• Embed Doc
  • Copy Link
  • Readcast
  • Collections
  • 1
    CommentGo Back
Download
 
PART
IV
P
HYSICAL
E
XAMINATIONOF
P
ATIENTSWITH
H
EADACHE
52835_CH13.qxd 9/11/08 05:49 PM Page 131
 
O
52835_CH13.qxd 9/11/08 05:49 PM Page 132
 
O
133
CHAPTER
13
Clinical Reasoning in theDiagnosis:HistoryTaking in Patientswith Headache
Peter A. Huijbregts, PT, MSc, MHSc, DPT, OCS, MTC, FAAOMPT, FCAMT
ROLE OF HISTORY TAKING INTHE CLINICAL EXAMINATION
In physical therapy, as in other health care professions, there are five el-ements to patient management. The examination is followed by evalu-ation of the examination findings, establishing a diagnosis, producing aprognosis and developing a plan of care, and, finally, performing the in-terventions (American Physical Therapy Association [APTA], 2001). Theexamination element of this process of care usually consists of historytaking, systems review, and tests and measures. Unique to professionssuch as physical therapy with a limited scope of practice, a systems re-view is a brief history and physical examination specifically reviewingthe cardiopulmonary, integumentary, musculoskeletal, and neuromus-cular systems, but also meant to get an impression of a patient’s com-munication ability, affect, cognition, language, and learning style (APTA,2001).Generally, the role of the examination process is twofold. First,intended to be comprehensive with regard to screening and specifictesting, this process ideally leads to diagnostic classification. A second im-portant role of the physical therapy examination and related to the lim-ited neuromusculoskeletal scope of practice of physical therapy is theidentification of problems outside this scope of practice that require a
CHAPTER OUTLINE
Role of History Taking in theClinical ExaminationDemographicsLocation of PainOnset and Course of HeadacheCharacter and Intensity of HeadacheAggravating and Easing FactorsNeurologic SymptomsOtolaryngologic SymptomsSystemic SymptomsMedical HistoryMedication HistoryFamily HistoryPrevious Diagnostic TestsPrognostic IndicatorsSystems ReviewClinical Prediction Rules forDiagnosisOutcome MeasuresPain MeasuresDisability MeasuresRed FlagsConclusion and Implications of History FindingsAcknowledgmentsReferences
52835_CH13.qxd 9/11/08 05:49 PM Page 133
of 00

Leave a Comment

You must be to leave a comment.
Submit
Characters: ...
You must be to leave a comment.
Submit
Characters: ...