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
inspection
you are comparing side to side
specific and obvious observations
ex. of inspection
A-P
distal to proximal
symmetric
skin color
atrophy
palpation
involves systematic touching
feeling for tone, levels, texture and temp
what motion is tested first
active ROM
active ROM
want to see what they could do on their own
what does active ROM give us
info about contractile and non-contractile tissue
gives some info about muscle strength
–> can perform against gravity = at least a 3
passive ROM provides
info about the inert structures surrounding the joint
inert structures =
capsule and ligs
resisted ROM
provides info on contractile tissue
when we do MMT
neurologic testing
sensory
tone
reflexes
sensory tests
provides info on nerve damage on sensory level
how’re sensory tests done
by dermatomes
dermatomes
area of skin supplied with afferent nerve fibers by a single posterior spinal nerve root
goes by spinal levels
tone
provides info about extent of nerve damage and abnormal muscle tone
what does tone assess for
spasticity
rigidity
etc.
reflexes
provides info about nerve damage on a motor level
tests and measures =
special tests
special tests
tests that are appropriate to the area being examined
what do special tests help indicate
specific pathology present
correlation or analysis of further findings =
evaluation
assessment
what are we constructing in the evaluation
an asset and problem list
what are we determining in the evaluation
which findings will be placed in each category
what does the evaluation help determine –> goals
what goals to be set
a long-term goal is set for each problem in the problem list
what does the evaluation help –> problem
isolate the problem
allow you to focus in on the problem
not over treat or treat in “general”
what does the evaluation help set
priorities
some problems such as pain may need to be addressed first to achieve the next step
the evaluation should be state in
fxnal terms
necessary and followed up with long term goals
what does an evaluation help determine –> PT
need for PT or the pt’s rehab potential
evaluation will determine any
inconsistencies b/w the objective findings and pt’s complaints
everything should make sense
treatment plan =
plan of care
plan
what will we describe for each anticipated goal
one or more types of interventions
plan will include
frequency that the pt must be seen
the quantities, levels and amounts needed for tx
plan may also have
the progression the pt will follow
equipment used if not already stated
equipment needed and/or ordered for the pt
any family involvement used or needed
possible referral to other sources
re-examination
evaluative process throughout tx
re-exams must be done
at regular intervals or w/in tx sessions
re-exam will provide
treating therapist with important info concerning the effectiveness of their interventions
if the pt has improved
effective re-exams will guide
future tx sessions
