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Flashcards

History Taking Lecture

Calvin Soares Biomechanics and Technique Grado Superior English 37 cards

History Taking Lecture

Cards in this deck (37)

  1. 1BCC Patient Management ProtocolBCC Patient Management Protocol
  2. 2BCC Patient Model for CareBCC Patient Model for Care
  3. 3BPS concerns are summarised with the BCC Flag System1. Red: emergencies / contraindications / adaptations.
    2. Yellow: thoughts, emotions and beliefs toward health. (Toxins)
    3. Orange: significant mental or psychological factors.
    4. Blue: social & financial factors or perceptions related to work.
    5. Black: environmental / physical factors related to work. (sport or
    hobby.)
  4. 4What are you looking for with Red Flags?emergencies / contraindications / adaptations.
  5. 5Patient Management Step by Step• Managing a Patient along their journey requires
    deductive clinical reasoning / critical thinking.
    • One step leads you to the next step down the path.
    • However, the path is not definite – answers or info
    may lead you to explore different routes.
    • Sometimes, these alternate routes lead to dead
    ends and you therefore go back to the original path
    and try a different route.
  6. 6Patient Management Step by Step (Full steps)1. Patient completes Patient Intake form (PIF) & 1º PROM´s. (General)
    2. DC reviews PIF / 1º PROM´s & any other info the patient brought
    3. Conduct a comprehensive patient Hx. (CC, HHx, FHx, BPS Hx)
    4. Working Hypotheses. (WH) (What do you think could be going on? WH used to direct PE.
    5. Patient Examination. (PE)
    6. Referrals, if Necessary. (More blood, xrays, specialist opinion etc)
    7. Clinical Impression. (CI) (BCC Formula)
    8. 2º PROM´s. (More specific to patient.)
    9. Care Plan. (CP) (Chiro tx, freq, duration, goals, BPS recommendations, exercises etc.)
    10. Report of Findings. (ROF)
    11. Execute your CP. Monitor each visit.
    12. Conduct Patient Review & Redo PROM´s.
  7. 7BPS Model: BCC Flag SystemBPS Model: BCC Flag System
  8. 8Patient History Info1. Patient medical history and present condition
    2. Communication tool for the health care team
    3. Quality control and research
  9. 9History Taking Pitfalls1.Patients do not understand the body.
    2.Patients do not know what information is relevant or not
    (how things relate in the body).
  10. 10Overcoming PitfallsUnderstand that most first-time patients have already had unsuccessful treatment elsewhere and are frustrated, skeptical and often anxiety.
    Thus, you need to take a thorough comprehensive history.
  11. 11What are the main General PrinciplesSet the environment – good lighting, comfortable chair, etc
    • Develop a rapport, be friendly.
    • Show interest – be present!
    • Use eye contact.
    • Let the patient tell their story in their words.
    • Actively Listen.
    • Use appropriate language and terms.
    • Mirror their body language – and be aware of yours!
  12. 12What are the second General Principles IIKeep the history flowing.
    • Minimize interruptions.
    • Be empathic and attentive.
    • Be friendly but professional.
    • Don’t give unwanted advice
  13. 13What are the third General Principles IIIBalance open and closed questions.
    • Avoid Leading questions.
    • Ask non-biased questions.
    • Explore vague responses.
  14. 14Patient History ComponentsA. Chief Complaint History (CC Hx)
    B. Patient Health History (Past and Present) (PHx)
    C. Family History (FHx) Childhood Illnesses
    D. Biopsychosocial History (BPS Hx)
  15. 15A. BCC Protocol for CC Hx = LMNOPPQRST• Location
    • Medical Treatments (prior Tx)
    • Number of episodes (prior episodes)
    • Onset (how and what)
    • Precipitating factors (aggravating factors)
    • Palliative factors (relieving factors)
    • Quality of CC (characteristic / description)
    • Radiation (other locations)
    • Severity
    • Temporal
  16. 16L = LocationWhere is the CC?
    • Get the patient to be specific.
    • Point.
    • Ant / Post / Lat / Med?
    • Deep / Superficial?
    • More than one location?
    • Continuous or separate?
  17. 17M = Medical Treatments or TestsPrior Tx, Consults or Diagnostic tests.
    • What consultations, diagnostics or Tx have they already had for their
    CC?
  18. 18N = Number of Episodes• Prior Occurrences.
    • Have they had this before?
    • How many times?
  19. 19O = OnsetWhat happened?
    • When did it begin?
    • Was onset of symptoms immediate or
    delayed?
  20. 20P = Precipitating FactorsAggravating Factors.
    • What makes it worse?
    • What positions?
    • What movement?
    • What activity?
  21. 21Palliative Factors• Relieving Factors.
    • What makes feel better?
    • What positions?
    • Does rest make it feel better?
    • Does medication help? What meds?
  22. 22Q= Quality of PainPain Characteristics.
    • Can you describe your pain?
    • What is Somatic pain?
    • Visceral pain?
    • Neuropathic pain?
  23. 23R= Radiation Pain (often done with Location)Is the pain localized?
    • Does it Radiate out from the
    source?
    • Does it hurt in location not
    directly related to the source?
  24. 24S= Severity: Pain & other Symptoms• Pain is a subjective experience.
    • Pain is based on past experiences of pain, personal biases, cultural factors, gender,
    religion, emotional and cognitive factors.
    • Ask what the level of pain is? (severity)
  25. 25Severity:Severity:
  26. 26T = Temporality• Frequency - Constant, Intermittent, Episodic
    • Duration - How long does each episode last
    • Current Status - Is it getting worse or better? Is it stable?
    FDC
  27. 27Patient Health HistoryComponents of Patient Hx:
    1. Past and Present important Health
    History
    2. Systems Review.
    3. Medication Review.
  28. 28Health History1. General well being
    2. Current Medical Problems
    3. Childhood Illnesses
    4. Injuries
    5. Accidents
    6. Falls
    7. Surgeries
    8. Hospitalizations
    9. Allergies & Sensitivities
    • When? Diagnosed?
    • How presented, symptoms
  29. 29Systems reviewUsually part of your Patient
    intake form.
    • Review answers with patient
    • Organise questions by systems
  30. 30MedicationsWhat medications are they taking?
    • How long have they been taking them?
  31. 31Family HxImmediate family & sometimes
    extended family:
    • Diagnoses
    • Ages.
    • Outcomes.
    • Cause of death.
  32. 32Important family history for chiropractors• History of Cancer
    • History of DM
    • History of Osteoporosis
    • History of Stroke or CVD
    • History of Respiratory Disease
    • History of Arthritides
    • History of Mental Illness
  33. 33D. Biopsychosocial History1. Bio
    2 Psycho
    3. Social
    4. Spiritual
  34. 341. Bio & Lifestyle Health• Diet
    • Hydration
    • Exercise
    • Sleep
    • Vitamins & Supplements
    • Smoker
    • Alcohol
    • Drugs
  35. 352. Psychological Health• Personality type
    • Mental health
    • Emotional health
    • Stress
  36. 363. Social Health & Support• Relationships incl. Marital status
    • Children
    • Occupation
    • Hobbies
    • Community Involvement &
    Network
    • Spiritual health
  37. 374. Spiritual Health & ConnectionSpirituality
    • Connection to the world
    • Centeredness
    • Mindfulness
    • Meaning

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Description
Grado Superior Biomechanics and Technique Flashcards on History Taking Lecture, created by Calvin Soares on 10/06/2022.
Created by
Calvin Soares · Jun 2022
Updated
Jun 10, 2022
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