Patient intake

Chapter 1 Patient intake



Chapter contents



Where to begin?


Outline


Expectations


Humor


Thick-file patients


Unspoken questions


Starting the process


Leading questions

Some key questions

Body language

The physical examination


Clinical reasoning

The therapeutic plan


A summary of approaches to chronic pain problems


Choices: soft tissue or joint focus?


Recording a solid case history, deciphering presenting symptoms and developing a treatment strategy are among the most challenging aspects of any health care practice. Choosing where to begin, knowing where and when not to work, prioritizing elements of the treatment time, and designing a home care program, are just a few of the critical components of a successful manual therapy practice.


As the practitioner begins to classify the (often considerable degree of) detail acquired through the case history, patient interviews, physician reports, manual tests and palpation exams, the process abstractly resembles that of putting together a jigsaw puzzle. The history and interview build the framework of the case, just as the puzzle side pieces frame the picture. Sorting the symptoms into potential categories, such as neurological, orthopedic, nutritional, and habitual use, is as valuable as sorting the puzzle pieces by color, patterns and design. Ideally, one would like to view the box cover to see what the full picture should look like, but, in the treatment room, the situation is seldom that clear. It is often more like holding a plastic bag filled with pieces, with no accompanying box, no idea how many pieces are missing, and possibly a few extra pieces thrown in that have nothing to do with that particular puzzle. How can one possibly have success with this as the starting position?



Where to begin?


This opening chapter will help lay the foundation upon which the treatment strategies will be built. It makes some suggestions regarding the initial sifting and sorting required, in order to make sense of a new patient’s needs. Applying this as a routine sequence, a virtual checklist of what needs to be done, helps to turn a potentially confusing and stressful encounter into one that is reassuring for the patient and vitally helpful for the practitioner.


If the sort of information-gathering exercise outlined below is to be followed, involving a detailed interview as well as a physical examination, adequate time has to be allowed. Not less than an hour, and ideally 90 minutes, should enable this process to be accomplished without any sense of feeling rushed.



Outline


An outline of the intake procedure might include the following, or these might be used as a guideline for designing a written case history form.




Patient profile




• the patient’s name, age and current occupation


• occupational history


• leisure/sporting activities and exercise pattern (if any)


• psychosocial influences (enjoys work, relationships, home life, financial concerns).



Health and family history




• the patient’s previous medical history


• pertinent family history, particularly as it pertains to this condition


• current medications and nutritional supplements


• nutritional habits, sleep patterns and use of alcohol, tobacco, and drugs


• any unusual features (congenital problems, drug reaction history).



Presenting complaint(s)




• the main symptom(s) – including what aggravates the condition, makes it better, what it affects (work, sleep, recreation, relationships, etc.)


• a history of the presenting complaint – etiology (if known)


• a review of the main systems associated with the complaint (musculoskeletal, nervous, endocrine, etc.)


• significant contributing factors.



Prior clinical evidence and previous treatment(s)




• relevant previous medical and CAM history


• investigations/treatment received for this complaint (X-rays, scan, chiro/PT, medical, etc.)


• include diagnosis, prognosis, and results of treatment and self care.



Current clinical evidence and treatment plan




• physical examination, including range of motion, functional assessments, palpation, strength evaluation


• special tests or referral for these


• clinical impression and reasoning


• formulation of a treatment plan and home/self care suggestions.


Much of the above is expanded further within this chapter, with numerous specific ‘key questions’ offered that can be used within the interview or as a written case history. Clinical application of neuromuscular techniques: practical case study exercises, a study guide designed to accompany this textbook and its companion, can assist in the development of skill to usefully apply the information gathered in the above procedures.



Expectations


What do the two parties to a consultation encounter expect? Much depends on the nature of the consultation. If it relates to a simple musculoskeletal problem, the depth of inquiry need not be as great as in the case of someone with, for example, a rheumatic or systemic disease, such as fibromyalgia syndrome or osteoporosis. However, even in apparently simple presentations, such as ‘low back pain’, there are many pitfalls and darker possibilities (see Box 10.1 in Chapter 10, regarding ‘impostor’ symptoms or, as Grieve (1994) calls them, ‘masqueraders’; see also Box 1.1).



