Examination and Assessment Flashcards
Q: What are the parts of the SOAP note?
Subjective, Objective, Assessment and Prognosis, Plan of Care
Term: Collecting information from patients or responsible parties
Subjective examination
Q: What percent of the information you need comes from the subjective examination?
80-90%
Term: includes tests and measures
Objective examination
Term: identifies the relationship between the findings of the subjective and objective evaluation
Clinical judgement
Q: What part of the SOAP note contains reported symptoms?
Subjective
Q: What part of the SOAP note contains information on function?
Objective
Q: For what part of the SOAP note would you use clinical judgement?
Assessment or evaluation
Q:Our clinical judgment allows us to raise “________ ___________”
working, hypotheses
Q: During what part of the SOAP note is the diagnosis determined?
Assessment or evaluation
Term: combination of symptoms and signs that determine a particular condition.
Clinical syndrome
Term: related to the pt’s functional ability, reported by the pt., and/or detected during the objective exam
Problem
Term: conditions that may change with the intervention
Problem
Term: predicting the pt’s recovery
Prognosis
T/F: The diagnosis, problem, and prognosis all fall under the P portion of the SOAP note.
False, under A (assessment)
Term: reversing impairments
Remediation
Term: changes in the environment and tasks
Compensation or adaptation
Term: management of anticipated problem
Prevention
Q: Define the acronym SINSS
Severity, irritability, nature, stage, stability
Q: What is SINSS used for?
The base for the assessment
Q: What are important verbal communication skills to have during an examination? (5)
- ask one question at a time 2. speak slowly 3. avoid medical jargon 4. make no assumptions 5. belief and empathy
Q: What are important non-verbal communication skills to have during an examination? (2)
- eye contact 2. body language
Content: SE - Patient Profile (5)
- Age
- Occupation
- Current daily activity level
- Recreation/hobbies
- Psychosocial factors
Content: SE (6)
- Pt. profile
- Chief complaint
- Body chart
- Behavior of symptoms
- History
- Pt. goal
Content: Chief complaint (7)
- Pain
- Stiffness
- Stability
- Sensation of instability
- Weakness
- Loss of function
- Surgery/trauma/immbolization
T/F: The least stable joint is the knee.
False: Shoulder
Content: consider the following 1. Movement dysfunction 2. Neurophysiological symptoms 3. Contraindications 4. Illness experience and behavior 5. Treatment objectives 6. Prognosis - short and long term effects
First hypotheses
Content: Things to put on the body chart (5)
- Location/target area
- Description of pain
- Clear other (pain free) areas
- Assign each pain (P1, P2, etc)
- Establish a relationship between symptoms
Content: Pain sensations (2)
- Nociceptive
- Peripheral nervous system
Content: Types of nociceptive pain (3)
- visceral - diffuse and difficult to locate
- Deep somatic
- Superficial somatic
Term: pain that is sickening, deep, squeezing, and dull
Visceral
Term: pain that is dull, aching, and poorly localized
Deep somatic
Term: pain that is superficial, sharp, and well defined
Superficial somatic
Term: pain that is burning, tingling, electrical, stabbing, or pins and needles
Peripheral nervous system
Content: Hypotheses based on location (5)
- Nature of symptoms
- Source of movement impairments
- Tissue mechanisms
- Neurophysiological symptom mechanism
- Precautions
Q: What are the two components to keep in mind when evaluating the behavior of symptoms?
- Severity 2. Irritability
Term: intensity of symptoms and the effect on functional ability
Severity
Q: What are the two key components to severity?
- Intensity 2. Functional ability
Term: The amount of activity to produce an exacerbation of symptoms and the time to subside or ease.
Irritability
Q: What are the three key components to irritability?
- Amount of activity 2. Exacerbation 3. Subside
Q: Severity: painful, but can perform all work activities - What is the level of severity?
Low
Q: Irritability: standing for 30 min aggravates, sitting for 5 min eases - What is the level or irritability?
Min
Q: What are the two time frames for behavior of symptoms?
- Over 24 hrs 2. Over 7 days
Term: symptoms that come and go, could be related to sport or work activities.
Over 7 days
Diagram: Behavior of Symtpoms
Term: details with regard to the present episode
Present History
Term: Information with regards to previous episodes of the same or similar disorders
Past history
Content: Parts of present history (4)
- Length of time
- Onset of symptoms (stage)
- Progression (stability)
- Comparison symtpoms now with inital stage
Q: What are the 3 stages of symptoms?
- Acute or inflammatory
- Subacute or tissue formation
- Chronic or remodeling
Term: stage lasting 7-10 days
Acute
Term: stage lasting 10 days to weeks
Subacute
Term: stage lasting more than several weeks
Chronic
Content: Parts of past history (4)
- Episode frequency
- Possible treatments and outcomes
- Comparison with the current problem
- Activity limiation
Content: Hypotheses based on history (4)
- Precautions and contraindications
- Sources of dysfunction
- Psychosocial factors
- Management
Q: The following items fall under what category of the SE?
- General health, medication, BP, previous operations, lab results, imaging, CV or resp problems
Special questions
Q: What 4 vital signs are important to take note of?
- Temperature
- HR
- BP
- RR
Diagram: Ex. SE
Content: Parts of the assessment (4)
- Diagnostic hypothesis (SINSS)
- Problem list
- Intervention plan (Rx)
- Prognosis
T/F: Putting the SINNS together helps in determining the diagnostic hypothesis.
True
Content: Positives when determining prognosis (3)
- Pt. age
- Understands condition
- Motivated
Content: Negatives when determining the prognosis (3)
- Chronic condition
- Job
- No improvement with treatment (recurrence)
