Patient Clinical History

Original Editor - Kim Jackson

Top Contributors - Kim Jackson, Jorge Rodríguez Palomino, Ahmed M Diab and Stacy Lawrence  

Introduction

When a patient presents in clinic it is important to carry out a comprehensive and systematic assessment to fully understand their symptoms and problems. The patient’s clinical history provides valuable information that helps to confirm the diagnosis of various conditions that affect movement and function, such as joint disorders, muscle injuries, and nerve dysfunction. By carefully examining both the nervous and musculoskeletal systems, physiotherapists can:

• Identify abnormalities
• Assess the severity of the condition
• Determine an effective treatment plan

The assessment also plays an important role in tracking the patient’s progress, ensuring that the treatment plan remains effective and is adjusted as needed.

General Principles of Assessment

Conducting a neuromusculoskeletal assessment requires following several key principles to ensure the process is effective and patient-centred:

1. Patient Comfort: Ensure the patient is comfortable and relaxed throughout the assessment. This helps in obtaining accurate findings and encourages patient cooperation.
2. Informed Consent: Before beginning any assessment, explain the procedures to the patient and obtain informed consent.
3. Standardised Approach: Use a consistent and standardised method for all assessments to maintain reliability and comparability of results. This helps in creating a baseline for future assessments.
4. Good Communication: Maintain clear, empathetic communication with the patient, explaining each step of the assessment, what you are looking for, and why it is being done. Good communication helps to build trust and rapport.
5. Safety First: Always prioritise patient safety. Be mindful of any movements or tests that could exacerbate symptoms or cause discomfort. Adjust your approach based on the patient's responses and feedback.

Initial Interview

Patient Identification and Demographics

This section provides essential identifying information about the patient. It’s important for record-keeping, contacting the patient, and in case of emergencies. It also gives a quick snapshot of basic patient characteristics that might influence care decisions.

• Full Name. Example: John Doe
• Date of Birth (Age). Example: February 15, 1980 (43 years old)
• Gender.  Example: Male
• Contact Information. Example: Primary Phone: (555) 123-4567; Email: [email protected]
• Emergency Contact. Example: Jane Doe (Spouse), Phone: (555) 987-6543
• Occupation. Example: Electrician (relevant to potential health risks; for instance, electricians may face injury risks)
• Family Status. Example: Married, two children (ages 8 and 12) (provides context for genetic conditions, household stress, etc.)
• Address. Example: 123 Maple Street, Springfield, IL 62701 (useful in emergencies or assessing environmental health risks)
• Ethnicity (if relevant). Example: Hispanic (can help identify genetic predispositions or health disparities)

The Subjective Assessment

The subjective assessment involves gathering detailed information from the patient about their symptoms and medical history. This step helps form the basis for the physical examination and guides the therapist in identifying potential problem areas.

History of Present Condition (HPC)

The patient describes his problem and the issues he is experiencing in his own words. This section captures the patient’s main health concern and their history. It helps focus the assessment and provides context for the current condition.

It may be useful to include a body chart, a visual representation where the patient indicates areas of pain or discomfort. This helps the physiotherapist understand the location, nature, and extent of symptoms, guiding further examination. Additionally, understanding the behaviour of symptoms, how symptoms behave throughout the day, with different activities, and under various conditions, provides insights into the nature of the condition.

Understanding the progression and characteristics of symptoms is crucial for accurate diagnosis and treatment planning.

• Reason for seeking medical attention. Example: A 35-year-old patient visits the clinic due to persistent lower back pain that has been bothering them for the past two weeks, which worsens after sitting for long periods at their desk job.
• Description of symptoms and their perception of their condition. Example: The patient describes the pain as a constant dull ache in the lower back, which they feel is related to poor posture during long work shifts.
• Onset. Example: The symptoms started gradually about a week ago after lifting heavy boxes at work, with the pain intensifying as the week progressed.
• Duration. Example: The pain has been present for the last 10 days and has not improved despite over-the-counter painkillers and self-care measures.
• Progression and changes of symptoms over time. Example: Initially, the pain was mild and intermittent, but it has become more frequent and now radiates down to the patient's left leg, especially after standing or walking for extended periods.
• Impact on daily activities and quality of life. Example: The patient reports difficulty walking long distances and climbing stairs due to the pain, impacting their ability to participate in daily activities like grocery shopping or taking walks.

