History Taking History Taking ProcessProcessDX 611 OrthopedicsDX 611 Orthopedics

James J. Lehman, DC, MBA, DABCOUniversity of Bridgeport College of Chiropractic

IntroductionIntroduction

Make eye contact and shake hands

Demonstrate an interest in the patient

A Time to Listen and A Time to Listen and Learn…Learn…

Present time consciousness is essential

Be with the patient

First Impression is a First Impression is a Lasting OneLasting One

Build the doctor/patient relationship

Commence therapeusis

Closed End v. Open End Closed End v. Open End HistoryHistory

Intake forms Interview

Introductory MaterialsIntroductory Materials

Date Age Sex Race/ethnic origin Birthplace Occupation

List the Sources of…List the Sources of…

Referral History Reliability

Main Parts of HistoryMain Parts of History

Chief complaint Present illness Past health history Current health status

Family Psychosocial Review of systems

History Taking ProcessHistory Taking Process

Chief complaint Present illness Past history

Comprehensive v. Limited Comprehensive v. Limited HistoryHistory

Specific complaint Stiff neck Muscle strain Strain

Complicated condition Obese with diabetes Loss of weight and

fatigue Poor response to care

Comprehensive HistoryComprehensive History

Medico-legal Motor vehicle

accident Work related injury

SequenceSequence

Begin with a general question.

Please tell me what brings you into the office?

SequenceSequence

Next, ask direct questions without leading the patient.

Where is the pain? What does it feel

like?

Direct QuestionsDirect Questions

Does the pain move around?

Show me. Point to the pain.

Graded ResponseGraded Response

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

Spinal StenosisSpinal Stenosis

How far can you walk before you have to stop?

Inability to Describe Inability to Describe SymptomsSymptoms

Is your pain burning, aching, sharp, pressure-like, stabbing, shooting, or what?

Avoid ConfusionAvoid ConfusionAsk one question at a time…Ask one question at a time…

You injured your back while lifting a box?

How much did the box weigh?

Avoid Medical Avoid Medical TerminologyTerminology

Use language that the patient can understand.

Try to use their words…

Sensitive QuestionsSensitive Questions

Tobacco Recreational drugs Alcohol Domestic violence Psychiatric

illnesses

Special ChallengesSpecial ChallengesSilence v OvertalkativeSilence 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 HostilityAngry or Hostility

In pain Not in control Frightened Loss of income Tired of waiting

Accept the Feelings Accept the Feelings Defuse the AngerDefuse the Anger

Once the patient calms down, you should continue…

Illiteracy Illiteracy

May have difficulty completing the intake forms

DepressionDepressionIdentify and Explore Identify and Explore

Manifestations Manifestations Fatigue Weight loss Insomnia Mysterious aches

and pains

Neuro-musculoskeletal HistoryNeuro-musculoskeletal History

Onset Palliative/provocative Quality of pain Referred or radiating Severity of pain Timing and treatment

Final QuestionsFinal Questions

Is there anything else that is bothering you?

Final QuestionsFinal Questions

What do you expect me to do for you?

Acute ConditionAcute Condition

Pain is the most outstanding feature Rubor Dolar Tumor Calor

Chronic ConditionChronic Condition

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

History Taking ExerciseHistory Taking Exercise

O,P,Q,R,S,T