Physical Therapy Exam and Eval - Class 1 Flashcards
2 rules to remember when performing an exam
- it is a continuous process that is always updated during treatment of the pt
- never let one positive finding stop you from completing your eval –> that finding should be confirmed by alternate techniques or methods
evaluation
to determine or fix the value of something
to examine and judge concerning the worth, quality, significance, amount, degree or condition of something
PT exam
process that includes taking the history, conducting a systems review and administering tests and measures to identify potential and existing problems
history
an account of past and present health status
what does history include
identification of complaints
what does the history provide
provides the initial source of info about the pt/client
what does the history suggest
individual’s ability to benefit from PT
what does the PT do while taking the history
identifies health-risk factors, health restoration and prevention needs and co-existing health problems that have implications for intervention
how is history obtained
through gathering of data from the pt/client, family, SO, caregivers and other interested persons
who else could we speak to to obtain history
through consultation w/ other members of the health care team
review of the medical chart
systems review
brief or limited examination that provides additional info about the general health of the pt/client
what does the systems review help the PT do
formulate dx, prognosis and POC and select direct interventions
how else does the systems review assist the PT
identifying possible health problems that require consultation w/ or referral to another health care provider
systems review helps answer
what should I do next?
what do I need to examine in depth?
what don’t I need to do?
when do you do tests and measures
after analyzing the info gathered from the history and review of systems
tests and measures
therapists will select tests and measures to elicit additional info
PT evaluation
done to establish dx and px by synthesizing the exam data
putting together the parts
purpose of a PT eval (1-3)
identify the specific lesion responsible for the pt’s chief complaint of pain and fxnal impairment
to assess the integrity and performance of the involved tissues and structures that we have identified
to determine the pts baseline fxnal abilities during … so future measurements may be compared
identify the specific lesion responsible for the pt’s chief complaint of pain and fxnal impairment –> purpose
so we could direct our interventions towards that
to determine the pts baseline fxnal abilities during … so future measurements may be compared –> purpose
ADLs
occupational activities
recreational activities
purpose of PT eval (4-5)
documentation to prove to insurance companies that PT is working and helping the pt to improve
to ensure that each pt is an appropriate candidate for PT
to ensure that each pt is an appropriate candidate for PT –> purpose
part of this process is screening for medical dz
PT dx
term that names the primary dysfxn toward which the PT directs treatment
how is the dysfxn identified by the PT
based on info obtained through
-history
-S&S
-examination
-tests the therapist performs or requests