Box 1.1 Impostor symptoms


Grieve (1994) has described ‘impostor’ symptoms (see Box 10.1 page 228).




If we take patients off the street, we need more than ever to be awake to those conditions which may be other than musculoskeletal; this is not ‘diagnosis’, only an enlightened awareness of when manual or other physical therapy may be more than merely unsuitable and perhaps foolish. There is also the factor of perhaps delaying more appropriate treatment.


He suggests that we should be suspicious of symptoms which present as musculoskeletal if:



• the symptoms as presented do not seem ‘quite right’; for example, if there is a discrepancy between the patient’s story and the presenting symptoms


• the patient reports patterns of activity which aggravate or ease the symptoms, which are unusual in the practitioner’s experience.


Grieve cautions that practitioners should remain alert to the fact that symptoms that arise from sinister causes (neoplasms, for example) may closely mimic musculoskeletal symptoms or may co-exist with actual musculoskeletal dysfunction.


If a treatment plan is not working out, if there is lack of progress in the resolution of symptoms or if there are unusual responses to treatment, the practitioner should urgently review the situation.


A lengthy, in-depth gathering of information is therefore ideal, if time allows.


The patient is (usually) hoping that his problem(s) will be heard and understood and that helpful suggestions, and possibly treatment, will result. For this to occur, the practitioner needs to be able to listen to, summarize and take notes on the information provided. Ideally, the practitioner should be satisfied that the patient is presenting an accurate history and is answering reasonably, honestly and frankly.


In the first consultation some structured direction and guidance may be called for, to prevent the symptoms, along with the history (often involving multiple life-events and influences), from being presented in a jumbled and uncoordinated manner. The more anxious the patient, the more likely this is to occur. Anxious or not, some patients seem incapable of actually giving direct answers to the questions posed and drift into delivering rambling discourses of what they think the practitioner should know. Care should always be taken when interrupting the patient’s flow; if necessary, this should be done in such a way that it does not inhibit his willingness to discuss his problems. A gentle firmness is needed to redirect the individual. ‘That’s interesting, and I am sure we will have time to discuss it, but so that I don’t lose track of the information I am looking for right now, please answer the last question I asked you.’ Such tactics frequently require repetition until a flow of appropriate responses is achieved. When information is confusing, it is best to seek clarification immediately, with a comment such as, ‘I haven’t quite understood that. Let’s try to make it clearer, so that I am not mistaken, tell me again about…’



Humor


Somewhere in the initial interview humor may be useful and appropriate. Some patients, however, may see this as making light of their undoubted anxieties, so care is needed. In most instances, a carefully moderated sense of fun may be interjected, to lighten the atmosphere and put the patient at ease, although this should never be at the expense of the patient’s dignity.


Attention should also be paid as to whether the patient is using an excessive degree of humor or is constantly joking about his/her condition. This could be a result of being shy about discussion of a physical condition (particularly in more intimate body regions) or to cover hidden emotions from having been ‘dismissed’ by other practices as being ‘psychosomatic’. Although psychological problems can certainly be the root cause or a perpetuating factor in myofascial pain, mysterious symptoms that are often associated with trigger points and other myofascial conditions often baffle practitioners who have no training or skill in treating them. It is easy to dismiss this person as having a problem that is ‘all in the head’, a diagnosis that may significantly affect the attitude and outlook of the patient.



