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Patient-Client Management Model

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Adapted from American Physical Therapy Association. Guide to physical therapist practice (2nd ed). Physical Therapy. 81(1). Copyright 2001 by the American Physical Therapy Association.

History Taking—Relevant Items

Past Medical History/Birth History

  • Significant medical history of biological parents

  • Mother's history related to pregnancy, labor, delivery

  • Child's history related to pregnancy, labor, delivery

  • Significant medical history of relatives including siblings

  • General health status

  • History of major childhood/adolescent illnesses

  • History of any surgical or medical procedures

  • Known allergies to food, medications, substances, etc.

  • Neonatal screening and immunization history

  • Diagnostic or medical tests related to past history

Current Medical History

  • Current sign and symptoms

  • Onset, duration, and severity of presenting problem

  • Current health-care practitioners involved with child's care (includes physicians, therapists, psychologists, orthotists, etc.)

  • Current medications—purpose, dosage, history of adverse reactions

  • Date and, if available, results of recent medical and diagnostic testing

  • Current and planned medical and surgical interventions

  • Current functional and activity levels

  • Use of adaptive equipment or devices

Developmental History

  • Infant/child temperament

  • Child/caregiver interactions

  • Growth and nutrition (including rate of growth in height, weight, head circumference; timing of tooth eruption)

  • Feeding—daily routine, preferences, difficulties

  • Achievement of major milestones (including sensorimotor, social-emotional, cognitive, language, self-care, etc.)

  • Bowel and bladder control/toilet training

Social History

  • Parents/caregivers' employment status

  • Home layout and environment (including safety issues/childproofing; exposure to lead, tobacco, or other hazards)

  • Sleep routine, child's sleeping position

  • Use of car seat

  • Child care and school history

  • Signs of abuse and neglect

Systems Review/Basic Screening

Cardiovascular-Pulmonary System

  • Vital signs: Heart rate, respiratory rate, blood pressure, temperature, pain*

  • Observation: Difficulty breathing or crying, excessive crying, cyanosis, retractions, nasal flaring, cough, response to change in position, activity; fatigue, weight loss or gain

  • Palpation: Peripheral pulses, tactile fremitus

  • Auscultation: Heart and lung sounds

  • Percussion: Any areas of dullness over lung fields

*see Examination of Cardiovascular-Pulmonary System for more details.

Neuromuscular System

  • Newborns: APGAR, gestational age, birth weight; suck and swallow; irritability/consolability, state regulation*

  • Observation: General resistance to passive movement; is it velocity-dependent?

  • Observation: Ability to make eye contact and track objects

*see Examination of Neuromuscular System for more details.

Musculoskeletal System

  • Anthropometrics: Height, weight, head circumference*

  • Observation: Size and shape of head, face, skull; any abnormalities of eyes, ears, nose, mouth, palate, teeth; skeletal asymmetry; swelling, bruising

  • Complaints: Pain; refusal to bear weight, walk, move; fever; night pain

*see Examination of Musculoskeletal System for more details.

Integumentary System

  • Observation/palpation: Texture, temperature, color and pigmentation, scarring, presence of hair, turgor/hydration, swelling*

  • Observation: Presence ...

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