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Clinical Assessment Protocol > General > Flashcards

General Flashcards

1
Q

Assessments must be (3)

A

organized, comprehensive, reproducible

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2
Q

Therapists gather information three ways:

A

audio- what the patient tells you (subjective information)
visual- what the therapist observes (objective information)
palpation- what is the quality of the tissue or structure

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3
Q

Therapists are most efficient when we (4):

A

listen- to what the patient is telling you verbally
watch- what the patient’s body, movement, palpation is telling you
create a goal- deduce areas of concern, possible causes and what change the therapist wishes to create
reassess- to know what the markers are of completing the goals

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4
Q

Order of procedure:

A
  1. case history form
  2. interview form
  3. initial scan exam form (observations, palpations, functional tests)
  4. postural assessment
  5. joint assessment
  6. gait assessment
  7. treatment goals and treatment modalities
  8. remedial exercise
  9. management plan
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5
Q

Clinical encounter (7)

A

history, observation (inspection), palpation, motion (functional, AROM, PROM, RROM), neurovascular screen, referred pain, special/orthopedic tests

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6
Q

Adequate knowledge

A

to safely know what you intend to assess, treat, and manage

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7
Q

Adequate application of knowledge

A

to clinically defend you choices of modality and home care for your patient

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8
Q

Informed consent

A

A description of the treatment including techniques and goals, description of draping, (and what will be undraped and worked on ), any risks, benefits, contraindications and/or possible complications, informed they can ask at any time for any reason to stop or modify treatment, must get a CLEAR yes or no to proceed.

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9
Q

Patient confidentiality

A

to continue patient file safety, to not discuss patient information in a public space, be aware of any identifying information, file names facing away from casual eyes.

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10
Q

Terms of confidentiality (3)

A

Privacy- the right to decide what information may be collected, used, and share
Freedom of Information and Protection of Privacy Act (FOIPPA)- BC law providing specific info and privacy rights concerning info collected and controlled by public bodies in BC
Personal Information- any recorded info that identifies a person, name, address, phone number, race, age, sex, symbols relating to person, their opinions (unless about someone else) etc.

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11
Q

Confidentiality breaches:

A
  • Removing patient files from clinical setting (home for an assignment)
  • Accessing info not related to duties (looking up records that aren’t you clients)
  • Discussing patient info in an inappropriate area where it can be overheard (hall, stairs, bathroom)
  • carrying/delivering info in a way that exposes patient details/leaving files in inappropriate areas
  • discussing patient cases with fellow students in a way that reveals identifying information
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12
Q

Red Flags/Yellow Signs

A

indicate a need for a referral to a physician

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13
Q
  • Persistent pain at night
  • constant pain anywhere in the body
  • unexplained weight loss (4.5-6.8kg in 2 weeks or less)
  • loss of appetite
  • unusual lumps or growths
  • unwarranted fatigue
A

Cancer

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14
Q
  • Shortness of breath
  • dizziness
  • pain or feeling of heaviness in the chest
  • constant and severe pain in lower leg (calf) arm
  • discolored or painful feet
  • swelling (no history of injury)
A

cardiovascular

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15
Q

-Frequent or severe abdominal pain
-frequent heartburn or indigestion
–frequent nausea or vomiting
change in or problem with bowel/bladder formation
-unusual menstrual irregularities

A

GI OR GU

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16
Q
  • Fever or night sweats
  • recent severe emotional disturbances
  • swelling or redness in any joint with no history of injury
  • pregnancy
A

miscellaneous

17
Q
  • changed in breathing
  • frequent or severe headaches with no history of injury
  • problems with swallowing or changes in speech
  • changes in vision (blurriness, loss of sight)
  • problems with balance, coordination, falling
  • fainting spells (drop attacks)
  • sudden weakness
A

neurological

18
Q

When escorting patient to clinic room, attempt to observe: (7)

A

Functional movement, body type, gait, emotional attitude, footwear, facial expression, general ease of self

19
Q

Every page of clinic forms must contain (4) _____ in BLACK pen in LEGIBLE writing

A

Patients name, interns name, date, clinic instructor

20
Q

Open format interview question examples

A 
How can I help you?
Tell me about your problem?
How did this happen?
How do you feel about that?
How is your general health?
How does this affect you/your life?
21
Q

Closed format question examples

A

Pain/stress complaints: where, quantity, duration, relief, aggravates, onset (sudden/gradual), mechanism of onset
Motion/Activity restriction: what motion/activity, quantity, pain, duration, relieves, aggravates, onset,

22
Q

Questions for history (5)

A

Location: where does is hurt? Point. Does the pain move anywhere, where? What is the mechanism of injury?
Onset: when did it start? gradual or sudden? cause of chief concern? mechanism of injury (how it happened)?
Chronology/timing/prior episodes: anything like this before? constant? episodic? occasional? How many times a day/week/month?
Quality: describe the pain with a word or two, worse or better?
Severity (0-10)/effect on ADL: rate the pain current, best, worst, does/how affect daily activities?

23
Q

ISE observation

A

Initial scan exam. Soft eye overall view of habitual standing of patient. Record as process. Organized. Note obvious deviations, areas of pain. Primary secondary areas to be treated. General overview at the beginning of information gathering process.

24
Q

Fracture Screen (if indicated)

A

history of significant trauma, older than 55, 4 step test (walking), torsion test/percussion/light palpation, 128 Hz tuning fork, ultrasound

25
Q

4 T’s of Palpation

A

temperature, texture, tone, tenderness

26
Q

Range of Motion

A

Function test, active ROM, passive ROM, resisted ROM

27
Q

Neurovascular Screen

A

Sensory (light touch, vibration), motor (muscle strength test, tendon reflexes, pathologic reflexes, vascular screen (pulse, blanching, temperature)

28
Q

Referred pain & special tests

A

Screen adjacent area: observation, AROM, palpation, trigger point referral patterns
Special tests- orthopedic tests (covered in ortho class)

Clinical Assessment Protocol (2 decks)

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