Intro Lecture Flashcards
Components of Patient Management
- Examination: interview, testing, observation, palpation, etc. (produces data)
- Evaluation: clinical judgement (what you do with the info)
- Diagnosis: pathologies
- Prognosis: expected recovery
- Intervention: techniques to help problem
- Outcomes: results of patient management
Physical Therapy examination model
PT Exam-> History, Systems Review, and Tests&Measures—-> [Analyze and Synthesize] Evaluation-> Diagnosis, Prognosis, and Plan of Care
Information to get from Patient History Examination
Chief Complaint/CC Demographics PMH/Surgeries Medications Health Status Family History Tests/Findings Functional Status Social History Employment Living Environ Patient's GOALS!
How do you get patient history?
- Chart review
- Medical records
- Subjective interview: open ended questions that focus and deter irrelevant info in organized sequence
Purpose of History
- develop patient/therapist relationship
- establish communication
- Identify RED FLAGS
- Determine if candidate for PT
- Activity Restrictions/Participation Limitations
- Find out GOALS
- Know what to further examine
Observation as part of history
- initial consult
- provides info on: nonverbal cures, position of comfort/discomfort, level of function, pain/fatigue, emotional status, intro to system review
What is a systems review?
Identifies possible health problems that may require referal/consultation with another health care provider
Systems to examine in systems screening
Cardiopulm integumentary neuromusc muskoloskel cognition
Components of Cardiopulmonary system screen
HR BP Resp Rate Lung and Heart Ausculation Pulses Palpation of skin for temperature Observation of extremities for edema, discoloration, venous distention
Components of Integumentary system screen
Temp more than 100 or less than 96
Edema
Skin changes (dry, cracks, cuts, bruise, course hair, brittle nails, fungus, wounds, color, rashses, etc.)
Palpations (skin mobility, texture, pliability, pulses and temp)
Components of neuromuscular system screen
Gait, locomotion, balance, and coordination
CNS and Peripheral nerve integrity (sensation, motore, reflex testing)
Cranial nerve integrity
Components of muskoloskeletal system screen
Posture
Gross ROM
Gross Strength assesment
Functional assessment
Tests and measures
Continuation/expanding on systems review
Detailed physical exam of patient
Objective data to identify impairments- activity restriction and participation limitation
Narrow down hypothesis and lead to diagnosis
Things you measure
Posture Mobility Gait Sensation Balance Strength
Reasons for tests and measures
Determine structures involved
reproduce symptoms
confirm/refute hypothesis
objective data baseline
