Introduction to Clinical Assessment Flashcards
__________ provides us with an objective means to identify an injury or dysfunction and to monitor the effectiveness of a treatment plan.
Assessment
What is the clinical assessment mantra?
Find the cause, then treat the cause.
A term denoting the disease or syndrome a person has or is believed to have. Identification of a disease by history, physical examination, laboratory studies, and radiological studies.
Diagnosis
________ is the identification and naming of a disease or pathology.
Diagnosis
T/F - RMTs can provide patients with a diagnosis
False - RMTs cannot because they don’t have access and/or training to interpret diagnostic tests.
What do RMTs use instead of a diagnosis?
Clinical Impression
T/F - Diagnosis is protected under the ‘Regulated Health Professions Act’ (RHPA)
True
An appraisal or educated evaluation of a patient’s condition and physical basis for their symptoms that have caused them to complain. It is a means to fully understand the patient’s problems, from the patient’s perspective as well as the clinician’s.
Assessment
Any loss or abnormality of psychological, physiological, or anatomical structure or function. Can occur as a result of a medical condition, pathology or injury and can be applied to the wellness model of care as well.
Impairment
What does ADL stand for?
Activities of Daily Living
Name the 5 reasons why we assess?
1) Gather information necessary to devise a SAFE TREATMENT PLAN
2) Gather information necessary to devise an EFFECTIVE TREATMENT PLAN
3) A tool to MONITOR PROGRESS/EFFECTIVENESS of treatment
4) A means to COMMUNICATE with other health care professionals
5) REQUIRED BY LAW
Which reason to assess includes identifying possible red flags, previous injury that may contraindicate certain techniques, medications, and underlying pathology or health condition that may contraindicate treatment?
1) Gather information necessary to devise a SAFE TREATMENT PLAN
Which reason to assess includes identifying patient goals/impairments, establishing goals of treatment, facilitating treatment that has direction/intent, and ensuring that you are treating the cause of the complaint?
2) Gather information necessary to devise an EFFECTIVE TREATMENT PLAN
Which reason to assess includes using objective means to track results of treatment/self care/function and providing information for informed clinical decision making?
3) A tool to MONITOR PROGRESS/EFFECTIVENESS of treatment
Which reason to assess includes being able to speak the language other practitioners will understand and exhibiting a professional image?
4) A means to COMMUNICATE with other health care professionals
Which reason to assess falls under the CMTO standards, RHPA, and MTA?
5) REQUIRED BY LAW
A very common assessment recording method used by many health care professionals.
Problem-Oriented Medical Records Method
What type of notes does the problem-oriented medical records method use?
SOAP Notes
What 4 parts of the assessment does SOAP stand for?
Subjective Data
Objective Data
Assessment
Plan
The patient’s perception of their current symptoms and their health history (what they tell you). Very important information gathered during the initial interview that is key to the assessment process (ex. LOFDSAAQR + ADLs + MOI).
Subjective Data
On subsequent visits, the ____________ should include how the patient has been doing since the last visit (ex. changes in symptoms/level of function, compliance with self-care).
Subjective Data
The practitioners observations, testing, and physical findings (ex. postural observations, palpation, functional/ROM testing, special orthopaedic tests).
Objective Data
The examiners diagnosis or __________ of the condition and an interpretation of the subjective and objective data.
Assessment
In student clinic, a concise statement that may include more than one finding. It is what you believe the cause of the patient’s complaint to be.
Clinical Impression
T/F - it is not necessary to repeatedly state the clinical impression from treatment to treatment on a single treatment plan.
True
Under which section would the clinician comment on progress to date and whether the treatment plan needs revision or not?
Assessment
The treatment ______ or what the therapist will do to treat the problem. Under this section, treatment aims and goals are stated along with the strategies to attain them.
Plan
What 4 things should all treatment plans include?
1) Treatment GOALS or aims of treatment
2) TECHNIQUES used to achieve an effect
3) STRUCTURES those techniques are applied to (how long/how often)
4) NUMBER & FREQUENCY of future treatments & when to RE-EXAMINE
The sequence that an assessment should progress in and is adaptable to the body part being assessed. Following it will help you arrive a logical explanation for your patient’s complaint.
Assessment Protocol
What are the 10 steps of the assessment protocol?
1) Case History
2) Observation
3) Palpation
4) Rule Outs
5) Functional Tests
6) Special Tests
7) Muscle Tests
8) Neurological Tests
9) Joint Play Examination
10) Lesion Site Palpation
What are the 4 T’s of palpation?
