History and Systems Lecture 3

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History and Systems Lecture 3 by Mind Map: History and Systems Lecture 3

1. Physical Therapy Services

1.1. Chief complaints

1.1.1. Usually: Lower back Shoulder Knee

1.1.2. Questioning should begin with chief complaint What brings you here today? I understand you are having trouble with your knee (or back or shoulder) - is that what brings you here today?

1.2. Follow-up questions

1.2.1. Do the chief symptoms move or spread up, down, or around you?

1.2.2. Can you rate your symptom intensity on a 0-10 scale?

1.2.3. Do you have symptoms anywhere else?

1.3. SINSS

1.3.1. Severity Intensity of the patient's symptoms as they relate to functional activity

1.3.2. Irritability The ease with which the symptoms can be provoked or stirred up 3 components:

1.3.3. Nature of complaint Term describes the clinician's assessment of the following: Hypothesis of: Anything about the problem or overall condition that may warrant caution with the objective examination The character of the presenting patient or the problem

1.3.4. Stage of pathology Stage at which the disorder is presenting Acute Subacute Chronic

1.3.5. Stability Progression of the patient's symptoms over time Is the problem getting better, worse, or staying the same?

1.4. Examination process

1.4.1. Evaluation Phase 1 Refer/consult Diagnose and treat Treat and refer Phase 2 Diagnosis Data organized into defined clusters, syndromes, or categories Prognosis Interventions Outcomes

1.5. Symptom investigation

1.5.1. Subcategories of symptom location and description

1.5.2. History Current or most recent episode Impairment related Traumatic event Accident Repetitive overuse Sustained postural strains Insidious onset? Comparing and contrasting current with past events

1.5.3. Behavior or pattern of symptoms Relationship of symptoms to: Rest Activities Time of day Positions/Postures Constancy Frequency Duration Fluctuations of intensity Symptoms that move or start in different areas Night pain Follow-up questions Other questions Flags Yellow flags Red flags

1.5.4. Symptoms usually related to: Sprain Strain Poor posture Arthritic condition

1.6. Body diagrams

1.6.1. Helpful in noting the exact location of symptoms and describing

1.6.2. Include: Quality Paresthesia Numbness Weakness

1.6.3. Note where the patient does and does not have pain

1.7. Visceral local and referred pain

1.7.1. See slide 11 for diagram

1.7.2. Vascular Throbbing Pounding Pulsating Beating

1.7.3. Neurogenic pain Sharp Crushing Pinching Burning Hot Searing Itchy Stinging Pulling Jumping Shooting Electrical Gnawing Pricking

1.7.4. Visceral Aching Squeezing Gnawing Burning Cramping Colicky

1.7.5. Musculoskeletal Aching Sore Heavy Hurting Deep Cramping Dull