Foundation of the Physical Therapy Healthcare Process(Part 4)
January 9th 2008 05:30
In taking down medical notes, we do away with the use of nonprofessional terminologies. Instead, we use medical terminologies to describe the different anatomical features of the body. Below are examples of common medical terminologies we use in practice (Marieb).
• Anterior- front
• Posterior-back
• Abdominal- anterior body trunk inferior to ribs
• Antecubital- anterior surface of the elbow
• Axillary- armpit
• Brachial- arm
• Buccal- cheek
• Cervical- neck
• Cephalic- head
• Gluteal- buttocks
• Lumbar- low back
• Umbilical- navel
There are other terminologies we need to learn. They were not included in this module. And so looking up for them may become useful in our future discussions.
History Taking
The patient’s medical history, as well as his or her family’s, is very important in order for us to be guided with our examination. A spontaneous interview with the patient may reveal the history of his/her present illness, past medical history, and family history, and even the patient’s personal-social-environmental background. However, if the patient has the inability to communicate effectively because of cognitive problems, we may have to rely with what his/her family has to say.
Nevertheless, history taking does not stop there. A good clinician may also be observed to investigate the patient’s workplace and other types of environment where the patient is exposed. We have to remember that the patient’s environment may determine a patient’s disease process.
Prior to history taking, it is important that we take note of the patient’s general information. This includes his/her name, address, gender, age, civil status, handedness, occupation, religion, and a physician’s diagnosis of his/her current condition (if there is any). It is also important to take note of the dates when the patient was referred to us, or when the patient was admitted, or when the patient undergone initial evaluation. These details are important because it should affect the manner we deal with our patients. And so if we know that a patient belongs to a conservative religion, in which interaction with the opposite sex may be limited, then we may do something about the issue (e.g. a female patient has to be attended by a female physiotherapist). The age and the gender of an individual may also give us an idea on the course or prognosis of a patient’s condition, or a patient’s predisposition to diseases. A patient’s civil status may give us an idea on the type of support system a patient has. Handedness and occupation give us a clue on how functionally compromised our patient is.
In taking the patient’s history of present illness (HPI), we investigate on the incidents that lead to the patient’s current condition. It is ideal to ask first: when did the present condition started?; what did the patient manifest?; was it immediate or did it take a long time before a patient had a full blown manifestation of the condition?; what were the last activities of the patient before he/she actually feel the symptoms?; what did the patient or the family do after the attack?; did they immediately seek medical advise?
After knowing the answers to the above questions, we then organize the information in a paragraph or two. However, remember, our presentation of the HPI should be free from any unnecessary adjectives or adverbs. It is inappropriate that we write in our chart phrases like: “the patient was overwhelmed by his laborious task and so he felt these numerous symptoms”.
It is also important to review a patient’s past medical history (PMHx). This may help us uncover causes or predispositions of individuals to his/her current condition. This may tell us a story on how a patient actually got the disease or lesion. And for this same reason, we try to discover the medical history of his/her parents/family.
It is important to remember that all of the things we ask to our patient and the family should have bearings on the case at hand. Otherwise, we need to stop asking irrelevant questions.
• Anterior- front
• Posterior-back
• Abdominal- anterior body trunk inferior to ribs
• Antecubital- anterior surface of the elbow
• Axillary- armpit
• Brachial- arm
• Buccal- cheek
• Cervical- neck
• Cephalic- head
• Gluteal- buttocks
• Lumbar- low back
• Umbilical- navel
There are other terminologies we need to learn. They were not included in this module. And so looking up for them may become useful in our future discussions.
History Taking
The patient’s medical history, as well as his or her family’s, is very important in order for us to be guided with our examination. A spontaneous interview with the patient may reveal the history of his/her present illness, past medical history, and family history, and even the patient’s personal-social-environmental background. However, if the patient has the inability to communicate effectively because of cognitive problems, we may have to rely with what his/her family has to say.
Nevertheless, history taking does not stop there. A good clinician may also be observed to investigate the patient’s workplace and other types of environment where the patient is exposed. We have to remember that the patient’s environment may determine a patient’s disease process.
Prior to history taking, it is important that we take note of the patient’s general information. This includes his/her name, address, gender, age, civil status, handedness, occupation, religion, and a physician’s diagnosis of his/her current condition (if there is any). It is also important to take note of the dates when the patient was referred to us, or when the patient was admitted, or when the patient undergone initial evaluation. These details are important because it should affect the manner we deal with our patients. And so if we know that a patient belongs to a conservative religion, in which interaction with the opposite sex may be limited, then we may do something about the issue (e.g. a female patient has to be attended by a female physiotherapist). The age and the gender of an individual may also give us an idea on the course or prognosis of a patient’s condition, or a patient’s predisposition to diseases. A patient’s civil status may give us an idea on the type of support system a patient has. Handedness and occupation give us a clue on how functionally compromised our patient is.
In taking the patient’s history of present illness (HPI), we investigate on the incidents that lead to the patient’s current condition. It is ideal to ask first: when did the present condition started?; what did the patient manifest?; was it immediate or did it take a long time before a patient had a full blown manifestation of the condition?; what were the last activities of the patient before he/she actually feel the symptoms?; what did the patient or the family do after the attack?; did they immediately seek medical advise?
After knowing the answers to the above questions, we then organize the information in a paragraph or two. However, remember, our presentation of the HPI should be free from any unnecessary adjectives or adverbs. It is inappropriate that we write in our chart phrases like: “the patient was overwhelmed by his laborious task and so he felt these numerous symptoms”.
It is also important to review a patient’s past medical history (PMHx). This may help us uncover causes or predispositions of individuals to his/her current condition. This may tell us a story on how a patient actually got the disease or lesion. And for this same reason, we try to discover the medical history of his/her parents/family.
It is important to remember that all of the things we ask to our patient and the family should have bearings on the case at hand. Otherwise, we need to stop asking irrelevant questions.
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