1) Tone
2) Texture
3) Temperature
4) Tenderness
A term that refers to eliminating something else that is causing the patient’s pain.
Rule Out
What are 3 examples of functional ROM tests?
1) Active Free
2) Passive Relaxed
3) Active Resisted
T/F - when utilizing a muscle test, you would use the muscle’s primary action to be the most specific.
False - using alternate actions in combination with the primary action allows for you to be more specific.
What do neurological tests examine and why are they done near the end of an assessment?
They look at nerves, which are quite sensitive, and can therefore obscure the assessment if tested too early.
Observe and test __________ for all observations and functional/ROM testing.
Bilaterally
Test the __________ side first to provide a baseline for comparision.
Unaffected
Do the most __________ test last by modifying the order of your testing and prevent the results of your assessment from being skewed.
Painful
If your patient experiences pain during a particular movement or test have them ______ and identify the ________ and ________ of the pain.
Stop
Location
Nature
Taking a thorough ____________ saves you time by avoiding unnecessary testing.
Case History
Always support the limb in a secure and ________ position.
Neutral
Rule out the ________ and ________ joints to ensure that you are assessing the proper joint.
Proximal
Distal
Be aware of ________ pain, that could be neurological, a trigger point, or visceral.
Referred
What are the 3 testing positions, in addition to supine and prone?
1) High Seated
2) Long Seated
3) Hook Lying
A testing position in which the hips and knees are at 90 degrees of flexion. ROM of the neck, shoulder, and elbow can be assessed.
High Seated
A testing position in which the hips are at 90 degrees of flexion and the knees are extended. Movements of the ankle and knee can be assessed.
Long Seated
A testing position in which the patient is supine, hips are at 45 degrees of flexion and knees are at 90 degrees of flexion. Knee ROM and hip tests can be performed in this position.
Hook Lying
An assessment should be thorough, systematic and conducted in an efficient manner. ________ and a ______ is the key.
Practice
Plan
What should you conduct in order to significantly reduce the amount of time required to conduct the rest of the assessment?
Case History
What are 2 things you should do as a therapist when taking a patient’s case history?
1) LISTEN TO THE PATIENT
2) ASK THE RIGHT QUESTIONS
T/F - the information gathered in the case history will dictate the proper order of functional testing.
True
Being polite, respecting privacy, body language, maintaining eye contact, thinking before speaking, speaking confidently, showing empathy, paraphrasing to clarify, slowing down, and listening to the patient are all pointers on ____________.
Communication
When taking a case history, don’t ask any __________ questions. Instead, try to keep questions ______ ended as this will help you gather the information you need from the patient’s perspective.
Leading
Open
______ ended questions are more helpful when gathering important information and keeping the interview focused.
Close
What information should be gathered during the intake?
1) Presenting Complaint
2) General Health
3) Occupation
4) M.D. & Meds
5) Previous Injury
6) Pain
7) Function
8) Therapies
9) Current Symptoms
Information gathered during the intake relating to why the patient is coming to see you and what their goals/expectations are for the treatment. This will give you direction to your assessment and determine if the patient’s goals are realistic.
1) Presenting Complaint
Information gathered during the intake from the health history form. Therapist should pay attention to things that may have an influence on the primary complaint and/or may require modification to treatment.
2) General Health
Many conditions occur within certain ____ ranges.
Age
Something that would require referral to a physician.
Red Flag
Information gathered during the intake relating to what the patient does for a living and any hobbies/sports. Can help therapist identify any repetitive motions or prolonged postures that may be contributing factors to the complaint.
3) Occupation
Information gathered during the intake regarding if they’ve seen a ________ about their complaint (including any test results/diagnosis’s) and if they are using any __________ (how often, side effects).
4) M.D. & Meds
If the patient is on steroidal drugs, pain killers, muscle relaxants, or mood altering drugs, __________ to treatment may be required.
Modification
Information gathered during the intake relating to if they have had a ____________, how it was treated, if it affected other joints, or if their present complaint may be the result of poor healing or rehab.
5) Previous Injury
Information gathered during the intake relating to ______ or discomfort (LOFDSAAQ) can help you gain a thorough understanding of what the patient is experiencing.
6) Pain
Information gathered during the intake relating to if the complaint is interfering ADLs.
7) Function
Information gathered during the intake relating to if the patient is receiving any other __________ for their current complaint and if it is helping. It is good to coordinate care between other healthcare practitioners.
8) Therapies
Information gathered during the intake relating to how the patient is feeling today, which can limit the amount or type of testing.
9) Current Symptoms
Another key piece of information gathered during the intake that can be very helpful for assessment.
MOI
