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