slowly and stifly, speaks monotonically and softly, and has minimal facial expression & tells you that he has swallowing difficulty.  Examiner would need to ask for other parkinsonian risk factors and physical findings such as tremors, cogwheel rigidity and gait abnormalities.
  • 20.  I'm beginning to get an idea of the nature of your problem. Let me ask you some other questions. At this point the interviewer may begin to use closed-ended questions (i.e., questions requiring the answer to be "yes" or "no") in order to characterize the symptoms more clearly.
  • 21.  Open-ended questions  Closed-ended questions  Funnel sequence or technique  Paraphrasing technique
  • 23.  Patient centered interviews  Clinician centered interviews  Combination of both
  • 24. Questioning skills Relationship building skills  Non-focusing skills: ◦ Silence ◦ Nonverbal encouragement ◦ Neutral utterances  Focusing skills: ◦ Echoing ◦ Open ended requests ◦ Summerising/ ◦ paraphrasing  Emotion seeking skills  Direct inquiry  Indirect inquiry ◦ Self disclosure ◦ Impact of the problem ◦ Patients’ explanatory model  Empathy skills(NURS) ◦ Name ◦ Understand ◦ Respect ◦ support
  • 25. Step 1: Setting the stage for the interview(30- 60sec) ◦ Welcome the patient ◦ Use patient’s name ◦ Introduce yourself and identify your specific role ◦ Ensure patient readiness and privacy ◦ Remove barriers to communication. ◦ Ensure comfort and put the patient at ease.
  • 26.  “SALAM/ Good morning(?), Mr. ZAHID(?). I am Dr.ALI, and I will be your doctor today(?). (He may Shakes patient’s hand; positions chair so that he is at the same eye level with the patient(?); closes the door to ensure privacy; and puts the patient at ease with some small talk.) “I hope you had no trouble getting here today(?).”
  • 27.  Indicate time available  Indicate interviewer’s needs  Obtain list of all issues the patient wants to discuss.(chief complaint)  Summerize and finalize the agenda
  • 28.  “We have 15 minutes together(?). I will need about 5 minutes to examine you and go over some of your vital signs(?). But before I do that, I’d like to get a list of what you want to talk about today.…(?)  Is there something else? So you’d like to talk about your headache and get some refills; anything else?”….(?)
  • 29.  State opening question (ok! Tell me about the headache)  Listen attentively for clues to the patient’s personal circumstances…using non focusing questioning skills( remain silent,nodding,lean forward)  Obtain additional data from non-verbal sources (patient’s physical characteristics and appearance)
  • 30.  “Okay, tell me all about the headache.” (Remains silent while the patient talks; nods head, leans forward, and intermittently says “uh huh” to encourage the patient to keep talking. Listens for at least 30 seconds, or longer if the patient is giving a coherent, nonrepetitive story.)
  • 31. Help patient to tell his Bio-psycho-social story( symptom, emotional & personal story)  Obtain the patient’s description of his symptoms/problems(good overview of problem in patient’s own words…avoid CCQ like onset? Duration? Severity?)  Develop personal(work) and emotional context(scared) of patient’s story…focus Q and emotion seeking skills  Expand the patient’s story
  • 32.  Continuing from above, the interviewer focuses on a symptom mentioned by the patient: “You said the headache was really painful….” This invites the patient to expand on the symptom description. Then the interviewer picks up a personal issue mentioned by the patient: “work . . . say more about that….” The interviewer listens for the first opportunity to naturally ask for emotion, “How do you feel about that?” When the patient responds with an emotion (eg, scared), the interviewer NURSes emotion by (1) naming (“scared”), (2) understanding (“I can see how that would be scary.”), (3) respecting (“It’s been a hard time for you.”), and (4) supporting (“Let’s work together to get to the bottom of it.”).  The interviewer then expands on the patient’s story by focusing on another symptom or personal issue previously mentioned by the patient: “You mentioned your son; tell me about him.” The  interviewer continues with cycles of focusing-emotion- seeking-NURS.
  • 33.  Summerize patient centered HPI (review the list of patient’s symptoms, personal and emotional story in 2-3 sentences…you have headache that get worse at work and u r worried about losing your job)  Check accuracy  Ask patient whether it is ok to ask more specific questions.
