Clinical Assessment Flashcards
Define diagnosis
A term denoting the disease or syndrome a person has or is believed to have
Identification and naming of a disease
What are some ways to gather information in order to make a diagnosis?
Identification of a disease by history, physical examination, laboratory studies, and radiological studies.
What act are diagnosis protected under?
Regulated Health Professions Act
What is a requirement in order to be permitted to give a diagnosis?
Professions able to communicate a diagnosis have access and training to interpret diagnostic tests.
Define Assessment
An appraisal or evaluation of a patient’s condition
An educated evaluation of a clients condition and physical basis for their symptoms.
What is the goal of an assessment?
A means to fully understand that patients problems, from the patients perspective as well as the clinicians, and the physical basis for the symptoms that have caused the patient to complain.
Define Impairment
Any loss or abnormality of psychological, physiological, or anatomical structure or function.
Impairment of the client’s body structure or function.
What are some ways impairment occurs?
Medical condition, Pathology or injury
Can an impairment be treated using a wellness model of care?
Yes
What are the 5 reasons it is required we assess?
- Safe treatment plan
- Effective treatment plan
- Monitor progress/ effectiveness
- A means to communicate with other health professionals.
- Required by law
What four things a therapist should know in order to carry out a safe treatment plan?
- Identify red flags (Serious underlying pathologies)
- Previous injury
- Medications
- Underlying health condition or pathology that may contraindicate the treatment.
What information should be gathered in order to carry out an effective treatment?
- Identify clients goals
- Identify impairments
- Establish goals for treatment
- Facilitates treatment that has direction and intent
- ensures that you are treating the cause of the complaint, otherwise treatment will yield poor results.
What are SOAP notes?
Soap notes are an acronym that stands for: Subjective information Objective Information Assessment Plan
What information should be included in Subjective Data?
Patients perception of current symptoms
Health history
If a client is returning for the second time what information should be collected to be put under subjective data?
Have their symptoms changed? and did they comply with self care.
What information should be included in objective data?
Practitioners observations, testing, and physical findings.
What are some ways to find objective data?
Postural observations
Palpation
Functional/ROM testing and special orthopedic tests
The assessment portion of the intake process should include?
- what you believe the cause of the complaint to be
- an interpretation of the subjective & objective data
- concise statement that can include more then one finding.
Your interpretation of the subjective and objective information in student clinic would be known as?
A clinical impression
The planning portion of the intake process should include?
- What the therapist will do to treat the problem
- Treatment aims/ goals are stated along with the strategies to attain them.
- Techniques used i.e type of massage, stretching, TrT therapy, self care, hydrotherapy, client education)
- what structure those techniques were applied to and for how long
- number and frequency of future treatments & when to re-examine.
What are the 6 steps to the evaluation process during intake?
Step 1: Conduct Subjective Examination
Step 2: Generate preliminary Clinical Hypothesis
Step 3: Conduct Objective Examination
Step 4: Confirm the clinical Hypothesis
Step 5: Summarize Clinical Findings
Step 6: Determine Appropriateness for Treatment
What is involved in conducting a Subjective examination?
- Determine if there is a specific diagnosis
If so ask relating questions to the diagnosis
What happens if while conducting a subjective examination no prior diagnosis has been given?
elicit general information that serves to clarify the presenting problem and suggest a clinical diagnosis.
What is involved when conducting an objective examination?
- Observe Client
- Select Tests & Measures
- Examine the client
Generally what sequence should an assessment protocol follow?
- Case History
- Observation
- Palpation
- Rule outs
- Functional tests
- Special Tests
- Muscle Tests
- Neurological Tests
- Joint Play examination
- Lesion site palpation
Which tests of the assessment protocol involve ROM/ AF/ PR/ AR?
Functional tests
What are the 8 guide lines of clinical assessment?
- Observe bilaterally
- Test unaffected side first
- Do the most painful test last
- If pain is reported during a test stop and identify location and nature of the pain.
- Take a thorough case history
- Always support the limp in a secure neutral position
- Rule out the proximal and distal joints
- Be aware of referred pain
Describe the position High seated?
Hips and knees are at 90 degree flexion
Describe Long seated position?
Hips at 90 degree flexion, knees extended
Describe the position Hook lying?
Supine, hips at 45 degrees flexion, knees at 90 degree flexion
Is it ever ok to ask closed ended questions?
Yes at times it will help you gather important information and keep the interview focused.
