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
