Ch 1 Intro to PT Examination Flashcards
Patient
Refers to individuals with a disease, condition, impairment, or disability who receive PT examination, evaluation (diagnosis and prognosis), and intervention
Client
Refers to individuals who seek PT services for consultation, professional advice, health promotion and wellness, or preventative services
Patient examination consists of:
-Patient history
-Systems review
-Tests and measures
Sources of information in the patient interview
-Patient
-Family member / caregiver
-Chart review
Patient History
Involves a verbal interview in which information relevant to the pt’s condition is gathered
Systems review
A brief assessment of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems as well as the pt’s cognitive, language, and learning abilities
What do you use to decide when to assess further than the systems review?
Clinical judgment / reasoning
Tests and measures
Selected based on hypotheses formed during the Hx-taking process and findings during the system review
Evaluation Process
Requires synthesis of all data collected during the examination and helps to answer the question “What does it all mean?”
Patient Evaluation Overall consists of
Interpretation of tests & measures results
-Synthesis of data
-Diagnosis
-Prognosis
Diagnosis and Prognosis
(Subfactors within the evaluation)
Subfactors within the evaluation process
Diagnosis
A label that describes a cluster of signs and symptoms typically associated with a disorder or syndrome leading to impairments, activity limitations, or participation restrictions
What does diagnosis guide the PT to?
Determining appropriate intervention strategies for each patient
Diagnosis answers what question?
“Into what clinical pattern does the patient presentation fall?”
Prognosis answers what question?
“what is the pt’s expected level of functional improvement based on all influential factors (biological, psychological, and social)?”
PLOF-previous level of function
PMH-past medical Hx
HPI-Hx of present illness
Interventions
Selected and implemented based on findings from the examination and evaluation
What interventions can be included?
-Therapeutic exercise
-Functional training
-Training inn self-care
-Patient instruction
Outcomes
The results of the interventions that can be assessed periodically during or at the end of episode of care (POC)
Outcome measures
Patient goals
Therapeutic alliance-patient participationPT facilitated
Collaborative
Through:
Patient reported
Performance based
PT Management
-Plan of care
-Coordination & communication
-Documentation
-Ongoing assessment
Clinical reasoning
-Apply knowledge and skill
-Intuitively make decisions based on self reflection, prior experience, pt characteristics/presentations
-Requires collaboration with pt
What must the Patient Interview Setting include?
-Patient comfort
-Patient privacy
-Avoid / minimize distractions
-Therapist appearance / dress
Responsibility for obtaining pertinent info lies with the PT by ensuring what?
-Clarifying questions
-Delve (into) as in: to explore, to search through or into
Not just specific and necessary info, but also details about and connect with patient
Interview techniques
- Open versus close ended questions
- Multiple option questions (ie pain: “is it dull, achy, burning?”)
- Prompters (tell me more, go on, yes)
- Clarifying questions: general more specific
- Reflection or echoing (can be strategy to get more clear answer)
- Reflective feeling: “it sounds as though this has been stressful”
- Paraphrasing: “let me be sure I understand what you have said”
- Summarizing: PT connects pertinent points (patient approves)
Nonverbal communication
-Facial expressions
-Hand gestures
-Body positioning
-Eye contact
-Cultural differences
What must you take into consideration while conducting the interview?
-Patient setting
-Patient cognition
-Pain levels
-Endurance / activity tolerance
-Signs (results of test/measures) vs Symptoms (felt/experienced)
-Red vs Yellow flags
-Differential diagnosis
Yellow flags
Proceed with caution
Factors that could affect treatment, sometimes refer to psychological
Red flags
Findings during the pt interview or examination possibly associated with:
-serious medical condition
-systemic/local infection
-viscerogenic pain
-fracture
-cancer
What are other pt statements that could be considered red flags?
-Heaviness in chest
-Difficulty breathing
-Unexplained weight changes
-Diaphoresis
-Vision/hearing changes
What must follow if you detect any red flags?
Immediate attention or physician referral
Differential diagnosis
Rule out diseases and conditions that masquerade as MSK conditions
What is relevant information?
-Current condition
-Patient’s history
-Life and Living environment
Theme 1: Current condition of patient (HPI)
-General demographics
-Current condition/ chief complaint
-Medications
-Lab or diagnostic results, imaging
Theme 2: Patient history (PMH)
-Past episodes of current condition & past interventions
-Past medical and surgical Hx
-Family medical HX
Theme 3: Patient’s life and living environment
-Physical env and available resources
-Employment
-Recreation and social activities
-Current and previous activity levels
-General health status and lifestyle
