Chapter 4: examination, evaluation, and plan of care

Question 1

PT diagnosis

Answer 1

Label encompassing a cluster of signs and symptoms commonly associated with a disorder or syndrome or cateogory of impairments in body structures and function, activity limitations or participation restrictions

Question 2

Examination

Answer 2

Process of obtaining a history, performing relevant systems reviews. And selecting and administering specific test and measure. Performed by PT

Question 3

Evaluation

Answer 3

Dynamic process in which the PT makes clinical judgements based on data gathered during the examination. Performed by PT

Question 4

Specific data collection

Answer 4

Can be performed by PTA if requested because it’s just test and measurements

Question 5

Pain description

Answer 5

Collected during examination (patient’s history) includes pain, extension or radiation, intensity, duration, onset, frequency, progression, aggravating or relieving factors, and previous test results in regard to pain

Question 6

VAS

Answer 6

Visual Analog Scale: 10 cm line with verbal or pictorial anchors indicating a continuum from no pain at one end to sever at the other. Patient asked to mark line and pain measured in cm

Question 7

NRS

Answer 7

Numerical rating system: range of number to reflect pain. Should be measureing before and after physical therapy interventions for pain

Question 8

Patient history

Answer 8

Complete medical history of the patient’s chief complaints, present illness, past history, allergies, current medications, lifestyles and habits, social history, vocational or economic history, and family history

Question 9

Sensory examination

Answer 9

Tests for superficial, deep, and combined sensations

Question 10

Superficial sensory exam

Answer 10

Pain, temp, light touch and pressure

Question 11

Deep sensory exam

Answer 11

Kinesthesia, proproiception, and vibration

Question 12

Combined sensory exam

Answer 12

Tactile localization, 2-point discrimination, barognosis, stereognosis, graphesthesia, and recognition of texture

Question 13

Cranial nerve integrity

Answer 13

Examination of function of 12 pairs of cranial nerves that are distributed to the head and neck - not cranial 10 (vagas nerve) that is distributed to thorax/abdomen

Question 14

Vital signs

Answer 14

Investigation of cardiopulmonary system to examine vital signs (heart rate, respiration, and blood pressure) and to note any signe of cardiac decomposition - can interfere with physical therapy interventions as well as show patients aerobic capacity and endurance

Question 15

Anthropometrics

Answer 15

Measurements that give in for about length, girth, volume of patient’s body. Also includes height, weight, and BMI

Question 16

Mentation, hearing, and vision examination

Answer 16

Evaluate patient’s ability to concentrate/respond by examining patient’s attention, orientation, and cognition - gross examination of patient’s hearing during conversation - gross visual examination can assess patient’s visual acuity and peripheral field vision

Question 17

Attention

Answer 17

Awareness of environment or ability to focus on a specific stimulus without distraction

Question 18

Orientation

Answer 18

Refers to patient’s awareness of time, person, and place

Question 19

Cognition

Answer 19

Complex process that examines thinking skills such as language - use and calculation - perception - memory awareness - reasoning - judgment - learning - intellect - social skills - imagination

Question 20

Range of motion

Answer 20

ROM: evaluates amount of excursion through which a joint or a series of joints can move. Measured in degrees by a goniometer

Question 21

Manual muscle testing

Answer 21

MMT: evaluates relative strength of specific muscles and identifies patterns of muscle weakness. Normal 5, good 4, fair 3, poor 2, trace activity 1, absent 0

Question 22

Muscle tone

Answer 22

Abnormalities of muscular tone are common in neurological disorders. Spasticity — rigidity — flaccidity

Question 23

Tone

Answer 23

Resistance of muscles to passive elongation or stretch. Or how much tension a muscle has at rest. Hypertonia — hypotonia —dystonia

Question 24

Hypertonia

Answer 24

Muscle overactivity when communication between brain and spinal cord is affected by injury and weakness

Question 25

Hypotonia

Answer 25

Weak muscle tone

Question 26

Dystonia

Answer 26

Involuntary muscle contractions that cause repetitive or twisting movements

Question 27

Flaccidity

Answer 27

Lack of tension when the muscle is at rest. Patient has poor or no ability to create enough tension to move muscle

Question 28

Spasticity

Answer 28

Excessive contraction in response to stretch of a muscle that can occur when the patient is actively moving or being passively moved

Question 29

Rigidity

Answer 29

Inability of muscles to relax normally

Question 30

Postural analysis

Answer 30

Evaluates the position maintained by body when standing and sitting in relation to space and body parts - assessed from all angles (front, back, sides)

Question 31

Balance and control

Answer 31

Examines patient’s ability to control positions of body and body parts using skeletal muscles with respect to gravity - berg balance test - timed up and go - tinetti performance oriented mobility assessment

Question 32

Function

Answer 32

Determines the effect of the condition or injury on the patient’s daily life - ADLs BADLs and IADLs

