Patient Interview Overview

Purpose of the patient interview

 Establish rapport

 Formulate a diagnosis/hypothesis

 Source of symptoms or impairments e.g., joint, muscle, soft tissue, neural

 Determine precautions or contra-indications - depending on irritability & pathology

(if the symptoms can be treated by physiotherapy or if a referral is needed)

 Patient goals & expectations

 Baseline measurement

Patient-centered communication

 Responsive to patient’s needs & values

 Actively includes patient in decision making

 Elicit their understanding of the problem, concerns, expectations, preferences

 Should permeate interview, physical examination, planning interventions, decisions

regarding choice of interventions, outcomes

 Opportunity to address other health problems/behaviours

Forms of good communication

 Consider non-verbal signals & environment

 Attention to seeking reliable answers

 Unambiguous, unbiased questions

o Open & closed questions

o Elaborative probe questions

o Reflecting, summarizing, clarifying questions

 Not every question will need to be asked to the same depth

 • Open questions

 “What can I do for you today?”

 “Now, is there anything else you wanted to discuss?”

 “Are there any other areas of pain you haven’t mentioned” Good for getting started
or at the end of the interview

 • 90 second rule

 • Closed questions

 “Have you noticed any giving way when walking?”

 “Does it hurt at night?”

 To gain control and ensure specific questions are addressed

 • Elaborative probe questions

 ”How does your wrist pain affect your work?”

 “Have you ever had this problem before?”

 • Reflecting/summarizing/paraphrasing/clarifying questions
  • “So your pain starts in your knee and travels into your calf”

 • “I’ve noticed the pain is worse in the evenings on the days you sit for long periods”

The process

 Semi-structured interview

 90 second rule – give patient opportunity to give their account of their problem
unhindered

 Range of interview strategies

 Recording of information

 Identify (asterisk) key information

 Consider if the features fit, the value of information gathered

Key sections of patient interview

1. Main problem & perceived disability

2. Body chart – site/type of symptoms
3. Behaviour of symptoms
4. History (current + previous)
5. Medical screening
6. Social screening

ICF framework of health and disability

• Must consider all factors capable of having an impact on a person’s health

 In body chart, report:

1. Area of the symptoms (doesn’t always identify the structure at fault, it can also be
referred pain from another part of the body)
2. Symptom type – pain, numbness, etc.
3. Quality of pain – dull, throbbing, sharp, shooting
4. Any other symptoms – numbness, stiffness, instability, clicking, locking
5. If the symptoms are constant (all the time) or intermittent (come and go)
6. Depth of the pain – superficial (surface of the skin) or deep (deep inside)
7. If the pain radiates or not (is it localized or travelling further away)
8. If more than 1 area of symptoms -> denote as Pa and Pb
o Pa = pain a = main problem area
o Pb = pain b = second area of problem
9. If PA and PB are related/come together or if they are separate issues
10. Tick proximal areas when they are cleared
11. Regional special questions – p&n (pins & needles), numbness, locking, clicking, giving
way, instability etc.

Behavior of symptoms (BOS)

 Aggravating and easing activities - aggravating and easing factors should be

determined for each symptomatic area. This helps to determine the relationship
between symptoms

 Severity & irritability

 24-hour pattern of pain/symptoms – am, throughout day, night

 Daily activities

 Stage of condition – is the condition getting better, getting worse or remaining the
same

Common aggravating factors

Region/Structure Functional activity Analysis of activity

Temporomandibula Yawning Depression of mandible
r joint Chewing, talking Elevation/depression of mandible

Headaches Stress, eye strain, noise, excessive

eating, drinking, smoking, inadequate
ventilation, odors

Cervical spine Reversing the car Rotation

Sitting reading, writing Sustained flexion

Thoracic spine Reversing the car Rotation

Deep breath Extension

Shoulder Tucking shirt in, fastening bra Hand behind back

Lying on shoulder Joint compression
Reaching up Flexion

Elbow Eating, gripping Flexion/extension

Carrying Distraction
Leaning on elbow Compression

Forearm Turning key in a lock Pronation/supination

Wrist/hand Typing/writing Sustained extension

Gripping, power gripping Extension
Power gripping with twist Ulnar deviation and pronation /
Turning a key supination
Leaning on hand Thumb adduction with supination
Compression

Lumbar spine Sitting, lifting, stooping (bent) Flexion

Standing, walking Extension

Sacroiliac joint Standing on 1 leg Ipsilateral upward shear, contralateral

Turning over in bed, getting out of bed, downward shear
walking Nutation/counternutation of sacrum

Hip Squat Flexion

Walking, stairs Flexion/extension
Side-lying with painful hip uppermost Adduction and medial rotation

Knee Squat Flexion

Walking, stairs Flexion/extension

Foot and ankle Walking, running Dorsiflexion/plantarflexion,

inversion/eversion
Muscular tissue Contraction of muscle, passive stretch of
muscle

Nervous tissue Passive stretch or compression of

nervous tissue

Body chart example

Irritability

 Degree to which symptoms increase & reduce with provocation

 Can be classified as: low, moderate, or severe
 Based on 3 criteria:
1. Severity of symptoms
2. How much activity to initiate pain?
3. What is required to reduce the pain (and how long)? - If symptoms take a few
minutes or more to disappear then the symptoms are irritable

Purpose =
o To identify patients who won’t be able to tolerate a full physical examination
o To determine how vigorous an examination can be performed
Latent irritability =
o Happens occasionally when a movement or position induces symptoms that are
delayed by some minutes and often continue for a considerable length of time.
o Careful management is required to avoid unnecessary exacerbation

Patient Interview - Process & Questions

1. Main problem

- What brings you in today?

