SE&OE Flashcards
1
Q
T/F: The diagnosis, problem, and prognosis all fall under the P portion of the SOAP note.
A
False, under A (assessment)
2
Q
Term: related to the pt’s functional ability, reported by the pt., and/or detected during the objective exam
A
Problem
2
Q
Term: The amount of activity to produce an exacerbation of symptoms and the time to subside or ease.
A
Irritability
3
Q
Content: Parts of present history (4)
A
- Length of time
- Onset of symptoms (stage)
- Progression (stability)
- Comparison symtpoms now with inital stage
3
Q
Defn: Spasm end feel
A
Abrupt end
4
Q
Content: 6 intervention categories to consider for your treatment plan
A
- Education
- Modalities
- TherEx
- Manual therapy
- Assistive device
- Home Exercise Program
5
Q
Content: Chief complaint (7)
A
- Pain
- Stiffness
- Stability
- Sensation of instability
- Weakness
- Loss of function
- Surgery/trauma/immbolization
5
Q
Diagram: Progress and reasses - Clinical problem solving
A
6
Q
Term: reversing impairments
A
Remediation
7
Q
Q: What is the purpose of a special testing during the OE?
A
To confirm your hypothesis
8
Q
Term: conditions that may change with the intervention
A
Problem
8
Q
Q: What are important non-verbal communication skills to have during an examination? (2)
A
- eye contact 2. body language
8
Q
Content: 3 things that can be assessed from PROM during the OE
A
- AROM was limited
- Apply gentle overpressure
- End feel
9
Q
Term: management of anticipated problem
A
Prevention
10
Q
Defn: Restricted PAM
A
Joint surface and/or surrounding tissues are implicated
11
Q
Content: Parts of past history (4)
A
- Episode frequency
- Possible treatments and outcomes
- Comparison with the current problem
- Activity limiation
12
Q
Content: Normal End feel (according to Cyriax) (4)
A
- Capsular
- Bony
- Elastic
- Soft tissue approximation
13
Q
Term: symptoms that come and go, could be related to sport or work activities.
A
Over 7 days
13
Q
Q: Full and pain free ______ suggests normalcy.
A
AROM
14
Q
Defn: Empty end feel
A
Limitation without tissue resistance but with pain
15
Q
Content: Using the scanning examination (7)
A
- No history or trauma
- Radicular signs present
- Trauma with radicular signs
- Altered sensation in limb
- Spinal cord (“long track”) signs
- Pt. presents with abnormal patterns
- Suspected psychogenic pain
16
Q
Q: What are the parts of the SOAP note?
A
Subjective, Objective, Assessment and Prognosis, Plan of Care
16
Q
Term: Information with regards to previous episodes of the same or similar disorders
A
Past history
17
Q
Term: combination of symptoms and signs that determine a particular condition.
A
Clinical syndrome
18
Q: What are the 3 stages of symptoms?
1. Acute or inflammatory
2. Subacute or tissue formation
3. Chronic or remodeling
19
Q: What are the two time frames for behavior of symptoms?
1. Over 24 hrs 2. Over 7 days
20
Content: 4 types of abnormal end feel
1. Springy
2. Boggy
3. Spasm
4. Empty
22
Term: changes in the environment and tasks
Compensation or adaptation
23
Defn: Excessive PAM
Instability or joint laxity
24
Content: 5 parts of the objective examination
1. Determine structure(s) involved
2. Confirm/refute hypothesis
3. Est. baseline
4. Identify impairments
5. Determine effect on function
24
Q: What 3 things can be measured with goniometry?
1. AROM
2. PROM
3. Flexibility
25
Defn: Compression that is painful
Joint surface implication
26
Defn: Boggy end feel
Squishy sensation
28
Content: Types of nociceptive pain (3)
1. visceral - diffuse and difficult to locate
2. Deep somatic
3. Superficial somatic
28
Q: What 4 vital signs are important to take note of?
1. Temperature
2. HR
3. BP
4. RR
28
Q: What does the following MMT finding imply? Strong and painless
Normal finding
29
Term: pain that is burning, tingling, electrical, stabbing, or pins and needles
Peripheral nervous system
31
Q: What is SINSS used for?
The base for the assessment
32
Q: What are the two key components to severity?
1. Intensity 2. Functional ability
33
Term: intensity of symptoms and the effect on functional ability
Severity
35
Q: What are important verbal communication skills to have during an examination? (5)
1. ask one question at a time 2. speak slowly 3. avoid medical jargon 4. make no assumptions 5. belief and empathy
35
Term: pain that is superficial, sharp, and well defined
Superficial somatic
36
Q: What part of the SOAP note contains information on function?
Objective
36
Content: SE (6)
1. Pt. profile
2. Chief complaint
3. Body chart
4. Behavior of symptoms
5. History
6. Pt. goal
37
Q: What are some examples of functional tests?
Hop test, doulbe legged squat test, maximum jump height, etc
38
Q: With passive movements and ligamentous testing, both the _________ and ________ (end feel) of opening are important.
Degree, quality
38
Content: PAM (3)
1. Also called joint glides
2. Assess the accessory movements
3. Determine: hypo/norm/hypermobile
39
Term: includes tests and measures
Objective examination
40
T/F: The least stable joint is the knee.
False: Shoulder
41
Content: Things to put on the body chart (5)
1. Location/target area
2. Description of pain
3. Clear other (pain free) areas
4. Assign each pain (P1, P2, etc)
5. Establish a relationship between symptoms
43
Term: pain that is dull, aching, and poorly localized
Deep somatic
44
Content: Positives when determining prognosis (3)
1. Pt. age
2. Understands condition
3. Motivated
45
T/F: You should warn the pt. of potential exacerbations or painful parts of the OE.