• Areas of pain or discomfort. (It may be helpful to add the following information on a body chart.)
  • Location of current symptoms. Example: The pain is localised in the lower back, specifically near the sacroiliac joint on the left side.
  • Pain
    • Depth. Example: The patient describes the pain as deep within the muscle tissue of the lower back, indicating possible muscular strain rather than joint-related pain.
    • Quality. Example: The sensation has been described as a 'tightness' or stiffness, especially after sitting for long periods or during the early morning hours after getting out of bed.
    • Intensity. Example: The patient rates their pain as 6 out of 10 on the pain scale, which fluctuates depending on activity level, but it can increase to 8/10 after heavy lifting.
  • Abnormal sensation. Example: The patient reports experiencing occasional tingling and numbness in the right leg, which they believe might be linked to a nerve irritation.
  • Relationship of symptoms. Example: The patient notices that the pain in their back tends to worsen after long drives or periods of prolonged sitting, and improves when they walk or perform stretches.
  • Constant or intermittent symptoms. Example: The back pain is intermittent, with flare-ups throughout the day, especially after sitting or bending forward, but it tends to ease after the patient rests or lies down.
• Behaviour or symptoms
  • Assessing symptom patterns. Example: The patient observes that the pain is more noticeable during the workweek, especially after sitting for long hours, but tends to decrease during weekends when they have more time to rest and stretch.
  • Aggravating and easing factors. Example: Bending forward or lifting heavy objects aggravates the pain, while applying heat and gentle stretching exercises seem to ease the discomfort.
  • Severity, irritability, and nature (SIN). Example: The severity of the pain is moderate, but it is irritable, making it difficult for the patient to sleep. The pain is described as deep and sharp, particularly during certain movements.
  • 24-hour behaviour of the symptoms. Example: The patient notices that their pain is worst in the morning when they first get up and improves throughout the day as they move and stretch, although it reappears in the evening after sitting for long periods.
  • Daily activities. Example: The patient reports difficulty performing basic household tasks like vacuuming or bending down to tie their shoes due to pain in the lower back and legs.
  • Stage of condition. Example: The patient appears to be in the subacute phase of their condition, as the symptoms have persisted for two weeks without significant improvement, despite self-treatment and rest.

Patient Goals

Understanding a patient’s personal goals is essential to creating a meaningful and effective individualised care plan. While these are not treatment goals, they help physiotherapists appreciate what the patient hopes to achieve, enabling them to tailor interventions that align with these goals.

• Short-term Goals: These are goals the patient wishes to accomplish in the immediate future, typically within the next few weeks or months. Understanding the time frame for these short-term achievements allows both the patient and physiotherapist to monitor progress and make necessary adjustments to ensure the patient remains motivated and on track. Example: "The patient wants to confidently put weight through injured leg and walk without mobility aids or assistance within the next four weeks."
• Long-term Goals: Represent the patient's long term goals such as returning to work, sports, or engaging in daily activities without pain or restriction. These goals may take several months to a year or more to achieve and provide a vision and understanding of what is important and direct the treatment plan and therapy interventions. Example: "The patient want to return to their previous level of physical activity and resume playing football within a year."

Diagnostic Tests

Include the results of relevant diagnostic tests to confirm diagnosis:

• Imaging studies (X-rays, MRI). Example: An MRI of the lumbar spine reveals a mild bulging disc at L4-L5, while the X-ray shows signs of early degenerative disc disease with slight narrowing of the intervertebral disc space.
• Laboratory results. Example: Blood tests indicate a raised C-reactive protein (CRP) level, suggesting inflammation, and a slightly elevated alkaline phosphatase (ALP) level, which may indicate bone turnover or an underlying condition such as osteoarthritis.
• Specialised assessments. Example: A provocative lumbar discography was performed to assess the source of the patient's chronic lower back pain. The test confirmed discogenic pain at the L4-L5 level, with the patient experiencing a significant increase in pain when pressure was applied to the affected disc.