What general information should be gathered during the intake?
Presenting Complaint General Health Occupation M.D & Meds Previous Injury Pain Function Therapies Current Symptoms
What are the two types or causes of pain?
Inflammatory
Mechanical
What causes pain during an inflammatory response?
Pain results from chemical irritants of inflammation
Pain as a result of swelling
What causes a mechanical response to pain?
Pain results from the stretch or compression of pain and sensitive structures
These structures contain nociceptors, when they are stimulated, produce painful sensations.
Define Acute pain?
Pain provoked by a harmful stimulation produced by injury or disease
Define chronic pain?
Pain that persists beyond the usual course of healing
Chronic pain syndrome?
A clinical syndrome in which clients present high levels of pain that is chronic in duration.
Define neurogenic Pain?
Pain as a result of non inflammatory dysfunction of the peripheral or central nervous system that does not involve nociceptors stimulation or trauma
Define referred Pain?
Pain that is felt at another location of the body that is distant from the tissues that have caused it.
Why does referred pain occur?
occurs because the same or adjacent neural segments supply the referred site
Radiculopathy is also know as?
Radicular or nerve root pain
What is radiculopathy?
Pain that is felt in a dermatome, myotome, or sclerotome
What does radiculopathy involve?
Spinal nerve or nerve root
What is a dermatome?
an area of the skin supplied by one dorsal nerve root
What can cause dermatome pain?
Injury can cause sensory alteration to the skin, or pain (usually burning or electric)
What is myotome?
A group of muscles supplied by one nerve root
What is sclerotomal?
An area of bone or fascia innervated by a nerve root.
Define visceral pain?
Pain that can be felt in a dermatome as a result of visceral injury
What is trigger point pain?
referred pain arising from a trigger point
What are some pain syndromes untreated trigger points can cause?
radiculopathy
tension headaches
frozen shoulders
tennis elbow
What does the acronym LOFDSAQ stand for?
Location Onset Frequency Duration Severity Aggravating/ relieving Quality
What is Peripheralization?
As lesions worsens, the area of pain enlarges and moves distally from the original lesion this is known as peripheralization
As the pain resolves it becomes more localized this is known as?
centralization
What does it mean when pain is coming from a local area?
Usually indicates a lesion to a superficial structure such as muscles or tendons
What does it mean when pain is diffused?
Pain that is not coming from one localized area
What kind of injuries can cause diffused pain?
Injury to a deep neural somatic structure Joint subluxation or dislocation Severe hematoma Fractures Trigger Points
What are some questions that need to be answered when it comes to onset?
Was there a mechanism of injury (MOI)
How quickly did the pain or dysfunction begin
What does insidious onset mean?
It means it happens gradually
When someone reports of experiencing pain in an area all the time what might that indicate?
Usually indicates a severe injury or still in an active inflammatory state
When do ligaments cause pain?
When they are overstretched
When do muscles cause pain?
When contracted or stretched
What can sometime cause pain in the morning?
Sometimes caused by adaptive shortening
What does pain and stiffness in the more sometimes indicate?
Intrascapular swelling that builds overnight due to inactivity
Pain at night often indicates?
suggest inflammation due to overuse/ excessive stress
Postural strain
What does pain during weight bearing often indicate?
Pain only with weight bearing suggests articular (joint surface) or muscular injury
What are three ways to measure the severity of pain?
Verbal pain scale
Visual Analogue scale
mild/ moderate/ severe
What is something to look for when discussing aggravating factors of an injury?
any specific movements or positions that reproduce the pain
When pain is associated with feeling sharp if frequently means that the pain typically is coming from what part of the body?
The Skin and fascia Superficial muscle superficial ligament acute inflammation periosteum (tennis elbow) Radicular pain
When pain is felt as being dull it is usually coming from what part of the body?
Joints deep muscle Chronic muscles injuries subchondral bone chronic inflammation deep or peripheral nerve trigger points reffered pain
When pain is felt as tingling or parasthesia it usually comes from?
Nerve injury
Circulatory problems
What can cause numbness?
Can be caused by damage or impingement of nerve innervating a particular area.
What does the sensation of a twinge pain feel similar to?
plucking on a string
What can cause a twinge?
Could be due to a local injury to a muscle or ligament
What can cause snapping or clicking?