True
47
Term: Collecting information from patients or responsible parties
Subjective examination
48
Diagram: Behavior of Symtpoms
49
Content: 8 components of the OE
1. Observation/posture
2. Scanning/screening to rule out/in spine
3. ROM - active and passive
4. Joint play
5. MMT
6. Palpation
7. Special tests
8. Functional tests
50
Content: 5 things that can be assessed from AROM during the OE
1. Symptoms reproduction
2. Quantity of ROM
3. Integrity of contractile and inert tissue
4. Presence of muscle substituion
5. CPR
50
Q: What is goniometry used for?
Assessment and reassessment
51
Q: What are some examples of balance tests?
Single leg stance, start test, TUG
52
Content: Planning the objective examination (5)
1. Reflect if you've got everything
2. Decide on peripheral/spinal exam
3. SINSS - P/C
4. Extent of exam
5. Movements/tests that will confirm hypothesis
53
Q: Define the acronym SINSS
Severity, irritability, nature, stage, stability
53
Q: What does the following MMT finding imply? Weak or painful contraction (3)
1. Rupture
2. Palsy
3. Neuropathy
54
Term: pain that is sickening, deep, squeezing, and dull
Visceral
56
Content: Negatives when determining the prognosis (3)
1. Chronic condition
2. Job
3. No improvement with treatment (recurrence)
57
Q: What makes distraction painful?
Tearing of connective tissue
58
Q: What does the following MMT finding imply? Strong and painful
Minor muscle lesion
60
Q: Irritability: standing for 30 min aggravates, sitting for 5 min eases - What is the level or irritability?
Min
61
Term: identifies the relationship between the findings of the subjective and objective evaluation
Clinical judgement
62
Q: The following items fall under what category of the SE?
- General health, medication, BP, previous operations, lab results, imaging, CV or resp problems
Special questions
63
Content: consider the following 1. Movement dysfunction 2. Neurophysiological symptoms 3. Contraindications 4. Illness experience and behavior 5. Treatment objectives 6. Prognosis - short and long term effects
First hypotheses
64
Q: What does PAM stand for?
Passive articular mobility
65
Defn: Normal PAM
Integrity of joint and surrounding tissues
66
Q: What does the following MMT finding imply? Weakness (other source)
Preform a reassessment
67
Content: 3 ways to assess flexibility
1. Using end feel
2. Postural analysis
3. Special tests (SLR, Ober, etc)
69
Content: Hypotheses based on history (4)
1. Precautions and contraindications
2. Sources of dysfunction
3. Psychosocial factors
4. Management
70
Q: With ligamentous testing, ________ with increasing stress.
Repeat
72
Content: Key points to remember while performing an objective examination (7)
1. Tell pt. what you're doing
2. Test normal side 1st
3. Do active, then passive, then resisted isometric movements
4. Do painful movements last
5. Apply overpressure to test end feel
6. Repeat/sustain positions if history indicates
7. Take baseline signs
73
Content: SE - Patient Profile (5)
1. Age
2. Occupation
3. Current daily activity level
4. Recreation/hobbies
5. Psychosocial factors
74
Content: 2 types of compression
1. Eases pain
2. Painful
75
Q: With myotome testing, make sure that contractions are held for _____ \_\_\_\_\_\_\_\_.
5, seconds
76
Q: What about distraction eases pain?
Articular surfaces are implicated
77
Q: For what part of the SOAP note would you use clinical judgement?
Assessment or evaluation
79
Q: Severity: painful, but can perform all work activities - What is the level of severity?
Low
80
Term: stage lasting 10 days to weeks
Subacute
81
Term: predicting the pt's recovery
Prognosis
82
T/F: Putting the SINNS together helps in determining the diagnostic hypothesis.
True
83
Q: What limits distraction?
Contracture of connective tissues
85
Content: Hypotheses based on location (5)
1. Nature of symptoms
2. Source of movement impairments
3. Tissue mechanisms
4. Neurophysiological symptom mechanism
5. Precautions
86
Q: How many grades are involved in the Maitland approach?
I to V
88
Defn: Springy end feel
Rebound sensation
89
Content: Pain sensations (2)
1. Nociceptive
2. Peripheral nervous system
90
Q: What part of the SOAP note contains reported symptoms?
Subjective
91
Q: What are the three key components to irritability?
1. Amount of activity 2. Exacerbation 3. Subside
92
Content: Scanning exam for the peripheral joint assessment: Perform in the spine (2)
1. Active and passive movements
2. Resisted isometric movements
93
Q: Clinical problem sovling involves ______________ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Continued, assessment
94
Content: Two types of unrestricted PAM
1. Normal
2. Excessive
95
Q: During what part of the SOAP note is the diagnosis determined?
Assessment or evaluation
96
Term: stage lasting 7-10 days
Acute
97
Q:Our clinical judgment allows us to raise "\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_"
working, hypotheses
99
Q: What are the two components to keep in mind when evaluating the behavior of symptoms?
1. Severity 2. Irritability
100
Term: stage lasting more than several weeks
Chronic
102
Contents: 3 things to observe during an OE
1. Posture
2. Movement limitation
3. Care giver support
103
Defn: Compression that eases pain
Joint capsule implication
104
Content: 3 types of Distraction
1. Limited
2. Painful
3. Eases pain
105
Content: Scanning/Screening - "Quick look" (4)
1. Rule out possibility of referral symptoms (esp. from spine)
2. Confirm where pathology located
3. Ensure correct diagnosis
4. No more than 5-10 minutes
106
Content: Parts of the assessment (4)
1. Diagnostic hypothesis (SINSS)
2. Problem list
3. Intervention plan (Rx)
4. Prognosis
107
Term: details with regard to the present episode
Present History
108
Q: What percent of the information you need comes from the subjective examination?
80-90%
