history taking process - ask dr. lehman · 2008. 3. 17. · history taking process dx 611...
TRANSCRIPT
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History Taking ProcessDX 611 Orthopedics
James J. Lehman, DC, MBA, DABCO
University of Bridgeport College of Chiropractic
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Introduction
Make eye contact
and shake hands
Demonstrate an
interest in the
patient
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A Time to Listen and Learn…
Present time
consciousness is
essential
Be with the patient
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First Impression is a Lasting One
Build the
doctor/patient
relationship
Commence
therapeusis
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Closed End v. Open End History
Intake forms
Interview
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Introductory Materials
Date
Age
Sex
Race/ethnic origin
Birthplace
Occupation
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List the Sources of…
Referral
History
Reliability
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Main Parts of History
Chief complaint
Present illness
Past health history
Current health status
Family
Psychosocial
Review of systems
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History Taking Process
Chief complaint
Present illness
Past history
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Comprehensive v. Limited History
Specific complaint
Stiff neck
Muscle strain
Strain
Complicated condition
Obese with diabetes
Loss of weight and
fatigue
Poor response to care
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Comprehensive History
Medico-legal
Motor vehicle
accident
Work related injury
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Sequence
Begin with a
general question.
Please tell me
what brings you
into the office?
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Sequence
Next, ask direct
questions without
leading the patient.
Where is the pain?
What does it feel
like?
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Direct Questions
Does the pain
move around?
Show me. Point to
the pain.
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Graded Response
How long can you
play before you get
the pain in the
back?
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Spinal Stenosis
How far can you
walk before you
have to stop?
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Inability to Describe Symptoms
Is your pain
burning, aching,
sharp, pressure-
like, stabbing,
shooting, or what?
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Avoid ConfusionAsk one question at a time…
You injured your
back while lifting a
box?
How much did the
box weigh?
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Avoid Medical Terminology
Use language that
the patient can
understand.
Try to use their
words…
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Sensitive Questions
Tobacco
Recreational drugs
Alcohol
Domestic violence
Psychiatric
illnesses
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Special Challenges
Silence v Overtalkative Collecting thoughts
Determining trust
Recounting present
illnesses
Check non-verbal
signs
Give free-reign for 5
minutes
Show interest
Ask questions
Focus discussion
Be polite
Re-evaluate goals
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Angry or Hostility
In pain
Not in control
Frightened
Loss of income
Tired of waiting
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Accept the Feelings
Defuse the Anger
Once the patient
calms down, you
should continue…
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Illiteracy
May have difficulty
completing the
intake forms
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DepressionIdentify and Explore Manifestations
Fatigue
Weight loss
Insomnia
Mysterious aches
and pains
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Neuro-musculoskeletal History
Onset
Palliative/provocative
Quality of pain
Referred or radiating
Severity of pain
Timing and treatment
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Final Questions
Is there anything
else that is
bothering you?
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Final Questions
What do you
expect me to do for
you?
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Acute Condition
Pain is the most
outstanding feature
Rubor
Dolar
Tumor
Calor
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Chronic Condition
Pain is no longer
the most
outstanding feature
but stiffness,
weakness, and/or
loss of sensation.
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History Taking Exercise
O,P,Q,R,S,T