Red Flag Symptoms for Serious Pathology

To ensure there is no underlying serious pathology, it is important to ask special questions. These are important for gaining an understanding of a patient’s general health and identifying any contraindications or precautions that might affect treatment or reveal red flags. These questions help screen for serious conditions such as fractures, infections, or malignancies. These should be identified in the patient’s history to tailor treatment approaches, facilitate support, or refer to other professionals if needed.

There are other flags that can reveal patterns of behaviours and barriers to treatment and recovery:

• Yellow Flags - Psychological and social factors (e.g., fear-avoidance, anxiety, depression)
• Blue Flags - Work-related factors (e.g., job dissatisfaction)
• Black Flags - System or contextual obstacles (e.g., legal or financial issues)

Past Medical History (PMH)

It is important to know about a patient’s past medical history, including previous injuries, surgeries, or illnesses will help to identify any pre-existing conditions that could influence the current complaint or affect treatment options.

Socioeconomic (Social) History (SH) and Family History (FH)

Social and family history provides information on the patient's lifestyle, occupation, hobbies, and any family history of similar conditions. This can reveal potential contributing factors or genetic predispositions that may impact the patient’s current condition.

• SH
  • Tobacco, alcohol, and drug use. Example: Non-smoker, drinks alcohol socially (1-2 glasses of wine per week), no history of drug use.
  • Physical activity level. Example: Moderately active, attends a gym twice a week but has recently reduced sessions due to lower back pain.
  • Living situation and support systems. Example: Lives alone in a second-floor flat with no lift, receives occasional support from friends during flare-ups.
  • Occupational risks. Example: Works as a delivery driver, which involves prolonged sitting and occasional heavy lifting, both of which aggravate back pain.

• FH
  • Relevant medical conditions in immediate family members. Example: Father has osteoarthritis, and mother has a history of chronic lower back pain.
  • Genetic predispositions. Example: Family history includes scoliosis in a maternal aunt and rheumatoid arthritis in a paternal grandparent.

Example: Father had a herniated disc; mother has type 2 diabetes

Medication and Past Medical History

Understanding current medications and past medical history is critical to avoid interactions and manage conditions effectively.

• Previous surgeries: This section collects details about any past surgeries, including the type of surgery, the date, and the reason for it.
• Previous treatments: Includes any medical treatments or physical therapy the patient has undergone before, along with their effectiveness or outcomes.
• Allergies: This part also asks about allergies to medications, materials (like latex), foods, or others, to avoid complications during physiotherapy treatment.

The Objective Assessment

Based on the information from this assessment, the physiotherapist can now outline a plan for the (physical) examination. This plan focuses on areas identified as potentially problematic during the subjective assessment and ensures a thorough and systematic evaluation.

The objective assessment records measurable data and observational data to support the clinical findings . The purpose is to evaluate the neuromusculoskeletal system's integrity and function. This step-by-step process ensures a systematic and comprehensive examination.

Example: Lumbar flexion at 30 degrees, reduced strength in right leg, positive straight leg raise test.

Example: Tenderness in lower lumbar region, reduced range of motion, positive neurological tests.

Observation

Observation begins as soon as the patient enters the clinic. It includes assessing posture, gait, and any visible abnormalities or asymmetries. Observing the patient’s movements can provide valuable clues about their condition.

Palpation

Palpation involves the hands-on examination of tissues to detect tenderness, swelling, changes in temperature, and abnormal sensation or tone. This helps identify areas of inflammation, spasm, or other abnormalities.

Joint Assessment

This will assess the range of motion, stability, and integrity of the joints. Joint tests help identify joint-related issues such as stiffness, hypermobility, or instability, which may contribute to the patient's symptoms.

Muscle Assessment

This includes strength, endurance, and flexibility assessments, which evaluate muscle function and identify any deficits. This can indicate muscle imbalances or weaknesses that may need to be addressed in the treatment plan.

Neurological Assessment

The neurological assessment is important to identify any neurological involvement, including weakness, numbness, or reflex changes. Neurological tests assess the function of the nervous system, including reflexes, sensation, and motor control. These tests help determine if there is any neural involvement in the patient’s symptoms.

