Outpatient Interview

Methods of obtaining health history

Methods of obtaining health history

patient interview, medical record review, self report screening tools

components of health history

demographics, social history, general health status, past medical history, history of present condition, chief complaint/symptoms, functional limitations, goals

what pain questions should you ask?

behavior/quality of pain, what makes it better or worse, location

What does SINSS stand for?

severity, irritability, nature of complaint, stage, stability

what is the typical pain behavior curve after injury? can this be different person to person?

pain peaks shortly after injury and then begins to decrease again over time, yes

what are the 3 ways to manage a patient case?

treat, treat and refer, or refer

when should you refer

if you suspect the patient has a healthcare condition that cannot be managed by
PT at this time or a serious health concern

symptoms or possible indicators of serious pathology

red flags

what is required when a red flag is present?

referral to a physician or healthcare provider

common cancer red flags

Persistent night pain, unexplained weight loss, unusual lumps, unwarranted fatigue

common cardiovaascular red flags

SOB, dizziness, chest pain, discolored feet, unexplained sweeling

common GI/urinary red flags

Frequent abdominal pain, heartburn, nausea/vomiting, altered bladder function

common neurological red flags

altered hearing, frequent headaches, vision problems, balance/coordination issues, fainting spells, sudden weakness

Screening questions to identify flags

feelings of depression? feel unsafe at home? any of the following symptoms?

psycological factors like fear anxiety and depression that may affect prognosis and rehabilitation treatment decision making

yellow flags

When is it appropriate to treat and refer?

identification of medical problems, existing medical conditions, outside scope of PT practice and could benefit from other providers