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History taking in physiotherapy
This document provides guidance on effective history taking in physiotherapy. It discusses: - The importance of history taking for diagnosis, disease understanding, and physical exam focus. Trust and active listening are keys. - General guidelines for history taking, including gaining patient confidence, using simple language, and asking open, closed, or leading questions. - Elements to cover in the history such as preliminary data, chief complaint, present and past history, social history, and family history. - Challenges such as sensitive topics, anxious patients, language barriers, and avoiding common pitfalls like disrespecting culture or using confusing terminology. The overall message is that history taking is essential for physiotherapy, and
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History taking in physiotherapy
- 1. HISTORY TAKING IN PHYSIOTHERAPY ShrikantS. Sant. 1st yr. M.P.Th. Community Physiotherapy
- 2. The Value ofHistory Taking Some diseases are diagnosed only by history e.g. angina, epilepsy, migraine, psychotropic diseases Helping knowing the diseased system Helping differential diagnosis Evaluating the severity of the disease
- 3. Directs thefocus of the Physical Exam Often the basis for the differential diagnosis Keys Trust Right Questions Interpreting the responses Knowing what to do next Care begins simultaneously.
- 4. General guidelines Youare like detective do not be fooled by the patient Gain confidence of patient and melt the ice Patient is a living object: culture, emotion… etc Let patient express himself by his own words, be aware of: Lack of accuracy Historian patients ?Talkative Exaggeration of symptoms Aggression and annoyed Worse patients are people who have medical knowledge…. Misleading the diagnosis
- 5. Eye contact& Position at eye level Appropriate distance & position Safety Respect Personal Zone Use simple language to be understood The questions are either: Neutral: e.g. “tell me about what you have” Simple direct questions: “answered by yes or no” Leading questions: “pain before or after meal”.
- 6. Elements of the ComprehensiveHistory Tips for effective history-taking Open-ended questions “What seems to be bothering you today?” Closed-ended questions “Is your chest pain sharp or dull?” Multiple Choice Questions LISTEN ACTIVELY!!! ACT as if you are listening Repeat patient’s statements Clarify if needed Take notes Display your concern Confront with caution
- 7. Structure of History Preliminary data: Age, sex, …. Chief complain: Presenting symptoms Present history: detailed description of the illness Review other systems Past history Personal history: detailed occupation residency.. Etc Family history: similar disease in the family Social history smoking, alcohol, drugs… Summary
- 8. Preliminary Data Name: Age: children diseases, adult, genetic, autoimmune diseases Sex: hemophilia, CAD Marital status: Occupation: chemicals, mental stress Residence: unusual infection Traveling Nationality Religion
- 9. Chief complain Makeit simple, in patient own words At the time of examination Specify the duration No medical terms
- 10. Present History Detaileddescription of illness Analyze the complain in relation to other c/o Chronological sequence Consider the following: Onset: sudden (hrs), acute (1-3 days), sub acute (1- 2W), gradual and insidious.. (overtime) Course (progressive, retrogressive, stationary, fluctuant) Duration: for how long Severity (fro 1-10 score)
- 11. Past History Previousillness, operations, infection… in chronological order Surgery Illness: childhood, parasitic, hepatitis, rheumatic fever, venereal diseases … etc Trauma: fracture, hemorrhage… etc Traveling and residence abroad (immunization) Blood transfusion Pregnancy and prenatal history (German measles)
- 13.
- 14. Personal History Residence, Occupation: occupational hazards Dust: pneumoconiosis Chemicals: metals, insecticidal Physical factors: ionizing radiation, high temperature Infection: cattle, Degree of effort Education Hobbies
- 15. Habits: Tea,coffee, alcohol, tobacco, drugs: Ask about: duration and amount Hours of sleep and exercise Marital history: sex history and pregnancy history
- 16. Social History Economicstatus Housing, malnutrition Social problems
- 17. Family History Numberof patient’s family members Similar disease status Other diseases running the family e.g. IHD Cause and age of death Consanguinity Hereditary Diseases
- 18. Special Challenges SensitiveTopics The Right Location Does anyone present make the patient feel uncomfortable? GainingTrust ChoosingAppropriateWords Understand the patient’s feelings related to the sensitive nature Be Professional
- 20. The SilentPatient Short periods of silence may be normal Allow time to collect thoughts Provide reassurance & encouragement Consider: You have frightened the patient You are dominating the discussion You have offended the patient There is a physical or mental disorder
- 21. The Overly-TalkativePatient Allow patient to speak If necessary, politely interrupt and focus the discussion Focus on most critical issue Ask specific, closed-ended questions Summarize the patient’s story and move on Don’t display your impatience
- 22. The Anxiousor Frightened Patient Look for signs of anxiety or fear Try to alleviate concerns & develop trust No false reassurance “Everything is going to be fine” Identify the source of anxiety/fear Understand the patient’s feelings “I don’t know why you are so anxious’
- 23. The Angryor Hostile Patient Common feelings with stress or fear Understand the source of these feelings Respond in a professional & caring manner Personal Safety is a primary concern!!! Distance Assistance Firm but caring verbal & body language
- 24. The IntoxicatedPatient Irrational Altered sense of right & wrong May become violent If patient is shouting, increased potential for violent behavior listen don’t respond back with shouting have assistance for safety
- 25. The Depressedor Suicidal Patient Know the warning signs Explore the specific feelings of the patient Be direct and specific Question regarding thoughts of suicide or personal harm Talk openly and specifically about suicide plans
- 26. The Patientwith Confusing Behavior or History The entire history does not add up Assess mental status Consider possible dementia or delirium Identify cause if possible Consider specific causes based upon behavior Confabulation Multiple personalities
- 28. The Patientwith a Language Barrier Extremely difficult to assess Enlist friends or family to act as an interpreter Use pre-established questions in the patient’s language Language Lines
- 29. Intelligence &Literacy Does the patient really understand your questioning? History may be inaccurate Enlist friends or family Can the patient actually read? Read statements aloud to the patient
- 30. The Patientwith Sensory Deficits Hearing Impaired Does the patient read lips? Face patient, close to good ear Talk slowly and distinctly Sign language? Will a hearing aid help? Where is it? Blindness Voice and touch are critical Establish relationship & trust early on
- 31. Common Pitfalls Choosingto ask lots of questions to obtain a history WITHOUT also directing initial care or performing a physical exam Patient’s Impression Not doing anything for me Why are we wasting our time here? Stop asking all these silly questions
- 32. Using atone of voice that sends the wrong message “What is your ‘Problem’ TODAY Mrs. Jones? “Why did you call 911?” Patient’s Impression He thinks I call EMS for every little problem I must have called 911 and was not supposed to. I think I am bothering these nice people
- 33. Using atone of voice that sends the wrong message “What is your ‘Problem’ TODAY Mrs. Jones? “Why did you call 911?” Patient’s Impression He thinks I call EMS for every little problem I must have called 911 and was not supposed to. I think I am bothering these nice people
- 34. Lack ofrespect for cultural, religious or ethnic differences “Why do you people use these home herbal remedies?” “You have enough kids. You should consider birth control” Patient’s Impression This person thinks I am a fool She laughs at the traditions of my culture He does not respect my personal decisions
- 35. Poor choiceof words or using technical terms How many years has your husband been taking these ACE-inhibitors? Your wife is experiencing congestive heart failure Patient’s Impression What the heck is he talking about? My wife’s heart is failing?!?! Has her heart stopped yet? Son, could you speak English?