Thick-file patients


The patient who arrives bearing a thick folder, or even a satchel or box, containing notes, records, cuttings and computer print-outs, deserves a special mention. In Europe (and possibly elsewhere) these are often labeled ‘heart-sink’ patients, since this is the effect they may have on the practitioner. Commonly these patients will have been to many other therapists and practitioners and you are probably just one more disappointment-in-waiting, since they seldom seem to find what they are seeking, which is someone whose professional opinion tallies with their perception of what is happening (which may have bizarre elements of pseudoscience embedded in it). Many such patients may be categorized as having ‘chronic everything syndrome’, ranging from fatigue to pain, insomnia, gut dysfunction and a host of other problems, including anxiety and sometimes depression. Some will have been labeled as ‘neurotic’, others may have acquired a diagnosis of chronic fatigue syndrome or fibromyalgia, sometimes appropriately and sometimes not. There are no easy solutions to handling such patients, except to dig deep into the compassion resources that hopefully have not been exhausted.


Conversely, many times this type of patient actually turns out to be a very committed person, who has been consistent in looking for help and has not lost confidence that someone, somewhere can help him. He may have tried everything except soft tissue manipulation. The thick file is a result of a multitude of tests, which have been performed without finding the source of his pain. The missing element in this file may well be a thorough trigger point examination. It is seldom performed in medical examinations and, in the experience of the authors, is very commonly a significant part of this patient’s problem. (Lymphatic drainage is often another key element missing from these files.)


It is important that the manual practitioner should not become discouraged or intimidated by the fact that the patient has already seen a host of physicians (often the ‘best in town’ or those at famous clinics). The fact that there may have been a vast array of negative tests, which have ruled out serious pathologies, should encourage a search for alternative etiological patterns, possibly associated with myofascial trigger points, lymphatic stasis, hyperventilation or any of a number of ‘low-tech’ contributory factors, which have thus far been overlooked. Once treatment of trigger points has been applied to this ‘thick-folder’ patient, who very often has been suffering for many years, pain patterns may resolve very quickly. Although there will indeed be a collection of patients who fit the first description above, the attitude of the practitioner should always be one which offers (realistic) hope and encouragement, especially in the initial and early treatment sessions.



Unspoken questions


One unspoken area of the consultation involves the concerns the patient really wants answered. Seldom said, but always present, are questions such as ‘Will I get better (and, if so, how long will it take)?’ and ‘How serious is this (and, if serious, can you help)?’ It is well established that understanding the nature of the problem, knowing something about its causes and influences is a major therapeutic step forward for the patient. The practitioner’s role should be to educate and reassure (honestly), just as much as to offer treatment. By offering explanations, a prognosis and a plan of action, the practitioner can help to lift the burden. Where there was doubt and confusion, now there is a degree of understanding and hope, but this hope must be grounded in reality and not fiction. This calls for methods of communication between the practitioner and the patient that are clear, non-evasive and not embroidered with fantasy. It also requires a comprehensive grasp of foundational anatomy, physiology, function and dysfunction on the part of the practitioner, in order to be able to confidently (and accurately) convey these details.



Starting the process


‘Where shall I begin?’ is a frequent query when the patient is sitting comfortably and has been asked something such as ‘How can I help you?’ or ‘Why have you come to see me?’ or even ‘Tell me when you were last completely well’. Another approach is to say, ‘Start at the beginning, and from your point of view, tell me what’s causing you most concern, and how you think it began’.


After such a start it is appropriate to ask for a list of current symptoms (‘What’s giving you the most trouble at present? Tell me about it and any other symptoms that are bothering you’). It is useful to ask for symptoms to be discussed in the order of their importance, as the patient perceives things. Following this, a question-and-answer filtering of information can begin, which tries to unravel the etiology of the patient’s problems. During this process it is useful to make a record of dates (of symptoms appearing, life events, other medical consultations/tests/treatments) as the story unfolds, even if not presented strictly chronologically. If the patient has already prepared this in advance, the practitioner should read through the list with the patient as other (and often significant) details may emerge during the discussion.


