Introduction package Flashcards
term denoting the disease or syndrome a person has or is believed to have
diagnosis
appraisal or evaluation of a patient’s condition
assessment
Any loss or abnormality of psychological, physiological, or anatomical structure or function
impairment
what are the 5 reasons to assess
devise a safe treatment plan, effective treatment plan, monitor progress, communicate with other health care professionals, required by law
What does SOAP stand for?
subjective data, objective data, assessment, plan
what is subjective data
patient’s perception, health history, interview answers
what is objective data
practitioner observations, test/assessment results, physical findings
what is assessment
an interpretation of the subjective and objective data. a clinical impression
what is plan
the outline for what the therapist will do to treat the problem
what should all treatment plans include
goals/aims, techniques used to achieve an effect, structures those techniques are applied to and how long/often, number and frequency or future treatments, re-examination date
what are the 10 steps of assessment protocal
- Case history
- Observation
- Palpation
- Rule Outs
- Functional Tests (ROM tests AF,PR,AR)
- Special Tests
- Muscle Tests
- Neurological Tests
- Joint Play examination
- Lesion site palpation
how should one perform observations and testing
bilaterally, with the unaffected side first
in bilateral testing, which side should be tested first and why?
unaffected, to get a sense of what is normal
when should the tests likely to be the most painful be performed?
last in the sequence
what do you do if the patient experiences pain during a particular movement or test
stop and identify the location and nature of the pain
why should we take a thorough case history first?
save time by avoiding unnecessary testing
how do we support the limbs we test
in a secure an neutral position
why do we rule out the proximal and distal joints?
ensure that we’re assessing the proper joint, as complaints may be the result of dysfunction at another location/referred pain
what are 3 forms of referred pain
neurological, trigger point, visceral
what is the high seated testing position
hips and knees are at 90 degrees of flexion
what is the long seated testing position
hips at 90 degrees flexion, knees extended
what is the hook lying testing position
supine, hips at 45 degrees of flexion, knees at 90 degrees of flexion
how should an RMT phrase their questioning during assessment?
don’t ask leading questions where possible
what is the Presenting Complaint
why the patient is coming to see us, their primary complaint, and their goals/expectations of treatment