Some examples of tools for a neurological assessment are:

• The Neck Disability Index and Patient-Specific Functional Scale are useful tools when assessing patients with cervical radiculopathy, providing reliable and valid measures for both pain and function .
• Clinical tests such as the Spurling test, cervical distraction test, and upper limb tension test have been shown to be predictive for cervical radiculopathy, and their diagnostic accuracy is supported by research .

Functional Assessment

Functional tests in physiotherapy provide real assessments of a patient's ability to perform tasks important to their daily life, work or sport. These tests not only reveal the level of impairment, but also help to target specific treatments to improve specific functional deficits. Tests should be individualised to the patient's specific needs and the results should be used to monitor progress over time.

• Assess the patient's ability to perform specific tasks related to their daily activities (ADLs) or occupation.Examples of special texts for ADLS:
  • Sit to Stand Test: Assesses lower limb strength and balance, important for daily activities like rising from a chair.
  • Single Leg Stance Test: Evaluates balance and stability, relevant for activities requiring weight transfer.
  • Timed Up and Go (TUG) Test: Assesses mobility, balance, walking ability, and fall risk.
  • 6-Minute Walk Test: Measures endurance by assessing how far a patient can walk in six minutes.
• Sport or work-specific tasks: Assess movements required for sport or work-related activities. Examples of sports related tests are:
  • Vertical Jump Test: Useful for athletes to assess explosive lower limb power.
  • Grip Strength Test: Important for occupations or sports that require hand strength, such as manual labour or tennis.
  • Agility T-Test: Commonly used for sports to assess the agility required for quick directional changes.

Special Tests

Special tests, also known as orthopaedic or clinical tests, are assessments designed to evaluate the integrity and function of specific structures, such as ligaments, tendons, muscles, and neural pathways. These tests help in identifying or ruling out specific pathologies, which aids in forming a precise diagnosis and informs a targeted treatment plan.

Special tests are used in physiotherapy to confirm diagnoses when a patient’s symptoms and functional limitations suggest issues in specific structures. These tests isolate certain movements or apply controlled stress to particular tissues, helping to detect the presence and severity of injuries, instability, or neural involvement. When combined with findings from the general assessment, special tests provide physiotherapists with a clear understanding of the patient’s condition, allowing them to design effective, individualised rehabilitation programmes.

Examples of Special Tests:

• Muscle and Tendon Assessment:
  • Thompson Test: For Achilles tendon rupture.
  • Empty Can Test: For supraspinatus tendon integrity in the shoulder.
  • Speed’s Test: For biceps tendon pathology, particularly at the shoulder.
• Ligament Integrity
  • Anterior Drawer Test of the Knee: Assesses the stability of the anterior cruciate ligament (ACL) in the knee.
  • Valgus/Varus Stress Tests: Evaluate the stability of the medial and lateral collateral ligaments, respectively.

• Meniscus
  • McMurray Test: Used to identify meniscal tears by applying rotational stress to the knee.
  • Apley Compression Test: Assesses potential meniscal injury or damage in the knee.

• Neural Structures:
  • Upper Limb Tension Test (ULTT): A series of tests to evaluate neural tension and diagnose issues related to nerve entrapment or irritation in the upper extremity.
  • Slump Test: Tests the flexibility and sensitivity of the sciatic nerve and neural structures in the lumbar spine.

• Joint and Structure-Specific Tests:
  • FABER (Patrick’s) Test: Assesses hip joint pathology or issues with the sacroiliac joint.
  • Thompson Test: Detects rupture in the Achilles tendon.

• Joint-Specific Stability and Impingement:
  • Apprehension Test: Assesses shoulder stability, particularly for anterior shoulder dislocation risk.
  • Hawkins-Kennedy Test: Tests for shoulder impingement, especially in the rotator cuff.
  • Finkelstein Test: Used for diagnosing de Quervain’s tenosynovitis in the wrist.

• Spinal and Sacroiliac Joint Tests:
  • Straight Leg Raise Test (SLR): Evaluates sciatic nerve tension, often used to assess lumbar disc involvement.
  • Sacroiliac Joint Compression Test: Tests for SI joint dysfunction, useful in assessing pain originating from the pelvic region.
  • Kemp Test: For detecting facet joint issues in the lumbar spine.