- Now, is there anything else you wanted to discuss?
- Are there any other areas of pain you haven’t mentioned? - good for getting started
or at the end of the interview
Actively listen to patient for 90 seconds without interrupting (90-second rule)

2. Body Chart

Now I will ask you a few questions to get a good understanding of what you are feeling,
where you are feeling it and when you are feeling it.

- Can you tell me about your symptoms?

- Where are your symptoms?
- What type of symptoms are you experiencing?
- How would you describe your pain?
- Do you experience those symptoms all day long or do they come and go throughout
the day?
- What number best describes the intensity of your pain, where 0 is no pain and 10 is
worst imaginable pain?
- Is the pain deep down or is it on the surface? Is it a radiating pain?
- Do you have symptoms all the time?
- Do these symptoms occur separately?
- Do you have any pins and needles, tingling, weakness, numbness or other unusual
sensations?
- Do you have any symptoms anywhere else?
- Does your first pain exacerbate your second pain?
 3. Behavior of symptoms (BOS)

- Is there anything that you do that makes your symptoms worst/better?

- How is your pain first thing in the morning?
- What are your symptoms like throughout the day/by the end of the day?
- Do you have difficulty getting to sleep because of your pain?
- Which positions are most comfortable or uncomfortable?
- Are you woken by symptoms, and if so how many times?
- Can you get back to sleep?
- How long does it take to get back to sleep?

4. History – Hx

Current History – CHx

- When did you first notice the symptoms?

- What symptoms did you notice first?

- Was there a sudden or slow onset?

- Was there a known or unknown cause that provoked the onset of symptoms e.g.
trauma or change in lifestyle?

- What did you do? Any treatments & effects?

- How has it progressed (same, better, worse)?

Previous History – PHx

- Have you had any previous experiences like this?

- Can you describe what was your first episode like in detail?

- What caused it/contributed to it?

- How many episodes?

- Is it the same each time?

- Are you 100% between episodes?

- Any previous treatment & effects?

5. Screening

Screening – Social
 - How old are you? What is your occupation?
- Do you have any family responsibilities?
- What kind of leisure and physical activities do you do?
- What do you think is causing your symptoms?

 Age, occupation, family responsibilities

 Leisure & physical activities

 Perspectives/experiences/expectations

- Does it impact your ability to work/do daily activities?

- Have you had time off work because of your problem?

- What are you doing to cope with your pain?

- What do you understand to be the cause of your problem?

- What are you expecting will help you?

Screening – Medical

Questions about patient’s general health:

- Do you have any history of THREADS? – Thyroid, Heart, Rheumatoid Arthritis,

Epilepsy, Asthma, Diabetes
- Do you take any medications?
- Have you had any previous surgeries?
- Do you have any family history?
- Have you had a loss of appetite or unexplained weight loss/gain?
- Do you have any night pain?

At the end of the patient interview

 Reconfirm briefly with the patient your understanding of their main complaint

 Offer opportunity to add anything

 Highlight (asterisk) key information for further examination, treatment or

reassessment

 Identify if information is missing

 Do the features fit?

  Are there any other areas of pain you haven’t mentioned? - good for getting started
or at the end of the interview

Patient Interview - Red & Yellow Flags

Red flags

Features that may alert the presence of serious but relatively uncommon
conditions/diseases requiring urgent evaluation

 Constant progressive, non-mechanical pain (an underlying non-musculoskeletal

condition provoking the pain; no relief with bed rest)

 Thoracic pain

 PHx of malignant tumor

 Age of onset <20 or > 55 years

 Violent trauma

 Prolonged use of corticosteroids

 Drug abuse, immunosuppression

 Fever

 Systematically unwell

 Unexplained weight loss

 Widespread neurology

 Structural deformity

Yellow flags

 Emotional or social factors affecting a patient’s thoughts

 A belief that pain is harmful

 Fear avoidance behavior

 Low mood and social withdrawal

 Expectation that passive treatment rather than active participation will help
In the first 90 seconds we want to ask
1. why they came
1. how it is affecting them on a day to day basis
a. What can't they do
2. what would they like to achieve out of physiotherapy
i. If they don't get them talking you can ask…..
1. Can go into general screening questions if they aren't talkers
a. Age, occupation etc.
3. Yellow flags
• P+N
• Stiffness
• instability
• How do you cope with the pain? Etc.
• Clearing other joints
1. Body chart
• Where the pain is
• Deep/superficial
• Can you describe the pain
• How bad is the pain right now out of 10?
• How bad can the pain be out of 10?
• Clearing questions again
1. BOS
• Aggs and eases
• How quickly does it come on
• How quickly does it take to settle
• Does it affect your sleep/wake you up?
1. History
• CHx
◦ When did you first notice the symptoms?
◦ Was there something that provoked it?
◦ Can he remember having an injury at the time of symptom onset
◦ When did you start/stop an activity
◦ Duration, intensity, volume of activity
• Gym/golf when did you start? how often do you play? What is your routine
like? Have you had a break?
◦ If the injury was acute
• Mechanism of injury (MOI) how it happened, direction, speed etc.
• How was it treated
• PHx
◦ Have you had any previous experience of the injury?
◦ If so, what are the details of that injury/s
• How many of these injuries have you had?
• Is it the same each time?
• Previous treatments
1. Screening
◦ GHx
• existing health conditions
• Medication
• Previous injuries
• THREADs
▪ Thyroid
▪ Heart
▪ Rhematoid arthritis
▪ Epilepsy
▪ Asthma
▪ Diabetes
◦ Tell me more about your job
◦ Tell me more about your living situation
◦ Tell me more about your sports
◦ Stress levels? Coping strategies?
2. Wrapping up
a. What are you expecting to happen to your shoulder?
b. Is there anything you would like to ask?