Can be caused by a tendon flipping over a bone, thickened bursa, meniscal tear, or synovial plica
What causes “grating”?
grating is most commonly caused by osteoarthritic changes to the joint
Sound of tearing during an injury may indicate what?
a muscle or ligament tearing
When a joint locks or catches what may this suggest about the injury?
That there is a loose body within the joint
What is a loose body?
Meniscal tear in which the part torn off stays within the joint capsule
When a joint gives way or is unstable what might this suggest?
severe joint injury damage especially to primary stabilizing ligaments
What causes popping in a joint?
caused by negative pressure within a tendon synovial sheath, a tendon flipping over a boney prominence, or possibly by rupture of ligament or tendon
When conducting an observation on a patient what are some things to look for?
Swelling Altered function Redness Deformities Imbalances
When palpating what is the most important T of the 4 T’s?
Temperature
What are the four T’s of palpation?
Texture
Tone
Tenderness
Temperature
When conducting rules what is a good starting point?
to assess the joints above and below the affected area
What is an active free test?
Amount of joint motion that can be achieved by the client during the performance of unassisted voluntary joint motion
What is an passive relaxed test?
Amount of joint motion available when an examiner moves a joint through its anatomical or physiological range, without assistance from the client, while the client is relaxed.
What is an active resisted test?
Used to determine the status of the contractile unit with the use of controlled isometric contractions, along the normal planes of movement of a given joint.
Resistance during an active resisted test should last for durations of how long?
5 seconds at a time
What range should your patient be in when conducting active resistance test?
Midrange
Which functional test typically should always be done first?
Active free test
How is the arrangement of testing done?
Most painful last
What kinds of tissues does passive testing engage?
Inert tissue and contractile tissue
What kinds of tissues does resisted testing engage?
engages contractile tissue only
What is the goal of functional testing?
To try and reproduce the pain/ dysfunction
What should be documented when conducting an active free test?
willingness to move the joint clients mobility or available ROM Amount of observable restriction Pain Quality of movement Compensation Noises
If a client comes in with a strained muscle what should be the order of testing?
Active free/ passive relaxed/ active resisted
If a client comes in with an injury to a ligament what should be the order of testing?
Active free/ Active resisted/ passive relaxed
How much force should be used during passive relaxed testing?
Enough force to determine the clients limitations
What does passive relaxed test test?
test the inert joint structures
What two tests can cause contractile tissue pain?
Passive relaxed and active resisted
What should be documented when conducting a passive relaxed test?
Hypermobility
Hypomobility
If, when, and where they feel pain
the end feel i.e bone on bone
what technique is used to feel the end feel or end range?
Over Pressure
What are Cyriax’s six end feels?
- Tissue approximation
- bone to bone
- Tissue Stretch
- Muscle spasm
- Capsular
- Spring block
- Empty end feel
what example off tissue approximation?
knee flexion
What is an example of bone to bone?
Elbow extension
What is an example of tissue stretch?
Internal rotation
What is an example of capsular?
Early stretch
What Cyriax notes four possible findings with resisted testing?
- Strong and Painless
- Strong and painful
- Weak and painless
- Weak and painful
What does strong and painless result from a resistance test usually mean?
1-2 degree muscle strain
A minor lesion
What does weak and painless results from a resistance test usually mean?
Interruption of nerve supply/ compression syndrome
Complete rupture of a muscle tendon
Nerve torn off no pain
What does weak and painful results from a resistance test usually mean?
Partial rupture of a muscle tendon
painful inhibition caused by pathology
What is Oxford Manual Muscle testing scale?
Rated 0-5 0 no contraction 1 slight 2 produce movement with gravity eliminated 3 overcome gravity 4 overcome some resistance 5 overcomes maximal resistance
When should palpation be performed?
at assessment points and through out the treatment
What questions should you be trying to answer while palpating?
What is the structure what is the quality how does it differ from others how does this relate to clients history How does the structure reflect clients function
What are the most common errors of palpation?
Lack of concentration/ too much pressure/ too much movement
What is a technique that can be used to asses the tissue when palpating?
Drag
What does turgor mean?
Fluid pressure
What is a physiological barrier?
range of motion of normal circumstances
midrange is the range with least amount of resistance
What is a elastic barrier?
When tissue is passed its passive range
What is an anatomical barrier?
final resistance to normal range any further movement will cause damage to the tissue
What is a fasciculations?
They are localized subconscious muscle contractions that do not involve the who muscle
What does crepitus mean?
Clicks or crunchy
