Clinical Assessment Flashcards
what does soap stand for?
-subjective, objective, assessment, plan
symptoms:
- symptoms are described by the patient
- severe headache, muscle pain, stiff neck, dislike bright lights, etc
signs:
- can be noted by examiner
- vomiting, fever, blotchy skin, confusion, convulsions, drowsy/dizzy
subjective; tips for conducting good clinical history
- smile
- eye contact
- ask open-ended questions (allows them to elaborate)
- empathize
- show competence without arrogance
- use clear language (minimize jargon/science talk)
- ensure privacy
- create space for question
- establish expectations (what assessments will look like)
- summarize what they told you (show you have been actively listening)
Elements of Subjective Assessment: History of Current Condition
- when it happened, how long has it been, what was MOI
Elements of Subjective Assessment: past history of current history
- have you had this before?
- have you had any lower extremity injuries?, etc…
Elements of Subjective Assessment: Past Medical/Surgical History
- have they had any previous surgery or imaging done in this area
Elements of Subjective Assessment: Medications
- have you taken any meds such as anti-inflammatories what would clear inflammation?
Elements of Subjective Assessment: Diagnostic tests
- any imaging? what does report say? what was the diagnosis?
Elements of Subjective Assessment: social habits
- what do they like to do for fun?
- work?
- this gives sense for types of movements in terms of repetition and load
Elements of Subjective Assessment: social history
- suggests what position they are in outside of sports or work,
- they may be a grandparent and lifting kids up
- they may be a gardener, etc
Elements of Subjective Assessment: family history
-example; x ray suggests OA, do you have a family history of OA?
Elements of Subjective Assessment: living environment
- post surgical and on crutched; how many stairs are in your house? do you have easy access to bathroom?, is bathroom same level as bedroom?
- do you need modification such as raise toilet or shower seat
- what social supports do they have that can help do activities at home? PSW?
Elements of Subjective Assessment: Occupation
- what does demands of job look like
Elements of Subjective Assessment: functional status/activity level
most important
- if we know their functional status before an injury we have a goal to work back to
- if person was an elite runner, we can ask if their goal is to return back to that level
- cannot assume someone is active, if we assume they are but they are actually sedentary, then we might prescribe exercises that are outside of their capabilities
Biopsychosocial Factors: Yellow Flag
- yellow refers to psychological or behavioural risk factors for prolonged disability (anxiety, lack of coping strategies)
- we want to refer or identify these risks that prolong ability
- if we can identify yellow flags we can refer to people who specialize in treating those flags such as someone who can help decrease anxiety, or stress that will have a positive output on bettering symptoms
Biopsychosocial Factors: Blue Flags
- conditions in the workplace that may inhibit recovery (poor relations with co workers or boss, high work demands)
- this will effect whether someone has a positive outlook to recover to return to work
- injury at workplace; number one predictor if they will recover and return to work is if they like their boss.
- psychological factor
- get people to talk through feelings about work
Biopsychosocial Factors: Black Flags
- organizational issues (workers comp, attitudes towards the sick worker)
- does person feel pressure to go to work early
- do they feel supported?
- if there is a case where someone is suing; may take longer to recover because they think outcome will be better
Red Flags
- need to screen for serious pathology to determine whether urgent transfer to emergency room is necessary
- asking closed-ended questions to be efficient
- be very explicit and clear, especially when assessing for a fracture
- ask if they feel they have a concern for something serious that may need referral
General Red Flag Screening: Cancer
- potential cause of pain with any assessment
- general malaise (fatigue) unlike normal
- unexplained fever
- unexplained weight loss (>5kg in 2 weeks)
- personal and/or family history of cancer
- unrelenting pain (particularly at night) independent and doesn’t matter what posture you are in
General Red Flag Screening: Infection
- redness, heat, change in function
- pain at rest or at night (inflammation)
- movement-independent pain; at rest do you have pain or only with movement? pain at rest is more nociceptive inflammatory pain
- fever
- general malaise
- night sweats
General Red Flag Screening: Fractures
- traumatic MOI
- identify fracture and educate them to take weight off it
- if not improving; even with rest, people can have pain every time they weight bear even after 2 weeks of rest
- severe pain; pain at night, unrelenting
- history of corticosteroid use?? decreases bone density
Region Specific (Neck) Red Flag Screening Vertebral-Basilar Insufficiency
- 5 D’s and 3 N’s
- dizziness
- diplopia (double vison)
- dysphagia (trouble swallowing)
- drop attacks (fainting spells)
- dysarthria (trouble speaking)
- numbness (more so around mouth)
- nystagmus- uncontrolled eye movement
- nausea
Objective Assessment
- look at observations (posture, asymmetries, impaired function)
- neuro exam (if applicable); assess nerves, dermatome, myotomes, reflexes and ROM (active > passive)
- strength testing (isometric MRC)
- joint stability; helps rule out ligamentous injuries
- special tests; rule in or out remaining conditions left
- palpation- poke areas we suspect are culprits
- least aggravating to most
Differentiating Inert and Contractile Tissue Injuries: Inert
- can’t move under own volition: it would include joint-joint capsule ligament
- painful when stretched
Differentiating Inert and Contractile Tissue Injuries: contractile
- what can contract
- muscle, tendon, musculotendinous junction
painful with:
- active contraction (AROM and isometric testing of agonist)
- passive stretching (AROM, PROM through antagonist)-if you hurt bicep and passively stretch it, it will still hurt
Inert: AROM
- pain in parts of ROM where ligament is stretched (closed-pack position)
- point in ROM where joint is locked (2 ends of bones are brought together and all structures around it are most stressed from inert standpoint)
- closed-pack is most stable, open pack is joint is open and inert structures are more relaxed
Inert: PROM
- pain in parts of the ROM where the ligament is stretched (closed-pack position)
Inert: Resisted Isometric
- no pain; isometric means not moving and since joints aren’t moving and stretching ligaments there is no pain
Contractile: AROM
- pain with agonist contraction, weakness
- possibly pain with antagonist AROM–> from stretching it
Contractile: PROM
- no pain with agonist (PROM) -slackened; Biceps, if you passively bring it into flexion, bicep isn’t activated so it is slackened
- possibly pain with antagonist PROM (stretch)
Contractile: Resisted Isometric
- pain and weakness with agonist contraction; if we turn on injured muscles it will hurt
- no pain with antagonist isometric
MCL sprain: flexion- AROM
- MCL is being slackened (knee flexion)
MCL sprain: flexion- PROM
- MCL is being slackened