Ordinarily, the patient history is obtained in an interview of the patient by the physician. If communication disorders and cognitive deficits are encountered during the rehabilitation evaluation, additional collaborative information must be obtained from significant others accompanying the patient. The spouse and family members are valuable resources. The physician also may find it necessary to interview other caregivers, such as paid attendants, public health nurses, and home health agency aides.
The major components of the history are the chief report of symptoms, history of the present illness, functional history, past medical history, review of systems, patient profile, and family history.
Chief Report of Symptoms
The goal in assessing the chief report of symptoms is to document the patient's primary concern in his or her own words. The report often is an impairment in the form of a symptom that implies a certain disease or group of diseases. The report of “chest pain when I walk up a flight of stairs” suggests cardiac disease, and a report that “ my hands ache and go numb when I drive” hints at carpal tunnel syndrome.
Of equal importance is recognition that a chief report of lost function also may be the first implication of a disability or handicap. The homemaker's report that “my balance has been getting worse and I've fallen several times” may be related to disease involving the vestibular system and to disability created by unsafe ambulation. Similarly, the farmer's declaration that “I can no longer climb up onto my tractor” not only suggests a neuromuscular or orthopedic disease but also conveys to the physician that the disorder has resulted in a handicap by virtue of the patient's inability to accomplish vocational expectations.
History of the Present Illness
The history of the present illness is obtained when the patient tells the story of the medical predicament. All physicians at some time during their medical education have no doubt been admonished to “listen to your patients, for they will tell you their diagnosis” Few maxims are so true. When necessary, patients should be asked to define the specific words they use. It is often surprising to find out what “numbness” or “weakness” really means. Specific questions relating to a particular symptom may also help focus the interview. Using these techniques, the physician gently guides the patient to follow a chronological sequence and to describe fully the symptoms and their consequences.
Above all, the patient should be allowed to tell the story. More than one symptom may be elicited during the interview, and the physician should document each problem in an orderly fashion (Table 1-2) (1).
|TABLE 1-2. Analysis of Symptoms|
1. Date of onset
2. Character and severity
3. Location and extension
4. Time relationships
5. Associated symptoms
6. Aggravating and alleviating factors
7. Previous treatment and effects
8. Progress, noting remissions and exacerbations
A complete list of current medications should be obtained. Polypharmacy is encountered commonly in people with chronic disease, at times with striking adverse effects. Side effects of medications can further impede cognition, psychological state, vascular reflexes, balance, bowel and bladder control, muscle tone, and coordination already impaired by the present illness or injury.
The history of the present illness should include a record of handedness, which is important in many areas of rehabilitation.