subjective assessment Flashcards
what is the process of assessment and treatment?
- subjective assessment
- objective assessment
- working diagnosis
- problem list
- treatment plan
what is a subjective assessment and what does it assess?
- system based assessment
- assesses the bodies physiological system
- follows a format
what does subjective assessment focus on?
- structure and function
where does subjective assessment take place?
- hospital
- acute
- community services
- outpatients
what does functional assessment focus on and what is it related to?
- focus on functional independence and mobility for patients
- may be employment or sports related
what does goal oriented assessment combine and what doesn’t it fit?
- combines goal setting and patient centred
- doesn’t fit a protocol
what are the six main subject headings?
- presenting condition
- history of presenting condition
- past medical history
- drug history
- social history
- significant family history
what should you always check before?
- name
- contact details
- date of birth
- where the referral has come from
how should you introduce yourself?
- name
- profession
- what you are doing
- check what they would like to be called (preferred title)
what are the functions of asking questions?
- guides objective assessment
- formulates working diagnosis
- creates problem list
identify sources of information
- patient
- nurses
- discharge letters
- medical notes
- next of kin
- handovers
- GP
- recent relavant correspondence
what is the presenting condition?
- what is the patient’s complaint?
- why have they come to physiotherapy for?
what are examples of presenting conditions?
- knee pain, back pain, shortness of breath, cough, numbness
what is the history of presenting condition ?
- trying to understand mechanism of injury
- what are the origins of your symptoms?
- when did you first notice the symptoms?
- what are the symptoms?
what other questions does history of presenting condition focus on?
- how long have they had the symptoms for?
- duration when symptoms present
- what makes symptoms better/ worse?
- visual analogue scale
- how do your symptoms present> pattern of behaviour (within 24 hour pattern)
what is past medical history?
- some conditions influence recovery process e.g., vascular conditions
- do you have any other medical conditions?
- have they been treated for this condition before?
- if so, what was used and how long did it take for symptoms to return
what is drug history?
- medications can influence healing or side effects leading to experiencing symptoms
- what medication is taken?
- how does it affect you or your symptoms?
- look at pharmacist’s assessment to gather history/ GP record
what is social history?
- establishes how much their symptoms have impacted daily life > hence QOL
- serves for goal setting
- activities of daily living/ personal activities of living
- who do they live with?
- what are their hobbies?
- employment history
what are the concerns associated with social history?
- concerns with mobility, are they intendent, or do they require walking aid?
- additional equipment at home
what other aspect is important to establish and why?
- goals
- what would you like to get out of your treatment?
- what is the patient aiming for?
- helps guide where your treatment > meaningful application
what does threads stand for? (past medical history)
Thyroid
Heart- including high blood pressure
Rheumatoid Arthritis
Epilepsy
Asthma
Diabetes
Steroids
what else can be asked?
- special questions
- dependent on specific assessment
what special questions are asked for lumbar spine or hip symptoms?
- bladder and bowel symptoms
- lower limb weakness
- saddle anaesthesia
- gait
what special questions are asked for cervical spine and shoulder symptoms?
- dizziness
- diplopia
- dysphagia
- dysarthria
- drop attacks
what special questions are asked for cervical spine and shoulder symptoms?
- numbness
- nausea
- nystagmus
what are special questions asked for knee and hip pain?
- locking
- clicking
- giving way
what are other questions to be clear of?
- unintentional weight loss
- unremittent night pain
- unremittent non mechanical pain
- fever
- feeling generally unwell
- widespread neurological symptoms
- family history of cancer