Question 33

ADL

Answer 33

Activities based on daily living

Question 34

BADL

Answer 34

Basic activities of daily living; dressing, walking, transfer

Question 35

IADL

Answer 35

Instrumental activities of daily living; meal prep, chores

Question 36

Gait examination

Answer 36

Observing patient from pelvis and lumbar spine down to ankle and foot - also watches trunk and upper limbs - observe with/out shoes, devices, level surfaces, and stairs

Question 37

Gait cycle

Answer 37

Moment one foot touches the ground until moment same foot touches agian

Question 38

Outcome measures

Answer 38

Use of standardized tests and measurements at regular intervals during a patient’s physical therapy episode of care is important way to objectify patient’s function and abilities - look at functional abilities and identify if PT intervention is moving toward predicted outcomes

Question 39

Orthopedic examination

Answer 39

Examine integrity of musculoskeletal components. Joint play movements examine the amount of passive motion available within a joint and help differentiate what structures may be injured

Question 40

Neurological examiniation

Answer 40

Consider both therapeutic interventions and psychological aspects of rehabilitation
- patient’s adaptation to disability - patient’s and patient’s family’s stages to adjustment to disease and disability - effects of impairments, functional limitations, and disability - patient’s reintegration into environment, family, and work

Question 41

Cardiopulmonary examintation

Answer 41

PTA must be able to reassess as necessary, moister patient in regard to treatment, monitor vital signs, and provide appropriate interventions to the patient

Question 42

Elements of cardinac examintation

Answer 42

Evaluation of patient’s medical status and history, physical examination, assessment of extremities, and results of diagnostic tests

Question 43

Symptoms of cardiac examination

Answer 43

Despeña or shortness of breath - feelings of fatigue - generalized weakness - palatations - dizziness - edema

Question 44

Examinations for cardiac

Answer 44

Radial pulse - femoral pulse - popliteal pulse - pedal pulse - listening to hear sounds - blood pressure - counting respitory rate

Question 45

Pulmonary examiniation

Answer 45

Eval through patient interview. PT inquires about patient’s habits, drugs, and alcohol - similar to cardiac but includes inspection / palpitation of neck and thorax - and listening to abnormal inspiration/expiration sounds

Question 46

Pediatric examination

Answer 46

Need specific knowledge about theories of child development, motor control, and motor learning

Question 47

Pediatric screening test

Answer 47

Patient history in regards to mother’s pregnancy and birth history and child’s medical history

Question 48

Newborn/infant exams

Answer 48

Neurological exams including consciousness, skeletal system and ROM exams, posture and neonatal reflexes - includes developmental milestones in gross motor development, fine development, and adaptive skills

Question 49

Children and adolescents

Answer 49

Monitoring of progressive diseases, mobility needs that need to grow as child grows, functional changes such as accomplishing school tasks and ADLs

Question 50

Geriatric examination

Answer 50

Musculoskeletal and neuromuscular conditions and dysfunction common to older adults. Mostly focus on patient’s level of functioning and ability to remain independent.
- elderly patients in control of decisions - cultural/ethnic sensitivities - social support needs to be integrated - demands for continuity of care needs to be integrated p patient’s capacity for safe function - effects of activity/in on patient - effects of normal aging on patient vs desease pathology

Question 51

Geriatric psychosocial exam

Answer 51

Includes mini-mental state assessment examination, a mental questionnaire, a drepression assessement, a stress assessment scale

Question 52

Geriatric function tests (4)

Answer 52

1. Physical: sensory and motor
2. Mental funciton: intelligence, cognitive ability, memory
3. Emotional function: ability to cope with stress and anxiety and the patient’s satisfaction with life
4. Social function: patient’s interaction with family members and community as well as economic consideration

Question 53

Geriatric optimal health

Answer 53

Contingent on health-conducive behavior, prevention of disability, compensation for health-related losses and impairment of age it

Question 54

Environmental examination

Answer 54

Of patient’s home or living institution. Internal and external check. Includes lighting

Question 55

Integumentary examination

Answer 55

Treats skin disorders. Assess patient for prurities (itching), rashes, excessive dryness, edema (swelling), unusual skin growths, changes in skin color/temp, sensory integrity, pain, soreness, and symptoms that indicate respiratory, circulatory, cardiac, or renal diseases - also treats wounds and burns (PT to determine location of wound, size, depth, drainage, skin changes, involved tissues color/temp, involved extremity’s girth, tissue, sensation

Question 56

Burns

Answer 56

3 zones, 3 degrees, respiratory involvement, smoke inhalation and destruction of skin

1. Zone of coagulation were cells are dead
2. Zone of stasis where cells are injured and can die without specialized treatment
3. Zone of hyper is where the injury is minimal and cells can recover

Question 57

Plan of care

Answer 57

PT develops a problem list form evatuation and identifies interventions to help improve the problem
**Plan guides PTA, PTA cannot change it

Question 58

Functional long term goals

Answer 58

Proposed outcomes for patient

Question 59

Medicare POC

Answer 59

Must also include physical therapy diagnosis, type of therapy to be provided, potential of patient to reach functional goals, and intensity, frequency, and duration of POC