• Vascular Health:
  • Ankle-Brachial Index (ABI): Checks for peripheral artery disease by comparing blood pressure in the ankle and arm.
  • Allen’s Test: Assesses blood flow in the radial and ulnar arteries in the hand.

Treatment Plan

The treatment plan outlines the approach based on the patient’s diagnosis and goals. It includes short- and long-term objectives, necessary lifestyle modifications, home exercises, and a follow-up plan. A comprehensive treatment plan ensures that all aspects of the patient’s care are addressed in a structured manner.

• Short-term goals (1-2 weeks). Example: Reduce lower back pain from 6/10 to 3/10 and improve sitting tolerance to 30 minutes without significant discomfort.
• Long-term goals (4-6 weeks). Example: Restore full range of motion in the lumbar spine, return to playing recreational football without pain, and prevent recurrence through strengthening.
• Specific interventions (e.g., medication adjustments). Example: Coordinate with GP to assess the need for anti-inflammatory medication alongside physiotherapy sessions.
• Frequency and duration of treatment. Example: Physiotherapy sessions twice a week for 4 weeks, followed by reassessment and potential reduction to weekly sessions.
• Home exercise program. Example: Daily lumbar mobility exercises, strengthening exercises 3 times a week, and a 10-minute walking routine.
• Activity modifications. Example: Avoid prolonged sitting and limit heavy lifting until pain subsides.
• Referrals to specialists if needed. Example: Referral to a sports medicine specialist if symptoms persist or worsen after 6 weeks.
• Follow-up plan. Example: Review progress in 2 weeks to adjust treatment plan, with a comprehensive reassessment at 6 weeks to determine readiness for discharge or continued care.

Outcome Measures

Outcome measures are validated tools that provide a quantitative assessment of a patient’s condition, allowing clinicians to monitor progress, evaluate treatment effectiveness, and adjust interventions as necessary. By using these standardised tools, physiotherapists can objectively assess areas such as pain, function, and disability, which helps create a tailored rehabilitation plan and facilitates consistent tracking over time.

Outcome measures are particularly valuable in the following areas:

• Neurological Assessments are useful in monitoring recovery in conditions affecting the nervous system, helping to track progress in areas like balance, coordination, and motor control.
  • Modified Rankin Scale (mRS) - Used to measure the degree of disability or dependence following a neurological event, such as a stroke.
  • Functional Independence Measure (FIM) - Assesses independence in physical and cognitive domains, commonly used in neurological rehabilitation.
  • Berg Balance Scale - Measures balance in patients with neurological conditions to evaluate their fall risk.

• Pain Assessments are essential for tracking changes in pain levels, gauging the effectiveness of pain management interventions, and tailoring treatments based on the patient’s subjective pain experience.
  • Visual Analog Scale (VAS) and Numeric Pain Rating Scale (NPRS) - Simple tools for quantifying a patient’s pain intensity on a linear scale.
  • McGill Pain Questionnaire - Evaluates the quality and intensity of pain, providing insights into the patient's pain perception and experience.

• Arthritis and Joint Health assess the impact of arthritis on daily life, helping guide treatment by targeting pain relief, improving joint function, and supporting patient mobility.
  • Western Ontario and McMaster Universities Arthritis Index (WOMAC) - Specifically designed to measure pain, stiffness, and functional limitations in patients with osteoarthritis.
  • Knee Injury and Osteoarthritis Outcome Score (KOOS) - Used to evaluate the functional status and symptoms of patients with knee injuries or arthritis.

• Functional Capacity and Disability outcome measures help in quantifying the impact of injury or illness on activities of daily living, work-related tasks, and other essential functions. These assessments guide therapeutic decisions and provide insights into the patient’s quality of life over the course of rehabilitation.
  • Oswestry Disability Index (ODI) - A widely used tool for evaluating the extent of disability in patients with lower back pain.
  • Lower Extremity Functional Scale (LEFS) - Measures functional limitations in activities of daily living for patients with lower limb conditions.
  • Roland-Morris Disability Questionnaire - Assesses disability in patients with back pain.

Recording the Assessment

Accurate and structured clinical records of assessment findings is essential for tracking patient progress, guiding treatment, and ensuring clear communication among healthcare providers. Common recording methods like SOAP (Subjective, Objective, Assessment, Plan) and DAP (Data, Assessment, Plan) help organise information in a clear and systematic way. Each system is tailored to different clinical needs, allowing for concise yet comprehensive documentation that supports continuity of care and informs treatment adjustments effectively.