Whatever method starts the disclosure of the patient’s story, a time needs to come, once the essentials have been gathered, when detailed probing by the practitioner is called for, perhaps involving a ‘system review’ in which details of general well-being, cardiovascular, endocrine, alimentary, genitourinary, nervous and locomotor systems are inquired after (as appropriate to the particular presenting symptoms, for such detailed inquiry would clearly be inappropriate in the case of a strained knee joint but might be important in more widespread constitutional conditions). For the practitioner whose scope of practice and training does not include a comprehensive understanding of these systems, a more generalized inquiry in the form of a case history questionnaire might point to the need to refer the patient to confirm, or rule out, possible contributory problems.



Leading questions


It is important when questioning a patient not to plant the seed of the answer. Patients, especially if nervous, may answer in ways that they believe will please you. Leading questions suggest the answer and should be avoided. See Box 1.2.



Box 1.2 Essential information relating to pain


If pain is involved as a presenting symptom the following information is of great importance.



• Where is the pain? Have the patient physically point out where the pain is experienced, as a comment such as ‘in my hip’ may mean one thing to the patient and quite another to the practitioner.


• Has this happened before or is this the first time you have had this problem?


• If you have had this before, how long did it take to get better (and was treatment needed)?


• How did it start?


• Does the pain spread or is it localized?


• Describe the pain. What does it feel like?


• How long has it been there?


• Is it there all the time?


• If not, when is it present/worst (at night, after activity, etc.)?


• What makes it worse (movement, rest, anxiety, etc.)?


• What eases it (movement, rest, relaxation, etc.)?


An example might involve the patient informing you that ‘My back pain is often worse after my lunch-break at work’. You might suspect a wheat intolerance and inappropriately ask ‘Do you eat bread or any other grain-based foods at lunch time?’ instead of less obviously suggesting ‘Tell me what sort of food you usually have at lunchtime’. And, of course, the increase in back pain may have nothing to do with food at all. Therefore, a more appropriate question might be ‘Is there anything about the lunch-break at work that might stress your back?’. A response that the seating in the café where the patient normally eats is particularly unsupportive of his back could be the reward for such an open query.


Questions need to be widely framed in order to allow the patient the opportunity to fill the gaps, rather than having too focused a direction which leads him toward answers that may be meaningless in the context of his problem or support your own pet theories (wheat intolerance, for example).



Some key questions


The following questions offer considerable and significant information. These can be included in the initial interview or can be presented as an ‘on paper’ interview to be completed prior to the initial visit. The latter option may offer the patient more time to consider a full range of memories that might not surface under the time constraints and pressures of a live interview.



• Summarize your past health history, from childhood, especially any hospitalizations, operations or serious illnesses.


• Have you any history of serious accidents, including those that were not automobile accidents?


• What has brought you to see me and what do you believe I might be able to do for you?


• Have you used or do you now use social drugs?


• Are your parents living?


• If not, what was the cause of death?


• If they are living tell me about their health history. (Note: family history can sometimes be extremely useful, especially regarding genetically inherited tendencies, for example sickle cell anemia. However, more often answers to these questions offer little value.)


• Do you have siblings?


• If so, tell me about their health history. Include any that are deceased, as well as cause(s) of death.


• How often do you catch cold/flu and when was the last time?


• When was the last time you consulted a physician and what was this for?


• Have you ever consulted a physician for an extended time or serious condition?


• Are you currently undergoing any treatment or doing anything at home in the way of self-treatment?


• Are you currently or have you in the past been on prescription medication? If so, summarize these (when, for what, for how long, especially if steroids or antibiotics were involved).


• How long have your current symptoms been present?


• Have the symptoms changed (for better or worse) and, if so, in what way(s)?


• Do the symptoms alter or are they constant?


• If they alter, is there a pattern (do they change daily, periodically, after activity, after meals, associated with phases of the menstrual cycle, etc.)?


• What seems to make matters worse?


• What seems to make matters better?


• Tell me about your sleep patterns, the quality and quantity of sleep.


• Tell me about any of the positions in which it is easy for you to fall asleep, those in which you sleep comfortably or those in which you awake with pain.


• What activities do the symptoms stop you (or hinder you) from doing?


• What diagnosis and/or treatment has there been and what was the effect of any treatment you have received?


