PT EVAL | MODULE 4

HISTORY TAKING CHIEF COMPLAINT

• Demographic Information - The symptom or concern that
- Pt’s name caused the pt to seek medical
- Address treatment
- Date of birth
- Sex Most common chief complaints
- Dominant hand seen in an outpatient physiatric
- Race practice:
- Ethnicity >Pain, weakness, gait
- Language disturbance of various MSk or
- Educational level neurologic origins
- Advance directive preferences
- Referral Pt can present w/ several related or
- Source unrelated complaints, in w/c case it’s
- Reasons for referral to therapy helpful to have the pt rank problems
from most bothersome to least
• General Information bothersome.

Ex of chief complaint:

Age – most common primary risk
factor for diseases, illnesses, & other
comorbidities
*Sherman diseases: growth disorder
that occurs in adolescence/teens
*Osteoarthritis & OP: older population
Gender – some cancers are prevalent
in men: prostate & bladder cancer;
women: cervical & breast cancer
Race – Black men have higher risk in
hypertension & heart diseases than
White men
PATIENT GOALS
Includes:
- Patient/client goals
- Sometimes family goals for
therapy as told to the therapist
by the pt/client or
family/caretaker in cases where
the pt can’t speak for him
- More of a generalized goal
Ex.
Pt’s goal: To be relieved of Sx, finish
chores efficiently & to generally have a
healthy spine
HISTORY OF PRESENT ILLNESS
- Details the C/c for w/c the pt is
seeking medical attention, as
well as any related or unrelated
functional deficits
PT EVAL | MODULE 4

- Primarily relates the sequence 9. Jt locking or giving way?

of events from the onset of a 10. Did u experience sudden
health problem to the time that fainting, bilateral spinal cord
is relevant to the case symptoms?
Includes: 11. Color of the limb?
• Onset date of the problem 12. Experience stress?
• Any incident that caused or 13. Ancillary procedures
contributed to the onset of the done?
problem 14. Medications received?
• Prior history of similar problems
• How the pt is caring for the problem Ex.
(aggravating & relieving factors)
• What makes the problem better &
worse
• Any other practitioner the pt is
seeing for the problem

HPI is not used to arrive at a MEDICAL

DIAGNOSIS
26.31
HPI is used in PT to:
- Elicit info that will benefit the PT
- Identify problems & anticipate
progression or
regression/complications
- Serve as a guide in setting
realistic goals
- Prognosticating the functional
outcomes & rehab potentials of
the pt
- Support the clinical findings
seen in the pt
*Can be used to know the pt’s pre-
injury status

Guide Questions:
1. What is the mechanism of
injury?
2. Onset of the problem?
3. Signs & Symptoms?
4. Movements of position that
aggravates & relieves the
symptoms?
5. Duration of the problem?
6. Is the problem a recurrence?
7. Injury to other jts near the
problem?
8. Quality of symptoms?