Patient History

Clinical Cornerstone:

• Taking a patient's history goes beyond data collection; it's about forging and upholding a therapeutic relationship. Actively and empathetically listening to the patient's narrative offers insights into their condition and its optimal approach to management. The essence of history-taking lies in turning into the patient's story, discerning their non-verbal cues, and steering the conversation to ensure a comprehensive, yet seamless, patient history.

• Adopting principles of trauma-informed care (safety, trustworthiness, collaboration, choice and empowerment, culturally responsive) could help minimize potential barriers. This might involve signposting to signal the direction of the consultation and explaining the rationale behind sensitive questions or tests.

• Particularly for concussion, diagnosis relies on a detailed history and the physical exam, to exclude other injuries with similar symptoms, and to identify more severe brain injuries.

• While history taking needs to be thorough, it does not need to be linear. Reports can be explored as the patient makes them, using care to ensure needed details are not subsequently missed. While certain topics like prior concussions, past care experiences, and recovery expectations are important, they may be broached at different times during the patient encounter, not just during the initial history.

• When re-evaluating existing concussion patients, a thorough assessment is imperative, just as it is with new patients. Explore the patient's new complaint to better understand it's characteristics. Identify any relationship between the new complaint and pre-existing conditions or treatments.

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• Chief complaint: Main issues.

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• Mechanism of Present Condition: Fall / blow to the head / impact or other force. Head movement (was the head whipped back and forth). Aware / surprised / intoxicated.

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• Characteristics of Present Condition: Onset and duration (when the mechanism of injury occurred, when the symptoms began). Loss of consciousness at onset. Alleviating/aggravating factors, timing (e.g. constant/intermittent, morning/end-of-day/night pain, improving/staying-the-same/getting worse), severity of initial symptoms.

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• Associated Symptoms of Present Condition: (e.g. dizziness, nausea, vomiting, disturbed balance, seizures, disturbed memory / amnesia, auditory or visual disturbances, slurred speech).

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• Associated Headache: Distribution, character, intensity, etc.

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• Associated Mental Health Symptoms: (e.g. sleep disturbance, fatigue, disturbed focus or processing, altered mood (depression, anxiety, irritability, impulsivity, etc.))

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• Additional Characteristics of Present Condition: frequency of symptoms, character, radiation (e.g. weakness or numbness, pain or tingling).

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• Narrative: How the issue affects activities of daily living.

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• Previous History of Concussion: Including experience with previous treatments – effective or any adverse effects. Expectations of treatment and recovery.

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• Associated Complaints: Identify any concurrent disorders (e.g., neck pain, TMD, occipital neuralgia, etc.).

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• Health Status: Previous or existing conditions (physical, systemic, and mental health conditions), medications, injuries, hospitalization, surgeries, and treatments.  Volume and intensity of weekly physical activity and exercise.

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• Review of Body Systems: Review of body systems to identify symptoms of any related or unrelated disorders (neurologic, mental health, cardiovascular (including hypertension), genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, bone density, medications, pregnancy, children).

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• Demographics: Age, sex and gender.

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• Family History: Familial major medical history (e.g. cancer, cardiovascular).

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• Social Environment: Family or caregiver support, personal roles / responsibilities.

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• Psychosocial Assessment (yellow flags):

  • Beliefs and perceptions: Negative beliefs about the prognosis or the nature of the condition.

  • Emotional factors: Symptoms of depression (can use the PHQ-9 outcome measure), anxiety (can use the GAD-7 outcome measure).

  • Behavioural factors: Avoidance behaviors, reduced activity levels, over-reliance on passive treatments, or high self-reported disability levels.

  • Social or environmental factors: Lack of social support, work-related issues, or family-related stressors.

  • Compensation or legal issues: Pending litigation or compensation claims.

  • Coping strategies: Maladaptive coping mechanisms (e.g., catastrophizing, relying heavily on medication), psychological resilience.

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• Lifestyle Assessment: Nutrition, exercise (type, duration and frequency), hobbies, sleep, stress; smoking, alcohol, and recreational drug use.

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• Occupational History: Type of work they do (sedentary, physical labour, etc.), ergonomics of workplace, other work stressors (including social environment), any time off due to neck pain, any work accommodations/modifications.

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• Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

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• Goals and expectations: Goals for treatment, expectations from intervention.

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Documentation: Record all findings in the patient record.