  • 34.  “You are having headaches that get worse at work and you are worried about losing your job—is that right? Is it okay if I ask you some more specific questions about the headaches?”
  • 35.  Patient centered interview gives you psychosocial information  Clinician centered interview helps u to make diagnosis(e.g. symptom characteristics, family, social history )
  • 36.  The clinician takes charge of the interaction to acquire specific details not provided already by the patient , usually to diagnose disease or to fill in the routine database.  Close ended questions  Open ended questions
  • 37.  7 cardinal features: 1. Onset and chronology 2. Position and radiation 3. Quality 4. Quantification 5. Related symptoms 6. Setting factors 7. Transforming factors Mneumonic OPQQRST
  • 38.  History of presenting illness  Inquire about symptoms in the same body system(focused review of systems)…absence of dyspnea in patient with chest pain weighs against the diagnosis of pulmonary embolism.  Ask about other relevant symptoms…ask for GI bleed in RA patient with fatigue.
  • 39. HISTORY TAKINGHISTORY TAKING Medical conditions Hospitalisations Serious illnesses / injuries Operations
  • 40. HISTORY TAKING Current medications: • Prescribed • Over-the-counter • Name • Dose • Frequency Recreational drugs
  • 41. Common medications side effects • Skin reactions, non-inflammatory joint pain (antibiotics) • Muscle weakness/cramping (diuretics) • Muscle hyperactivity (caffeine and medications with caffeine) • Back and/or shoulder pain (NSAIDs;retroperitoneal bleeding) • Hip pain from femoral head necrosis (corticosteroids) • Gait disturbances (Thorazine/tranquilizers) • Movement disorders (anticholinergics, antipsychotics, antidepressants) • Hormonal contraceptives (elevated blood pressure)
  • 42. Risk Factors for NSAID Gastropathy Back, shoulder, neck, or scapular pain in any client taking NSAIDs in the presence of the following risk factors for NSAID-induced gastropathy raises a red flag of suspicion: • Age (65 years and older) • History of peptic ulcer disease, GI disease, or rheumatoid arthritis • Tobacco or alcohol use • NSAIDs combined with oral corticosteroid use • NSAIDs combined with SSRIs • Chronic use of NSAIDs (duration: .3 months or more) • Higher doses of NSAIDs, including the use of more than one NSAID (dual or duplicate use) • Concomitant infection with Helicobacter pylori (under investigation! • Use of acid suppressants (e.g., HA-receptor antagonists, antacids);
  • 43. Is Your Client at Risk for NSAID- lnduced Gastropathy? • A g e in years x 2 = • History of NSAID symptomse.g., upper abdminal pain , bloating , nausea,heart burn, loss of appetit,vomiting + 50 points • A R A class; add 0, 10, 20 or 30 based on class • t N S A I D dose (fraction of maximum recommended) x 15 • If currently using prednisone add 40 points • TOTAL SCORE: Risk/year = [Total score - 100] / 40 • Range: 0-5
  • 44. American Rheumatism Association (ARA) Functional Class • +0 points for class 1 (normal) • +10 points for ARA class 2 (adequate) • +20 points for ARA class 3 (limited) • +30 points for class 4 (unable) ARA Criteria for Classification of Functional Status in Rheumatoid Arthritis: • Class 1 Completely able to perform usual ADLs (self-care, vocational, avocational) • Class 2 Able to perform usual self-care and vocational activities, but limited in avocational activities • Class 3 Able to perform usual self-care activities, but limited in vocational and avocational activities • Class 4 Limited in ability to perform usual self-care, vocational, and avocational activities
  • 45. Case study: • A 66-year-old woman with a history of rheumatoid arthritis (class 3) has been referred to physical therapy after three metacarpal-phalangeal (MCP) joint replacements. Although her doctor has recommended maximum dosage of ibuprofen (800 mg tid; 2400 mg), she is really only taking 1600/day. She says this is all she needs to control her symptoms. She was taking prednisone before the surgery, but tapered herself off and has not resumed its use. • She has been hospitalized 3 times in the past 6 years for gastrointestinal (GI) problems related to NSAID use, but does not have any apparent GI symptoms at this time. Use the following model to calculate her risk for serious problems with NSAID use:
  • 46. HISTORY TAKING Anyone in family had similar problem? Any serious illnesses in the family?
