Skip to Main Content

++

EXAMINING CHILDREN AND ADULTS

++

HISTORY

++

A good clinician can sometimes make a provisional diagnosis on the basis of history of the nature, onset, extent, and duration of the chief complaint and associated complaints. This should include previous diseases, personal and family history, occupational data, and social history. A complete listing of medications is essential. It may be desirable—or necessary—to interview relatives and friends.

++

Detailed information is particularly important in regard to the following:

++
A. Headache
++

Note the duration, time of onset, location, frequency, severity, progression, precipitating circumstances, associated symptoms, and response to medications. A worsening headache, or "the worst headache of my life," is especially concerning.

++
B. Seizures and Episodic Loss of Consciousness
++

Record the character of the individual episode, age at onset, frequency, duration, mental status during and after episodes, associated signs and symptoms, aura, and type and effectiveness of previous treatment.

++
C. Visual Disturbances
++

The frequency, or progression of scotomas, acuity changes, diplopia, field changes, and associated phenomena should be noted.

++
D. Motor Function
++

Has the patient become weak? Has the patient lost coordination? Are distal muscles (eg, those of the hand or foot) affected more than proximal ones (eg, those of the upper arm or leg)? Are there abnormal muscle movements?

++
E. Sensory Function
++

Has the patient noticed numbness or tingling? Over which part of the body? What is the location of the sensory loss? Can the patient tell where his or her legs are located? Is there a history of painless burns?

++
F. Cranial Nerve Function
++

Is there double vision? Note any facial drooping, slurred speech, difficulty swallowing, problems with balance, tinnitus (a ringing or buzzing sound in one or both ears), or impaired hearing.

++
G. Pain
++

Assess the onset, location, progression, frequency, characteristics, effect of physical measures, associated complaints, and type and effectiveness of previous treatment.

++
H. Time Course
++

It is important to obtain a clear picture of the time course of the disorder. Was onset of symptoms sudden or gradual? If gradual, over what time scale (hour, days, months)? Are symptoms always present, or are they intermittent? What precipitates symptoms, and what relieves them?

++

THE PHYSICAL EXAMINATION

++

Even before beginning the formal physical examination, important information may be gleaned by observing the patient while the history is given. Is the patient well groomed or unkempt? Is the patient aware of and appropriately concerned about the illness? Does the patient attend equally well to stimuli on the left and right sides; that is, does the patient relate equally well to the physician when asked questions from the left ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessPhysiotherapy Full Site: One-Year Subscription

Connect to the full suite of AccessPhysiotherapy content and resources including interactive NPTE review, more than 500 videos, Anatomy & Physiology Revealed, 20+ leading textbooks, and more.

$595 USD
Buy Now

Pay Per View: Timed Access to all of AccessPhysiotherapy

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.