Review of Basic Components of an Exam - Class 1 Flashcards
5 elements of pt/client management
- examination
- evaluation
- dx
- prognosis
- intervention
4 parts of a PT evaluation
subjective
objective
assessment
plan
what is a prognosis
determination of the level of optimal improvement
how might a px be attained
through intervention
amount of time required to reach that level
history =
subjective interview
when is an item subjective (pt 1)
the pt (or family member) tells the therapist the pt’s history
the pt (or family member) tells the therapist something about the pt’s lifestyle or home situation
the pt tells the therapist his emotions or attitudes
when is an item subjective (pt 2)
the pt states his or her goals (ex: I’am really angry about…)
the pt voices a complaint
the pt reports a response to tx (ex: a decrease in pain intensity)
a subjective item is…
anything the pt (or designated family member) tells the therapist that is relevant to the pt’s case or present condition
things that must occur during the interview/history
info transfer
establish communication
establish communication
make eye contact
match verbal and nonverbal behavior
clarify when needed
subjective questioning should determine
chief complaint
previous bouts of same illness
other medical problems
meds
factors that decrease/increase their sxs
occupation, MOI, pt goals and recreational activities
determine precautions
nature of the problem
site of the sxs
onset
chief complaint
complete description of the problem
meds
what are they taking
why are they taking them
side effects
factors that decrease/increase their sxs
what makes it better/worse
determine precautions
did the dr tell them not to do anything
is there anything else you want to tell me before tx
nature of the problem
includes quality of the pain, irritability and variability
quality of the pain, irritability and variability
can you describe the pain to me (don’t let them)
when do you experience the pain
how’re you in the morning/night
are there certain things that make it worse/better
site of the sxs
can pt location the area w/ one finger, any other areas?
do sxs move around
do they radiate
onset
how and when did this start
rapid? gradual?
following trauma or overuse
insidious onset
when was the first episode of these sxs
insidious onset
seems to be progressing in an unimportant way when it is actually really important
when we are finished with the history
we want to know their story
hopefully not a familiar story
physical examination =
objective information
observation
you are noticing exactly what they are doing
do not be obvious be be thorough