Patient History

Question 1

Examination

Answer 1

Patient history
Physical examination- systems review, tests and measures

Question 2

Patient history

Answer 2

Types of data that may be generated from a patient or client history
Interview
Review medical record
Combination of both

Question 3

Patient history demographics

Answer 3

Age
Referral source
Reason
Occupation

Question 4

Patient history chief complaint

Answer 4

Patient identified problems
Date of injury or diagnosis
Mechanisms of injury
Reason for seeking pt services
Sinss and body chart

Question 5

SINSS

Answer 5

Severity
Irritability
Nature
Stage
Stability

Question 6

Severity - SINSS

Answer 6

Intensity of symptoms as related to functional activity

Question 7

Irritability- SINSS

Answer 7

Time for symptoms to come on and go away

Minimal- tolerates repetitive, sustained activities
Moderate- tolerates brief activities less than 10 min
Maximal - activity not tolerated due to pain or symptoms last greater than 30 min

Question 8

Nature - SINSS

Answer 8

Musculoskeletal vs non musculoskeletal

Type of pain and symptoms
Reflection of systems review and differential diagnosis

Question 9

Stage - SINSS

Answer 9

Time frame with symptoms

Acute pain - recent onset 0-3 weeks
Subacute pain- later stage of healing or early chronicity 3-6 weeks
Chronic pain - extended duration past expected recovery greater than 6 weeks

Question 10

Stability - SINSS

Answer 10

Progressions of patients pain and symptoms over time

Getting better- improving
Staying the same
Becoming worse

Question 11

SINSS consideration

Answer 11

Does it limit you
Does it make patient worse

Question 12

Body chart

Answer 12

Shows Key characteristic of pain
- location
- quality
- depth
- frequency
- relationships between areas of symptoms
- clearing all other areas

Question 13

Location body chart

Answer 13

Documented as P1, P2, P3 with a rating 0/10 scale

Question 14

Quality body chart

Answer 14

Type of symptoms
Aching, numbness, tingling, burning, stabbing, tightness

Question 15

Depth of symptoms body chart

Answer 15

Deep or superficial or indescribable

Question 16

Frequency body chart

Answer 16

Constancy of symptoms
Constant C
intermittent I
variable V

Question 17

Radicular symptoms

Answer 17

Direct stimulation of a nerve root results in a sharp lancinating pain well localized to dermatome

Question 18

Visceral referral

Answer 18

Kidney pancreas, cardiac can mimic or masquerade as musculoskeletal pain

Question 19

Somatic referral

Answer 19

Symptoms that arise from referral of a musculoskeletal structure like a facet joint

Question 20

Red flags

Answer 20

Information that may suggest serious pathology
Should act as a stop sign and decide who a referral should be made to

Question 21

Red flag examples

Answer 21

Unexplained weight loss
Severe pain that is unchanged by position or movement
Changes in bowel or bladder function
Recent, persistent, history of fever, chills, night sweat nausea, or vomiting
Symptoms that a wicked patient at night that are not altered by change in position
Uncontrolled diabetes, hypertension, or eating disorders
Suicide, plans or attempts
Undiagnosed fractures

Question 22

Yellow flags

Answer 22

Factors that increase the risk of poor, prognosis or outcomes
Developing perpetuating, long-term disability
Comorbidities
Continue with interventions and plan of care, but always monitor this

Question 23

Yellow flags examples

Answer 23

Depression, anxiety, fear avoidance
Controlled diabetes, hypertension, and other comorbidities

Question 24

Red flag versus yellow flag

Answer 24

Red flag is a serious pathology or psychosocial factors requiring immediate referral includes emergent medical issues like depression

Yellow flag is a non-emergent condition or psychosocial factor which require caution could be monitored while patient is still being treated may hinder prognosis

Question 25

Cardiopulmonary collection of information

Answer 25

Do you have any heart or lung problems? Ask about hypertension, irregular heartbeat, chest pain, pacemaker, asthma, shortness of breath

Question 26

Endocrine collection of information

Answer 26

Do you often experience fatigue? Common things to ask, include about diabetes, thyroid problems, weight loss, weight gain, fever, chills, sweats

Question 27

Eyes ears nose and throat collecting information

Answer 27

Do you have any trouble with your eyes, ears, nose, or throat? Comment to ask about vision problems, hearing problems, allergies, difficulty swallowing

Question 28

GI GU collection of info

Answer 28

Have you had any changes in your bowel or bladder function? Common ones ask about include bowel or bladder, incontinence, nausea, vomiting, heartburn acid reflux, constipation, kidney problems

Question 29

Hematologic lymphatic info collection

Answer 29

Do you have any problems with your circulation? Common wants to ask about our blood clots, cancer, kidney or liver problems

Question 30

Integumentary information collection

Answer 30

Do you have any moons are open sores? Do you have a skin condition such as eczema or psoriasis?

Question 31

Neurologic info collection

Answer 31

Do you have any numbness or tingling? Common things to ask our stroke, MS, headaches, epilepsy, dizziness, lightheadedness, also, depression, anxiety, and suicidal thoughts

Question 32

Musculoskeletal info collection.

Answer 32

Do you have any problems with your bones are muscles Ask about fractures OA osteoporosis

Question 33

Social history of patients

Answer 33

Support systems Home environment Religious beliefs

Question 34

Current health behaviors

Answer 34

Drinks Smoking Nutrition Sleep Physical therapy Stress level