Patient Health History Investigation

Question 1

Patient centered interview

Answer 1

Exploring the patient’s disease/diagnosis and its effect on his or her life.
Understanding the whole person.
Finding common ground regarding intervention or management.
Advocating prevention and health promotion.
Enhancing the patient-provider relationship.
Providing realistic expectations.

Question 2

Goals of Patient history

Answer 2

1. Establishing rapport
2. Identifying any barriers to communication
3. Identifying the patient’s preferred learning style
4. Establishing the patient’s goals for physical therapy
5. SINSS

Question 3

Communication strategies

Answer 3

Ask one question at a time. 
Periodic restatement or summarization. 
Avoid medical jargon. 
Use patient’s line of thought. 
Avoid assumptions. 
Self-assessment.

Question 4

Patients with hearing deficits

Answer 4

1. Utilize a quiet area for the interview.
2. Patient should use hearing and visual aids when available.
3. Clinician should position themselves to facilitate lip reading.
4. Use of interpreter (ASL) may be needed.

Question 5

Angry patients: manifestations

Answer 5

Obvious 
Use of sarcasm or cynicism
Negativity 
Lack of compliance 
Non-verbal forms of communication
Escalation

Question 6

Angry patients: be cautions

Answer 6

Patient tensely moving to the edge of the chair.
Patient tensely gripping the arm rests.
Loud, forceful speech.
Restless agitation, pacing, and inability to sit still

Question 7

Depressed Patients

Answer 7

Impaired concentration. 
Poor compliance with home instructions.
Clinician should acknowledge the situation. 
Explore potential reasons. 
Recognize potential for suicide.

Question 8

Importance of a thorough exam

Answer 8

1. Differential diagnosis.
2. Safe delivery of physical examination.
3. Review patient’s list of medications.
4. Assess potential impact of co-morbidities.

Question 9

Patient Health History Data

Answer 9

1.Patient demographics.
2.Social history
3.Current medical situation
4.Past personal medical history
Illnesses
Allergies
Surgeries
Injuries
Medications
5.Social habits
6.Family medical history.

Question 10

Patient demographics

Answer 10

• Age
• Sex
• Race
• Marital status
• Level of education

Question 11

Information from a body chart

Answer 11

• Area of symptoms … and free of symptoms
• Qualifications of the symptoms
• Chronology of symptoms
• Relationship between symptoms

Question 12

Social History

Answer 12

• Cultural customs
• Religious beliefs
• Occupation and work status
• Living environment
• Family and social support

Question 13

Social Habits

Answer 13

• Exercise: Frequency and Intensity
• Use of tobacco
• Alcohol intake
• Caffeine intake

Question 14

Tobacco

Answer 14

•   Leading cause of preventable death
•   Smoking leads to disease and disability
•   Harms virtually every organ system in the body
•   Primary risk factor/causes:
Cancer
Heart disease
Strokes
Lung diseases
Diabetes
COPD

Question 15

CAGE (alcoholism)

Answer 15

• Have you ever felt you should Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?

Question 16

Caffeine intoxication

Answer 16

• Recent consumption of caffeine (≥ 2-3 cups)
• Multiple typical clinical manifestations
• Distress or impairment in social, occupational, rehabilitation, school, etc.

Question 17

Caffeine symptoms

Answer 17

• restlessness
• nervousness
• excitement
• insomnia
• flushed face
• diuresis
• GI disturbance
• muscle twitching
• rambiling flow of thought or speech
• periods of inexhaustibility
• psychomotor agitation

Question 18

Caffeine withdrawal

Answer 18

• headache
• lethargy
• fatigue
• dysphoric mood
• muscle pain/stiffness

Question 19

Family medical history

Answer 19

o Who in your family has heart/other disease?
o What type of disease do (did) they have?
o At what age was he or she diagnosed?
o What is his or her current health status?
o If the person has died, was it from the heart/other problem, and at what age?

Question 20

Documentation

Answer 20

Medical records 
Patient self-reports 
Screening Questionnaires 
- Red flags
- Yellow flags 
- Pregnancy (when indicated)
- Other