History Taking Process DX 611 Orthopedics James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic

Introduction Make eye contact and shake hands Demonstrate an interest in the patient

A Time to Listen and Learn… Present time consciousness is essential Be with the patient

First Impression is a Lasting One Build the doctor/patient relationship Commence therapeusis

Closed End v. Open End History Intake forms Interview

Introductory Materials Date Age Sex Race/ethnic origin Birthplace Occupation

List the Sources of… Referral History Reliability

Main Parts of History Chief complaint Present illness Past health history Current health status Family Psychosocial Review of systems

History Taking Process Chief complaint Present illness Past history

Comprehensive v. Limited History Complicated condition Obese with diabetes Loss of weight and fatigue Poor response to care Specific complaint Stiff neck Muscle strain Strain

Comprehensive History Medico-legal Motor vehicle accident Work related injury

Sequence Begin with a general question. Please tell me what brings you into the office?

Sequence Next, ask direct questions without leading the patient. Where is the pain? What does it feel like?

Direct Questions Does the pain move around? Show me. Point to the pain.

Graded Response How long can you play before you get the pain in the back?

Spinal Stenosis How far can you walk before you have to stop?

Inability to Describe Symptoms Is your pain burning, aching, sharp, pressure-like, stabbing, shooting, or what?

Avoid Confusion Ask one question at a time… You injured your back while lifting a box? How much did the box weigh?

Avoid Medical Terminology Use language that the patient can understand. Try to use their words…

Sensitive Questions Tobacco Recreational drugs Alcohol Domestic violence Psychiatric illnesses

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

Angry or Hostility In pain Not in control Frightened Loss of income Tired of waiting

Accept the Feelings Defuse the Anger Once the patient calms down, you should continue…

Illiteracy May have difficulty completing the intake forms

Depression Identify and Explore Manifestations Fatigue Weight loss Insomnia Mysterious aches and pains

Neuro-musculoskeletal History Onset Palliative/provocative Quality of pain Referred or radiating Severity of pain Timing and treatment

Final Questions Is there anything else that is bothering you?

Final Questions What do you expect me to do for you?

Acute Condition Pain is the most outstanding feature Rubor Dolar Tumor Calor

Chronic Condition Pain is no longer the most outstanding feature but stiffness, weakness, and/or loss of sensation.

History Taking Exercise O,P,Q,R,S,T