Patient Communication and Rapport

Building effective communication and rapport with the patient is a cornerstone of a successful assessment. It involves:

• Encouraging Openness - Foster an environment where patients feel comfortable sharing details about their condition, lifestyle, and concerns. This can be achieved through open-ended questions and active listening.
• Clarity in Explanation - Clearly explain the purpose of the assessment and each procedure. Avoid using medical jargon that could confuse the patient.
• Active Listening - Pay attention to the patient’s verbal and non-verbal cues. Acknowledge their concerns and validate their experiences. This not only helps in understanding the condition better but also builds trust.
• Empathy and Support - Show empathy towards the patient’s condition and concerns. Providing emotional support can significantly impact the therapeutic relationship and outcome.

Clinical Reasoning and Hypothesis Formation

Clinical reasoning involves integrating and applying knowledge, weighing evidence, and making informed decisions about patient care. It is important because it enables physiotherapists to collate and process information from multiple sources—such as patient history, physical findings, and clinical guidelines—to form accurate hypotheses and tailor effective treatment plans. Clinical reasoning enhances patient outcomes by fostering a systematic approach to assessment, ensuring that interventions address the root causes of dysfunction rather than just symptoms. It also encourages flexibility, as clinicians adapt their hypotheses based on new information or changes in the patient’s condition, supporting a responsive, patient-centred approach to care.

• Combining Findings - Use information from both subjective and objective assessments to generate hypotheses about potential diagnoses.
• Guiding Decision-Making - Develop a working diagnosis based on clinical findings, and use this to inform the treatment plan.
• Dynamic Process - Continuously update the hypothesis as new information becomes available or as the patient’s condition changes.

A Multi-disciplinary Approach

Effective patient care often involves collaboration with other healthcare professionals, such as referring patients to specialists when necessary.

• Referral to Specialists - Recognise when a patient needs to be referred to another specialist, such as an orthopaedic surgeon or neurologist, based on the assessment findings.
• Multidisciplinary Collaboration - Work closely with other professionals, such as occupational therapists, doctors, or psychologists, to provide comprehensive care. Sharing findings and treatment plans ensures a holistic approach to patient care.

Patient Education and Involvement

Educating the patient about their condition and involving them in their care plan can improve treatment outcomes.

• Explain the findings - Clearly communicate the assessment findings to the patient in a way that is easy to understand.
• Empowering patients - Help patients understand their role in managing their condition. This could include teaching them exercises, pain management strategies, or lifestyle modifications.
• Promoting self-management - Encourage patients to take an active role in their recovery by providing them with the knowledge and tools needed to manage their symptoms and prevent further issues.
• Educational handouts - Providing a handout to the patient explaining all of the above in simple language may be helpful.

Ethical Considerations and Cultural Sensitivity

Ethical practice and cultural sensitivity are important aspects of healthcare. It is essential to respect patient autonomy, maintain confidentiality, and be mindful of cultural differences in the perception of health and treatment.

• Respect Autonomy -Ensure that patients make informed decisions about their care. Respect their preferences and choices, even if they differ from the recommended approach.
• Maintain Confidentiality - Protect patient information and only share it with relevant healthcare providers.
• Cultural Awareness - Be mindful of cultural differences that may influence a patient’s perception of health, pain, or treatment. Tailor the assessment and treatment approach to align with the patient’s cultural values and beliefs.

Summary

A comprehensive and systematic assessment provides a solid foundation for understanding a patient’s condition and setting an individual plan based on the patient needs and expectations. By learning about the patient’s subjective experiences and assessing the objective findings, physiotherapists can identify key issues, confirm diagnoses, and track progress over time. Involving patients by discussing their goals—both short-term and long-term—ensures the care plan aligns with their expectations and supports their journey towards improved function and quality of life.

Continual reassessment allows physiotherapists to modify the treatment plan as the patient progresses, adapting it to meet changing needs. This approach promotes patient-centred care that addresses not only physical health but also the patient’s overall well-being and satisfaction with the therapeutic process.