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PTRS 745 Exam 1 > Examination and Assessment > Flashcards

Examination and Assessment Flashcards

1
Q

Q: What are the parts of the SOAP note?

A

Subjective, Objective, Assessment and Prognosis, Plan of Care

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2
Q

Term: Collecting information from patients or responsible parties

A

Subjective examination

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3
Q

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

A

80-90%

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4
Q

Term: includes tests and measures

A

Objective examination

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5
Q

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

A

Clinical judgement

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6
Q

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

A

Subjective

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7
Q

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

A

Objective

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8
Q

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

A

Assessment or evaluation

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9
Q

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

A

working, hypotheses

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10
Q

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

A

Assessment or evaluation

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11
Q

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

A

Clinical syndrome

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12
Q

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

A

Problem

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13
Q

Term: conditions that may change with the intervention

A

Problem

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14
Q

Term: predicting the pt’s recovery

A

Prognosis

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15
Q

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

A

False, under A (assessment)

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16
Q

Term: reversing impairments

A

Remediation

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17
Q

Term: changes in the environment and tasks

A

Compensation or adaptation

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18
Q

Term: management of anticipated problem

A

Prevention

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19
Q

Q: Define the acronym SINSS

A

Severity, irritability, nature, stage, stability

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20
Q

Q: What is SINSS used for?

A

The base for the assessment

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21
Q

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

A
  1. ask one question at a time 2. speak slowly 3. avoid medical jargon 4. make no assumptions 5. belief and empathy
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22
Q

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

A
  1. eye contact 2. body language
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23
Q

Content: SE - Patient Profile (5)

A
  1. Age
  2. Occupation
  3. Current daily activity level
  4. Recreation/hobbies
  5. Psychosocial factors
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24
Q

Content: SE (6)

A
  1. Pt. profile
  2. Chief complaint
  3. Body chart
  4. Behavior of symptoms
  5. History
  6. Pt. goal
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25
Q

Content: Chief complaint (7)

A
  1. Pain
  2. Stiffness
  3. Stability
  4. Sensation of instability
  5. Weakness
  6. Loss of function
  7. Surgery/trauma/immbolization
26
Q

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

A

False: Shoulder

27
Q

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

A

First hypotheses

28
Q

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

A
  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
29
Q

Content: Pain sensations (2)

A
  1. Nociceptive
  2. Peripheral nervous system
30
Q

Content: Types of nociceptive pain (3)

A
  1. visceral - diffuse and difficult to locate
  2. Deep somatic
  3. Superficial somatic
31
Q

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

A

Visceral

32
Q

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

A

Deep somatic

33
Q

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

A

Superficial somatic

34
Q

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

A

Peripheral nervous system

35
Q

Content: Hypotheses based on location (5)

A
  1. Nature of symptoms
  2. Source of movement impairments
  3. Tissue mechanisms
  4. Neurophysiological symptom mechanism
  5. Precautions
36
Q

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

A
  1. Severity 2. Irritability
37
Q

Term: intensity of symptoms and the effect on functional ability

A

Severity

38
Q

Q: What are the two key components to severity?

A
  1. Intensity 2. Functional ability
39
Q

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

A

Irritability

40
Q

Q: What are the three key components to irritability?

A
  1. Amount of activity 2. Exacerbation 3. Subside
41
Q

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

A

Low

42
Q

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

A

Min

43
Q

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

A
  1. Over 24 hrs 2. Over 7 days
44
Q

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

A

Over 7 days

45
Q

Diagram: Behavior of Symtpoms

A
46
Q

Term: details with regard to the present episode

A

Present History

47
Q

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

A

Past history

48
Q

Content: Parts of present history (4)

A
  1. Length of time
  2. Onset of symptoms (stage)
  3. Progression (stability)
  4. Comparison symtpoms now with inital stage
49
Q

Q: What are the 3 stages of symptoms?

A
  1. Acute or inflammatory
  2. Subacute or tissue formation
  3. Chronic or remodeling
50
Q

Term: stage lasting 7-10 days

A

Acute

51
Q

Term: stage lasting 10 days to weeks

A

Subacute

52
Q

Term: stage lasting more than several weeks

A

Chronic

53
Q

Content: Parts of past history (4)

A
  1. Episode frequency
  2. Possible treatments and outcomes
  3. Comparison with the current problem
  4. Activity limiation
54
Q

Content: Hypotheses based on history (4)

A
  1. Precautions and contraindications
  2. Sources of dysfunction
  3. Psychosocial factors
  4. Management
55
Q

Q: The following items fall under what category of the SE?

  • General health, medication, BP, previous operations, lab results, imaging, CV or resp problems
A

Special questions

56
Q

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

A
  1. Temperature
  2. HR
  3. BP
  4. RR
57
Q

Diagram: Ex. SE

A
58
Q

Content: Parts of the assessment (4)

A
  1. Diagnostic hypothesis (SINSS)
  2. Problem list
  3. Intervention plan (Rx)
  4. Prognosis
59
Q

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

A

True

60
Q

Content: Positives when determining prognosis (3)

A
  1. Pt. age
  2. Understands condition
  3. Motivated
61
Q

Content: Negatives when determining the prognosis (3)

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

PTRS 745 Exam 1 (9 decks)

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