• Are you settled and satisfied in your relationship(s)?


• Are there any relationships that are stressful or unfulfilling for you, including family, work and social?


• Would you describe yourself as anxious, depressed, an optimist or pessimist?


• If you are in a relationship tell me a little about your partner.


• Are you settled and satisfied in your home life?


• Are you settled and satisfied in your work/occupation/career or studies?


• Tell me a little about your work.


• Do you have any immediate or impending economic anxieties? Lawsuits?


• Are you satisfied with your present weight and state of general health (apart from the problems you have consulted me for)?


• What are your energy levels like (possibly with supplementary questions such as: Do you wake tired? Do you have periods of the day where energy crashes? Do you use stimulants such as caffeine, alcohol, tobacco, or other drugs, to boost energy? Do you use sugar-rich foods as a source of energy?)?


• Tell me about your hobbies and leisure activities.


• Do you smoke (and if so, how many daily)?


• Do you live, or work, with people who smoke?


• What elements of your life or lifestyle do you think might help your health problem, if you changed them?


• What are the main ‘stress’ influences in your life?


• How do you cope with these?


• Do you practice any forms of relaxation? Meditation? Focused breathing?


• Do you have an interest in spiritual matters?


If the patient is female it is also important to know if she is menopausal, perimenopausal, taking (or has taken) contraceptive or hormone replacement medication (which many do not report when asked about their medication history), is sexually active, has children (if so, how many and what ages and was each labor normal?). If she is still menstruating, information regarding the cycle may be useful, especially in relation to influence on symptoms.


If appropriate, questions can be discreetly asked about eating disorders, mental health and physical or emotional abuse. Unless the patient has freely offered this information in the above questioning, it is often best to postpone questions until a relationship of trust has been established.


Additionally, it is useful to have a sense of the patient’s diet, drinking habits (alcohol, water, coffee, cola, etc.), use of supplements, sleep pattern (how much? what quality? tired or fresh on waking?), exercise and recreation habits and, if appropriate, their digestive and bowel status.


Having the patient fill out a detailed questionnaire ahead of the consultation can certainly save time and assure that many of the basic details are recorded. However, it is it almost always much more effective to hear the answer, because the answer to a question is often less important than the way it is answered.


As questions are asked and answered, it is important that the practitioner avoids even a semblance of judgmental response, such as shaking of the head or ‘tut-tutting’ or offering verbal comments that imply that the patient has done something ‘wrong’. The practitioner is present as a sounding board, a recorder of information, a prompt to the reporting of possibly valuable data. There should be time enough after all the details have been gathered to inform, guide, suggest and possibly even to cajole, but not usually at the first meeting.


It is important that the practitioner be familiar with any listed medications the patient is taking, including potential side effects of those drugs. For instance, some blood pressure medications may induce muscular spasms and when such symptoms are present this may be an indication that the dosage requires modification. Referral to the prescribing physician would then be appropriate. Any anticoagulant (an effect of many pain medications) should be noted, as deep tissue work may cause bruising. For many years a physician’s desk reference, nurse’s guide to prescription drugs or similar handbook was consulted for any medications for which the practitioner was not familiar. Today these handbooks are almost obsolete since the information load changes so frequently that the internet has virtually replaced the printed copies as the most up-to-date reference source.


Similarly, the Merck Manual has always been useful to consult regarding any diagnosed conditions that the patient lists with which the practitioner is unfamiliar. These and other diagnostic handbooks are now available online, at little or no cost, making the latest edition easily searchable and readily available for any practitioner who has internet access. Information about the diagnosis may be of value when formulating a treatment plan or could suggest a contraindication to treatment or at the least flag a need for caution regarding certain procedures (see also Chapter 10, Box 10.1, on impostor symptoms). It is always possible, of course, that a previous diagnosis is not correct but understanding its nature may still offer value to the current analysis.

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Dec 11, 2016 | Posted by in NEUROLOGY | Comments Off on Patient intake

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