History Taking ProcessDX 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

Specific complaint

Stiff neck

Muscle strain

Strain

Complicated condition

Obese with diabetes

Loss of weight and

fatigue

Poor response to care

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 ConfusionAsk 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

DepressionIdentify 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