MS-Taking the pt hx

kms013's version from 2016-01-31 23:33


Question Answer
Evaluation Components:Hx (subj), examination, assessment, plan
History (subj)chronological record of significant events (Result: --> working hypothesis/Diff Dx)
Examination aa test or battery of tests done for the purpose of obtaining data (Result --> PT (movement) dx
Assessmenta clinical judgement based on the hx and examination
plana detailed intervention plan based on the assessment; includes treatment strategy, frequency, and duration
Pt hx Goal?complete medical/injury hx should be taken and documented to ensure reliability
pt hx requires....effective/efficient communication, the ability to develop a good rapport w the pt, family members, and other members of the health care team (speaking at an understandable level, using appropriate terms for the pt, listening attentively and actively, being empathetic, showing genuine interest and compassion, being professional and respectful
CP: Nobody cares how much you know until...they know how much you care
Pt hx: Keep the pt focused, be "in control" w/o being "controlled" Emphasis shoudl be placed on the portions of the pt hx that has the greatest clinical relevance"often as astute clinican can make a diagnosis by taking a thorough, focused hx, and simply listening to what the pt is telling them
CP: If we ask the right questions...the pt will generally tell us exactly what is going on!
Hx- general info we get...the type of person, the pts preferred language and cognitive ability, the pts ability to articulate, the behavior of the pts injury--the conditions present state, prognosis, and the appropriate tx, the pts feeling about PT
Hx- the clinican should listen for any potential Red flags (signs) that would indicate:the problem is not a MS one or 2. a more serious MS problem that is beyond the scope of a PT (should result in a referral to the appropriate health care professional (DO NOT PROCEED WITH TREATMENT)
Hx- Yellow Flags: the clinican should listen for any yellow flags (signs) that denote problems that may1. be more severe or may involve more than one area requiring a more extensive examination 2. relate to cautions and contraindications to tx that the examiner might have to consider 3. indicate overlying psychosocial issues that may affect tx (PROCEED WITH CAUTION)
Cancer Red flagspersistant p! at night, consistant p! anywhere int he body, unexplained weight loss, loss of appetite, unusual lumps or growths, unwarrented fatigue
Cardiovascular Red flagsShortness of breath, dizziness, p! or feeling of heaviness in the chest, pulsating p! anywhere in the body, constant and severe p! in lower leg (calf) or arm, discolored or p!ful feet, swelling (no hx of injury)
GI Red flagsFrequent or severe abdominal p!, freq heartburn or indigestion, freq nausea or vomiting, change in or problems with bowel and/or bladder fx (UTI), Unusual menstrual irregularities
Micellaneous Red flagsFever or night sweats, recent severe emotional disturbances, swelling or redness in any jt w no hx of injury, pregnancy
Neurological red flagschanges in hearing, frequent/severe headaches w no hx of injury, problems with swallowing or changes in speech, changes in vision, problems with balance, coordination, or failing, faint spells (drop attacks), sudden weakness
Yellow flag findingsabnormal s/s (unusual patterns of complaint, bilateral sx, sx peripheralizing, neurological sx (nerve root or peripheral nerve), multiple nerve root involvement, abnormal sensation patterns (do not follow dermatome or peripheral nerve patterns), saddle anesthesia, upper motor neuron sx (SC) signs, fainting, drop attacks, vertigo, ANS sx, progressive weakness, progressive gait disturbances, multiple inflamed jts, psychosocial stresses, circulatory or skin changes
Hx- basic InfoWhat- basic info used primarily for record keeping/billing purposes...where- intake form and/or referral, name, age, gender, occupation, medical dx, DOI
Age, gender, and occupation considerations...many conditions occur w/i certain age ranges, some conditions primarily or exclusively occur w a certain gender
what is teh pts occupation (questions to ask)what doe the pt do at work? What is the working environment liek? What are the demands (Fxs) postures assumed?, does the pt relate his/her sx to work or are they affected by work?
pt hx componentsHPI (CC), PMH, FH, PH, SH
CCa statement by the pt, or his/her reason or reasons for seeking help (an opportunity for pts to describe in their own words what is bothering them and the extent to which it bothers them) Usually this is a statement of fxl loss reported (usually this is a statement of a fxl loss reported by the pt-- Mrs. Jones, please tell me in your own words what brigns you in today
CP: of CC-- if we ask the right questions...the pt will generally tell us exactly what is going on
HPIoutlines details surround CC (PT will commonly collect a large amt of detailed info related to the present illness esp. when p! is a component of the CC)
Main components of HPIOnset of sx, location of sx, nature of sx, medical testing
DO you use leading questions?NO, AVOID leading questions
HPI-- Onset of Sxwhat was the mechanism of injury (MOI), was the onset of sx sudden/slow, have the s/s stayed the same/changed since the onset (knowledge of these facts helps the examiner start to generate a working hypothesis/diff dix)
p! is ____ and its _____ are unique to each individaulsubjective, manifestation
When tissue has been damaged, substances are released leading to inflammation and ____ of the nociceptores (also called primary hyperalgesia) resulting in localized p!Peripheral sensitization
if the injury does not follow a normal healing pathway and becomes chronic, _______ (also called secondary hyperalgesia) may occurcentral sensitization
___ is a local phenomenon-- site of injuryperipheral sensitization
_____ is more central process involving the CNS (SC and brain) and manifests itself as widespread hypersensitivity to such physical, mental, and emotional stressors as: touch, mechanical pressures, noise, bright light, temperature, medicationcentral sensitization
PMH goalsto ID any sig. probs that occurred in the pts past that may relate to the pts present problem OR may affect the pts current condition in some capacity including intervention (this info usually relates more to the nature of previous related sx and the tx done for those past related problems)
Physicians commonly go into much greater detail in the ____ than PTsPMH
FH primary purposeto determine whether there are any familial diseases that may be related to the pts present problems/
Common FH relatively few familial diseasesRA, developmental abnormalities of the lower extremity, OP, OA
primary purpose of PH and SHto obtain info from the pt related to hisher overall activity level, mental level and physical level of fitness