Examination and Assessment

Question 1

Q: What are the parts of the SOAP note?

Answer 1

Subjective, Objective, Assessment and Prognosis, Plan of Care

Question 2

Term: Collecting information from patients or responsible parties

Answer 2

Subjective examination

Question 3

Q: What percent of the information you need comes from the subjective examination?

Answer 3

80-90%

Question 4

Term: includes tests and measures

Answer 4

Objective examination

Question 5

Term: identifies the relationship between the findings of the subjective and objective evaluation

Answer 5

Clinical judgement

Question 6

Q: What part of the SOAP note contains reported symptoms?

Answer 6

Subjective

Question 7

Q: What part of the SOAP note contains information on function?

Answer 7

Objective

Question 8

Q: For what part of the SOAP note would you use clinical judgement?

Answer 8

Assessment or evaluation

Question 9

Q:Our clinical judgment allows us to raise “________ ___________”

Answer 9

working, hypotheses

Question 10

Q: During what part of the SOAP note is the diagnosis determined?

Answer 10

Assessment or evaluation

Question 11

Term: combination of symptoms and signs that determine a particular condition.

Answer 11

Clinical syndrome

Question 12

Term: related to the pt’s functional ability, reported by the pt., and/or detected during the objective exam

Answer 12

Problem

Question 13

Term: conditions that may change with the intervention

Answer 13

Problem

Question 14

Term: predicting the pt’s recovery

Answer 14

Prognosis

Question 15

T/F: The diagnosis, problem, and prognosis all fall under the P portion of the SOAP note.

Answer 15

False, under A (assessment)

Question 16

Term: reversing impairments

Answer 16

Remediation

Question 17

Term: changes in the environment and tasks

Answer 17

Compensation or adaptation

Question 18

Term: management of anticipated problem

Answer 18

Prevention

Question 19

Q: Define the acronym SINSS

Answer 19

Severity, irritability, nature, stage, stability

Question 20

Q: What is SINSS used for?

Answer 20

The base for the assessment

Question 21

Q: What are important verbal communication skills to have during an examination? (5)

Answer 21

1. ask one question at a time 2. speak slowly 3. avoid medical jargon 4. make no assumptions 5. belief and empathy

Question 22

Q: What are important non-verbal communication skills to have during an examination? (2)

Answer 22

1. eye contact 2. body language

Question 23

Content: SE - Patient Profile (5)

Answer 23

1. Age
2. Occupation
3. Current daily activity level
4. Recreation/hobbies
5. Psychosocial factors

Question 24

Content: SE (6)

Answer 24

1. Pt. profile
2. Chief complaint
3. Body chart
4. Behavior of symptoms
5. History
6. Pt. goal

Question 25

Content: Chief complaint (7)

Answer 25

1. Pain 2. Stiffness 3. Stability 4. Sensation of instability 5. Weakness 6. Loss of function 7. Surgery/trauma/immbolization

Question 26

T/F: The least stable joint is the knee.

Answer 26

False: Shoulder

Question 27

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

Answer 27

First hypotheses

Question 28

Content: Things to put on the body chart (5)

Answer 28

1. Location/target area 2. Description of pain 3. Clear other (pain free) areas 4. Assign each pain (P1, P2, etc) 5. Establish a relationship between symptoms

Question 29

Content: Pain sensations (2)

Answer 29

1. Nociceptive 2. Peripheral nervous system

Question 30

Content: Types of nociceptive pain (3)

Answer 30

1. visceral - diffuse and difficult to locate 2. Deep somatic 3. Superficial somatic

Question 31

Term: pain that is sickening, deep, squeezing, and dull

Answer 31

Visceral

Question 32

Term: pain that is dull, aching, and poorly localized

Answer 32

Deep somatic

Question 33

Term: pain that is superficial, sharp, and well defined

Answer 33

Superficial somatic

Question 34

Term: pain that is burning, tingling, electrical, stabbing, or pins and needles

Answer 34

Peripheral nervous system

Question 35

Content: Hypotheses based on location (5)

Answer 35

1. Nature of symptoms 2. Source of movement impairments 3. Tissue mechanisms 4. Neurophysiological symptom mechanism 5. Precautions

Question 36

Q: What are the two components to keep in mind when evaluating the behavior of symptoms?

Answer 36

1. Severity 2. Irritability

Question 37

Term: intensity of symptoms and the effect on functional ability

Answer 37

Severity

Question 38

Q: What are the two key components to severity?

Answer 38

1. Intensity 2. Functional ability

Question 39

Term: The amount of activity to produce an exacerbation of symptoms and the time to subside or ease.

Answer 39

Irritability

Question 40

Q: What are the three key components to irritability?

Answer 40

1. Amount of activity 2. Exacerbation 3. Subside

Question 41

Q: Severity: painful, but can perform all work activities - What is the level of severity?

Answer 41

Low

Question 42

Q: Irritability: standing for 30 min aggravates, sitting for 5 min eases - What is the level or irritability?

Answer 42

Min

Question 43

Q: What are the two time frames for behavior of symptoms?

Answer 43

1. Over 24 hrs 2. Over 7 days

Question 44

Term: symptoms that come and go, could be related to sport or work activities.

Answer 44

Over 7 days

Question 45

Diagram: Behavior of Symtpoms

Answer 45

Question 46

Term: details with regard to the present episode

Answer 46

Present History

Question 47

Term: Information with regards to previous episodes of the same or similar disorders

Answer 47

Past history

Question 48

Content: Parts of present history (4)

Answer 48

1. Length of time 2. Onset of symptoms (stage) 3. Progression (stability) 4. Comparison symtpoms now with inital stage

Question 49

Q: What are the 3 stages of symptoms?

Answer 49

1. Acute or inflammatory 2. Subacute or tissue formation 3. Chronic or remodeling

Question 50

Term: stage lasting 7-10 days

Answer 50

Acute

Question 51

Term: stage lasting 10 days to weeks

Answer 51

Subacute

Question 52

Term: stage lasting more than several weeks

Answer 52

Chronic

Question 53

Content: Parts of past history (4)

Answer 53

1. Episode frequency 2. Possible treatments and outcomes 3. Comparison with the current problem 4. Activity limiation

Question 54

Content: Hypotheses based on history (4)

Answer 54

1. Precautions and contraindications 2. Sources of dysfunction 3. Psychosocial factors 4. Management

Question 55

Q: The following items fall under what category of the SE? - General health, medication, BP, previous operations, lab results, imaging, CV or resp problems

Answer 55

Special questions

Question 56

Q: What 4 vital signs are important to take note of?

Answer 56

1. Temperature 2. HR 3. BP 4. RR

Question 57

Diagram: Ex. SE

Answer 57

Question 58

Content: Parts of the assessment (4)

Answer 58

1. Diagnostic hypothesis (SINSS) 2. Problem list 3. Intervention plan (Rx) 4. Prognosis

Question 59

T/F: Putting the SINNS together helps in determining the diagnostic hypothesis.

Answer 59

True

Question 60

Content: Positives when determining prognosis (3)

Answer 60

1. Pt. age 2. Understands condition 3. Motivated

Question 61

Content: Negatives when determining the prognosis (3)

Answer 61

1. Chronic condition 2. Job 3. No improvement with treatment (recurrence)