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ATwithEmily > Chapter 6 - Clinical Assessment and Diagnosis > Flashcards

Chapter 6 - Clinical Assessment and Diagnosis Flashcards

1
Q

Which assessment model is commonly used for a therapeudic intervention plan?

A

SOAP

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2
Q

Which assessment model is commonly used for an orthopedic assessment?

A

HOPS

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3
Q

Which assessment model is commonly used for a medical assessment?

A

HPE

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4
Q

What is a diagnostic sign?

A

An objective, measureable, physical finding (what you see, hear, feel, etc.)

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5
Q

What is a symptom?

A

information provided by the patient regarding their perception of the problem

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6
Q

What is the review of systems in an HPE?

A

Questions that target each of the body systems to screen for potential problems.

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7
Q

What does HOPS stand for?

A

history, observation palpating, stress tests

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8
Q

What is included in the S componant of a SOAP?

A

subjective, perceived state/ attitude

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9
Q

What is included in the O componant of a SOAP?

A

objective, measurable

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10
Q

What is included in the A componant of a SOAP?

A

assessment, injury severity, status, diagnosis

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11
Q

What is included in the P componant of a SOAP?

A

plan, modalities, exercise, functional
activities to achieve goals - immediate tx,
frequency/ duration, eval standards, patient
education, discharge criteria

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12
Q

When should short term goals be set for?

A

daily, weekly, updated regularly

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13
Q

When should long-term goals be set for?

A

@ end of rehab period

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14
Q

Which pain is a result of muscles, tendons, bones, the skin, and joints?

A

Somatic pain

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15
Q

Which pain is a result of organs, thoracic or abdominal cavity?

A

Viceral Pain

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16
Q

Where is the reffered pain for the liver?

A

right shoulder

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17
Q

Where is the reffered pain for the heart and spleen?

A

left shoulder

18
Q

What is the difference between observation and inspection?

A

Observation is overall appearance (like gait, movement patterns, etc.)
Inpection is at the injury site (SHARP)

19
Q

What is an antalgic gait?

A

a limp

20
Q

What things should be looked for with palpation? (8)

A
  1. Temperature
  2. Swelling
  3. Point Tenderness
  4. Crepitus
  5. Deformity
  6. Muscle Spasm
  7. Cutaneous Sensation
  8. Pulse
21
Q

What are the three normal joint end-feels during ROM and what do they mean

A

Soft - soft tissue approx
Firm - tissue, muscle, or lig. stretch
Hard - bone to bone

22
Q

What are the four abnormal joint end-feels during ROM?

A

Soft - sooner than normal
Firm - sooner than normal
Hard - occurs in joint that doesnt normally have one
Empy - end range never reached

23
Q

What are three reasons for an abnormal soft end feel?

A

soft-tissue edema
synovitis
ligamentus stretch or tear

24
Q

What are three reasons for an abnormal firm end feel?

A

increased muscular tonus
capsular, muscular, ligamentus shortening

25
Q

What are five reasons for an abnormal hard end feel?

A

chondromalacia
osteoarthritis
loose bodies in joint
myositis ossificans
fracture

26
Q

What are four reasons for an abnormal empty end feel?

A

acute joint inflammation
bursitis
fracture
psychogenic

27
Q

What is the C1-C2 myotome?

A

neck flexion

28
Q

What is the C3 myotome?

A

neck lateral flexion

29
Q

What is the C4 myotome?

A

Shoulder elevation

30
Q

What is the C5 myotome?

A

Shoulder abduction

31
Q

What is the C6 myotome?

A

Elbow flexion, wrist extension

32
Q

What is the C7 myotome?

A

Elbow extension, wrist flexion

33
Q

What is the C8 myotome?

A

Jazz hands/ thumb extension + ulnar deviation

34
Q

What is the T1 myotome?

A

intrinsic muscles of the hand

35
Q

What is the L1-L2 myotome?

A

Hip flexion

36
Q

What is the L3 myotome?

A

Knee extension

37
Q

What is the L4 myotome?

A

Ankle Dorsiflexion

38
Q

What is the L5 myotome?

A

Toe extension

39
Q

What is the S1 myotome?

A

Plantarflexion, eversion, and hip extension

40
Q

What is the S2 myotome?

A

Knee flexion

41
Q

What are the eight basic principles of documentation?

A
  1. correct medical terminology
  2. use only accepted medical abbriviations
  3. correct punctuation
  4. accurate as possible
  5. brevity
  6. write legibly
  7. complete document at time of rendered service
  8. sign and date each document clearly

ATwithEmily (13 decks)

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