Chapter 6 - Clinical Assessment and Diagnosis Flashcards
Which assessment model is commonly used for a therapeudic intervention plan?
SOAP
Which assessment model is commonly used for an orthopedic assessment?
HOPS
Which assessment model is commonly used for a medical assessment?
HPE
What is a diagnostic sign?
An objective, measureable, physical finding (what you see, hear, feel, etc.)
What is a symptom?
information provided by the patient regarding their perception of the problem
What is the review of systems in an HPE?
Questions that target each of the body systems to screen for potential problems.
What does HOPS stand for?
history, observation palpating, stress tests
What is included in the S componant of a SOAP?
subjective, perceived state/ attitude
What is included in the O componant of a SOAP?
objective, measurable
What is included in the A componant of a SOAP?
assessment, injury severity, status, diagnosis
What is included in the P componant of a SOAP?
plan, modalities, exercise, functional
activities to achieve goals - immediate tx,
frequency/ duration, eval standards, patient
education, discharge criteria
When should short term goals be set for?
daily, weekly, updated regularly
When should long-term goals be set for?
@ end of rehab period
Which pain is a result of muscles, tendons, bones, the skin, and joints?
Somatic pain
Which pain is a result of organs, thoracic or abdominal cavity?
Viceral Pain
Where is the reffered pain for the liver?
right shoulder
Where is the reffered pain for the heart and spleen?
left shoulder
What is the difference between observation and inspection?
Observation is overall appearance (like gait, movement patterns, etc.)
Inpection is at the injury site (SHARP)
What is an antalgic gait?
a limp
What things should be looked for with palpation? (8)
- Temperature
- Swelling
- Point Tenderness
- Crepitus
- Deformity
- Muscle Spasm
- Cutaneous Sensation
- Pulse
What are the three normal joint end-feels during ROM and what do they mean
Soft - soft tissue approx
Firm - tissue, muscle, or lig. stretch
Hard - bone to bone
What are the four abnormal joint end-feels during ROM?
Soft - sooner than normal
Firm - sooner than normal
Hard - occurs in joint that doesnt normally have one
Empy - end range never reached
What are three reasons for an abnormal soft end feel?
soft-tissue edema
synovitis
ligamentus stretch or tear
What are three reasons for an abnormal firm end feel?
increased muscular tonus
capsular, muscular, ligamentus shortening
What are five reasons for an abnormal hard end feel?
chondromalacia
osteoarthritis
loose bodies in joint
myositis ossificans
fracture
What are four reasons for an abnormal empty end feel?
acute joint inflammation
bursitis
fracture
psychogenic
What is the C1-C2 myotome?
neck flexion
What is the C3 myotome?
neck lateral flexion
What is the C4 myotome?
Shoulder elevation
What is the C5 myotome?
Shoulder abduction
What is the C6 myotome?
Elbow flexion, wrist extension
What is the C7 myotome?
Elbow extension, wrist flexion
What is the C8 myotome?
Jazz hands/ thumb extension + ulnar deviation
What is the T1 myotome?
intrinsic muscles of the hand
What is the L1-L2 myotome?
Hip flexion
What is the L3 myotome?
Knee extension
What is the L4 myotome?
Ankle Dorsiflexion
What is the L5 myotome?
Toe extension
What is the S1 myotome?
Plantarflexion, eversion, and hip extension
What is the S2 myotome?
Knee flexion
What are the eight basic principles of documentation?
- correct medical terminology
- use only accepted medical abbriviations
- correct punctuation
- accurate as possible
- brevity
- write legibly
- complete document at time of rendered service
- sign and date each document clearly
