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
what happened in 1984
PT may establish a dx w/in the scope of their knowledge, experience and expertise
dx
label encompassing a cluster of S&S, syndromes or categories
dx is a
decisions
reached as a result of the dx process
dx process
evaluating the info obtained through the exa–> organizing it into clusters, syndromes or categories and interpreting it
dx is giving the pt a
label
2 aspects of a dx
label is given to the condition
label provides characteristics of the conditions when it is communicated w/ others
what must PT must establish
diagnostic categories
diagnostic categories
direct treatment prescriptions
provide a means of communication both w/in the profession and w/ other practitioners and consumers about the conditions that require their particular expertise for effective treatment
PTs must not use diagnostic labels that
they cannot confirm through their own recognized examination and testing methods
dx could be made possible if
physical exam showed visual or manual evidence
PTs do not make
differential dx to identify a specific dz
what do PT dx and diagnostic categories help with
clinical decision making about the most appropriate intervention
what exist on PTs making a dx
legal limitations
clinical dx will help
make treatment plan
a PT dx
encompasses the pt’s impairments, activity limitation and participation restriction
leads our treatment
differential dx
comparison of sxs of similar dzs
why do we do a differential dx
so that a correct assessment of the pt’s actual problem can be made
rule-out concept
similar meaning to differential dx
means to “check out”
helps you arrive at a differential dx
initial exam and eval is done at
first visit
what does the initial exam/eval include
history of past illness
PMH
Dx tests
physical exam
evaluations
POC
setting anticipated goals
expected outcomes
px
duration of tx
most difficult part of initial visit
prognosis
prognosis is determined once
dx has been established
what is a px
determination of the predicted optimal level of improvement in fx and the amount of time needed to reach that level
what else may a px include
prediction of levels of improvement that may be reached at various intervals during the course of therapy
px is a
complicated process
what does a px require
both clinical experience and academic knowledge
reexamination is done
on a regular basis
discharge eval or summary is done to determine
the status of the pt at time of discharge
have they met all goals of PT?
what foes the discharge eval or summary help with
determine the type of follow-up plane or continued care to be recommended
