SUBJECTIVE ASSESSMENT Flashcards
≠ steps of assessment + brief description of each
EXAMINATION
- Process of obtaining history, performing systems review & selecting / administering tests & measures to gather data about patient
- Initial examination = comprehensive screening & specific testing process leading to diagnostic classification
- Examination process identifies possible problems requiring consultation with or referral to another provider
=> observation with verbal & non-verbal communication
EVALUATION
= dynamic process in which physical therapist makes clinical judgements based on data gathered during examination
- Process identifies possible problems requiring consultation with or referral to another provider
=> signs & symptoms
DIAGNOSIS
- Both process & end result of evaluating examination data, which physical therapist organizes into defined clusters syndromes or categories to help determine prognosis (including plan of care) & most appropriate intervention strategies
PROGNOSIS (including plan of care)
- Determination of level of optimal improvement that may be attained through intervention & amount of time required to reach that level
- Plan of care specifies interventions to be used & their timing & frequency
INTERVENTION
- Purposeful & skilled interaction of physical therapist with patient & if appropriate with other individuals involved in care of patient, using various physical therapy methods & techniques to produce changes in condition that are consistent with diagnosis & prognosis
- Physical therapist conducts reexamination to determine changes in patient status & to modify or redirect intervention
- Decision to re-examine based on new clinical findings or on lack of patient progress
- Process of reexamination identify need for consultation with or referral to another provider
OUTCOMES
- Results of patient management, which include impact of physical therapy interventions in following domains: patho, pathophysio, impairments, functional limitations & disabilities, risk reduction , health, wellness & fitness, societal resources & patient satisfaction
Function of clinical assessment + assessment ≠ parts
Identifying pbs within patient’s presentation through accurate recognition of sign & symptoms & accurate interpretation of sign & symptoms
Varying with environment
Gathering info -> interviewing patient -> completing objective assessment -> establish measurable baseline for evaluating response
Properties of consent
- given voluntarily
- given by patient who has capacity
- referable both to treatment & to person who is to administer treatment
- given by patient who is informed
Info gathering
- relevant info from existing patient documentation
- patient’s personal details as name, date of birth…..
- test results
Medical summary: 7 parts & description of each
- History of presenting condition
- When symptoms start?
- When condition diagnosed?
- Other investigations? - Previous medical history
- Respiratory conditions, surgery
- Other conditions (cardiac,psychological issues, diabetes => comorbidities)
- Smoking history (1 pack year: 1pack/day for 1year)
- Urinary incontinence
- Musculoskeletal pain, stiffness (chest pain) - Drug history
- Current respiratory medications, dosage (including type of devices)
- Other medications, dosage, allergies - Social history
- Occupation & hobbies(past & present)
- Work
- Living place (stairs)
- Smoking status
- Alcohol - Familial history
- Genetic component - Medical examination
- Medical objective assessment
- Medical diagnosis & plan - Patient goals/expectations
Effective patient interviewing: description
- Project sense of interest in patient:
- Privacy. Listen to patient. Eye contact. Respond to patient ś priorities
- Establish your professional role during introduction
- Dress professionally. Smile! IF possible shake patient ś hand. State your role & purpose
- Show your respect for patient ś beliefs, attitudes & rights
- Ensure patient covered. Avoid nonverbal messages that you don’t have time. Be honest. Make NO MORAL JUDGMENTS- set your values for patient care ACCORDING to patient ś values & believes.
- Be empathic
- Encourage patient to express his or her concerns. Close interview asking if patient has anything else to say. Tell patient when you will return (if you will!)
Purpose: - Confirm/clarify previously obtained information
- Seek any missing (physio-related) information
- Start with:
- Open-ended questions: How are you doing? What is your main problem? What brought you to hospital?
- Closed question: When did your cough start? How Long did the pain last?
- Neutral questions: What happened next?
Attention to Direct questions that can be intimidating!!! “Why?” can cause patient to minimize responses
5 Main symptoms
Dyspnea, cough, airway secretions & haemoptysis, modifications of lung sounds, chest pain & other as fever
Dyspnea: def & description
= Breathlessness
- Subjective awareness of shortness of breath
- Normal sensation after exercise vs disease
- Shortness of breath at rest
- Worse during exercise (number of stairs – distance of walk) - “Unsatisfied inspiration”
- Description vs quantifying
- Positionsal
* Orthopnea (reclining position)
* Platypnea (upright position)
* Trepopnea (side lying)
- Association with Paroxysmal Nocturneal Dyspnea (PND)
- Associated swelling of ankles
- Associated with recent weight gain
- Cyanosis, nail clubbing (objective assessment)
- Weight loss (Lung cancer)
Cough: def & description
- Stimulation of receptors in pharynx, larynx trachea or bronchi - Protective reflex
- Differences between healthy & chronic respiratory disease
- Effectiveness (respiratory muscle function) - Quality: productive/dry
- Severity
- Pain
- Timing
- Duration
- Link with incontinence
Sputum: def & description
= Haemoptysis
- Healthy person: 10-100 ml/day (swallowing)
- Sputum = excess of tracheobronchial secretions cleared by coughing/huffing
- Information from subjective confirmed by objective - Sputum vs mucus:
* Colour
* Amount (of blood)
* Consistency
* Purulence, odour (offensive=infections), foul taste * Time of day, worse
Lung sounds: def & description
- Wheezing
- Crackles
- Vesicular sound
- Bronchial Sound
- Broncovesicular Sound
Chest pain: def & description
Chest pain (lung parenchyma & small airways do not contain pain fiber innervation): neuro-MSK, cardiac, pulmonary
PULMONARY:
- Pleurisy
- Pulmonary embolus - Pneumothorax
- Tracheitis
- Tumours
NEURO-MUSCULOSKELETAL
- Rib fracture
- Muscular
- Costochondritis & Tietze syndrome - Neuralgia
MEDIASTINAL
- Dissecting aortic aneurysm - Oesophageal
- Mediastinal shift
Other symptoms: 3 ≠ types & description of each
- Fever (pyrexia) : common feature of infection, non-specific to cardiorespiratory condition, but needs to be considered in light of other findings
- Headache : uncommon feature of respiratory disease. May signify nocturnal CO2 retention (morning headaches in patients with severe respiratory failure).