  • 47. HISTORY TAKING • Current smoker? • Past smoker? • How many years? • Cigarettes/ roll-ups / cigars? • How many per day? • Who lives at home – partner? Children? • Stairs at home? • Need help with housework, shopping, cooking? • Do you drink alcohol? • What? Wine? Beer? • How much? • Calculate units/week
  • 48.  Have you had any fractures or dislocations to your bones or joints?  • Have you been injured in a road traffic accident?  • Have you injured your head? • Have you been in a fight or assault?
  • 49. Couple of questions for each body system e.g: • Fits, faints, funny turns • Headaches • Vision problems • Shortness of Breath (SOB) • Cough – blood (red flag) • Chest pain • “Heart fluttering” (palpitations) • Ankle swelling • Change in bowel habits – blood (red flag) • Nausea or vomiting • Weight loss – red flag • Change in waterworks • Blood in urine • Menstrual problems • Joint or muscle pain • Skin rashes • Lumps or bumps HISTORY TAKING
  • 50.  Fill in the HPI  Past medical history  Social history  Family history  Drug history  Review of systems
  • 54.  Human aging is best characterized as the progressive constriction of each organ system's homeostatic reserve.  "homeostenosis," begins in the third decade and is gradual, linear, and variable among individuals.  Acute confusion , Depression, Falling, Incontinence ,Syncope
  • 55.  A past medical history of prostate cancer in a 55-year-old man with sciatica of unknown cause should raise the suspicions of the therapist.
  • 56.  Guillain-Barre syndrome, Any age; history of infection/alcoholism  Multiple sclerosis; 15-50  Rotator cuff degeneration 30+  Spinal stenosis, Men > women 60+  Tietze's syndrome, Before 40, including children  Costochondritis , Women > men 40+  Neurogenic claudication 40-60+
  • 57.  AIDS/HIV Men > women; 20-49  Burger's disease; Men > women; 20-40 (smokers)  Abdominal aortic aneurysm (hypertensive); Men > women ;40-70  Cancer  Breast cancer; Women > men 45-70 (peak incidence)  Hodgkin's disease; Men > women ;20-40, 50-60  Osteoid osteoma (benign); Men > women; 10-20  Pancreatic carcinoma; Men > women; 50-70  Skin cancer Men = women Rarely before puberty  Gallstones Women > men; 40+  Gout Men > women; 40-59  Gynecologic conditions Women 20-45 (peak incidence)
  • 58. Male Gender ◦ the presentation of joint pain accompanied by (or a recent history of) skin lesions in an otherwise healthy, young adult raises the suspicion of a sexually transmitted infection (STI). ◦ Osteoporosis ◦ Mortality double after fracture Female gender ◦ hip fracture is equal to her combined risk of developing breast, uterine, and ovarian cancer. ◦ Women of age 26-49 more prone to mental illness.
  • 59.  When a 55-yearold woman with a significant family of heart disease comes to the therapist with shoulder, upper back, or jaw pain, it will be necessary to take the time and screen for possible cardiovascular involvement.  For women, gender-linked protection against coronary artery disease ends with menopause. At age 45 years, one in nine women develops heart disease. By age 65 years, this statistic changes to one in three women
  • 60. Clinical Presentation: A 45-year-old obese english woman presents with midthoracic pain that radiates to the interscapular area on the right.  What are risk factors???  If the client had a primary pain pattern with gastrointestinal symptoms, she would have gone to see a medical doctor first.  Physical therapists see clients with referred pain patterns, often before the disease has progressed enough to be accompanied by visceral signs and symptoms. They may come to us from a physician or directly.
  • 61.  Watch for specific risk factors. In this case, look for the five Fs associated with gallstones:  fat,  fair,  forty (or older),  female, and  fertile .
  • 62.  When the disease advances, gastrointestinal distress may be reported. This is why it is always important to ask clients if they are having any symptoms of any kind anywhere else in the body.  The report of recurrent nausea, flatulence, and food intolerances points to the gastrointestinal system and a need for medical attention.