- Modified Level of Consciousness (Alertness)
Disease Awareness : patient’s knowledge, level of compliance
Functional Ability : enquiring about daily activities, job…
General description for each symptoms
- Sudden or gradual
- Location: radiation
- Duration: frequency, chronology
- Characteristics: quality, severity
- Aggravating & precipitating factors
- Relieving factors
- Current situation (improving or deteriorating)
- Effects on Activities of Daily Living (ADL)
- Previous diagnosis of similar episodes
- Previous treatments & efficacy
- Quantification if possible
Clinical reasoning: def & cycle
D: = process in which clinician, interacting with significant others (clients, caregivers, healthcare team members), structures meaning, goals & health management strategies based on clinical data, clients choices & professional judgment
C: schéma
SMART goals acronym
Specific Measurable Attainable Relevant Time bound
Characteristics of clinical reasoning in Cardiorespiratory physio
Patient
- Acute / Chronic disease
- Child / Adult / Elderly
- Understanding: Active Participation
Setting
- ICU
- Rehabilitation/ward
- Return to community * Private practice
* Home
RED FLAGS: def, types & actions
“Red flags” = alarm or warning symptoms, signs & near- patient diagnostic tests that suggest potentially serious underlying disease
- All red flags can be regarded as ‘diagnostic tests’, in that their presence or absence adjusts probability of serious diagnosis. They can be used to ‘rule in’ & ‘rule out’ serious conditions (cancer for example).
- In context of primary care, further investigation or referral usually required if red flag features present. However, absence of such features can also provide useful diagnostic clue when ruling out serious underlying condition
T: YELLOW: psychological factors (patient’s beliefs about condition) BLUE: individual’s perception of work
BLACK: work conditions that could inhibit rehabilitation ORANGE: drug abuse / abnormal psychological processes
Acceptance of flags => ° of biopsychosocial model
Flags well known to many physio, yet used systematically by very few
A: RED: Specialist medical opinion asap
YELLOW: Biopsychosocial management (°integrated approach with removal of perceived obstacles to recovery)
BLUE: Identify modifiable work perceptions
BLACK: Appraise significance as potential rehabilitation ORANGE: To mental health specialist – Reassess
Common red flags in physiotherapy
Fever & night sweats
Constant progressive, non mechanical pain (no relief with bed rest) Thoracic pain (sudden, shooting, sharp)
Past medical history of malignant tumour (relative)
Prolonged use of medications (corticosteroids) (relative)
Drug abuse, immunosuppression, HIV
Systemically unwell
Unexplained weight loss
Widespread neurological symptoms
Sudden headaches
Questioning of dizziness (5D’s & 3N’s)
Red flags in pneumology
- Unexplained weight loss, night sweats
- Haemoptysis
- Rapid or slow respiratory rate
- SpO2 < 92% in healthy individual or < 88% in patients with known chronic lung disease
- Pulse rate < 40 > 100 bpm - Silent chest or confusion
Red flags in cardiovascular diseases
Symptoms of Cardiac Pathology
Chest Pain
Shortness of Breath
Cardiac arrhythmia
Fainting
Claudication
Fatigue
Edema especially of extremities UE, LE or both
Symptoms of that may indicate Myocardial Infarction= Heart Attack
Severe chest pain (substernal pressure, “There is elephant standing on my chest”.)
Chest heaviness
Radiating pain down one or both arms Weakness or unexplained fatigue Fainting
Nausea and or Vomiting
Diaphoresis
Shortness of Breath
Red flags in cardiopulmonary testing
Acute myocardial infarction
- Unstable angina
- Unstable arrhythmias
- Symptomatic severe aortic stenosis - Any acute pulmonary symptom
- Any acute infectious process
- Inability to comply with testing procedures
Documentation of assessment
Assessment should be documented
Document should be precise, avoid jargon, only acceptable terminology
Document influence by local & national legal & regulatory frameworks
Clinical assessment: def & determine management plan
identifying aspects of clinical presentation which are amenable to PT intervention
- Recognition of abnormal features in clinical assessment
- Order of relevance or urgency of clinical presentation
- Which aspects can or cannot be influenced by PT interventions
- Which interventions have highest likelihood of affecting more than one aspect of clinical presentation
