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KIN 440 > The Evaluation Process Pt. 1 > Flashcards

The Evaluation Process Pt. 1 Flashcards

1
Q

4 parts of the evaluation process:

A
  • recognition
  • evaluation
  • rehabilitation
  • re-evaluation
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2
Q

_____ is the foundation of rehabilitation.

A

evaluation

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3
Q

2 things to determine in the evaluation process:

A
  • a client’s chief complaint (CC)

- a client’s needs

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4
Q

The evaluation must be…

A
  • systematic
  • valid & reliable
  • reproducible
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5
Q

Common _______ _______ techniques is useful in helping the examiner to solve a problem.

A

assessment recording

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6
Q

Recognize consists of:

A
  • identify the physical basis for the symptoms that have caused the client’s pain or limited function/abilities
  • to fully and clearly understand the client’s problem
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7
Q

Evaluate consists of:

A

accurately diagnose or gather an index of suspicion (IOS)

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8
Q

When determining rehabilitation plan, consider…

A
  • severity
  • irritability
  • nature
  • stage of injury
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9
Q

Re-evaluation consists of:

A

monitor progress at every visit

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10
Q

3 types of evaluations:

A
  • pre-participation physical evaluation
  • primary and secondary survey
  • health care provider notes and evaluations
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11
Q

Pre-participation physical evaluations include:

A
  • medicals for sport

- examination for MV operators

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12
Q

Primary and secondary survey includes:

A

HOPS (for first aider or first responder, done at time of injury) (History, Observation, Palpation)

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13
Q

Health care provider notes and evaluations includes:

A
  • in clinic involving detailed history, assessment, and rehab notes
  • SOAP (MSK)
  • progress notes
  • mental health assessment
  • pain assessment
  • psychological assessments
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14
Q

Documentation must be _____, _____ and _____.

A
  • clear
  • concise
  • accurate
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15
Q

Common assessment recording technique:

A

medical records

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16
Q

Why are medical records helpful?

A
  • legal reasons

- for insurance, for third party billing

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17
Q

Challenges of documentation:

A
  • cumbersome and time consuming
  • becoming proficient
  • generate accurate records (inter, intra evaluator reliability)
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18
Q

4 keys to successful evaltation:

A
  • sequential approach (thorough)
  • systematic approach
  • reproducible
  • correct diagnosis
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19
Q

Why generate differential diagnosis?

A
  • even if the diagnosis is obvious, use valuable information to decrease assumptions
  • asking “what else could it be?”
  • treatment plans vary depending on proper diagnosis
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20
Q

SOAP is a _____, _____, _____ and ______ evaluation process.

A
  • systematic
  • sequential
  • developing
  • differential
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21
Q

SOAP stands for:

A
  • subjective
  • objective
  • assessment
  • plan
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22
Q

SOAP is an _____ ____ technique and a method of _____.

A
  • assessment recording

- documentation

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23
Q

Subjective (of SOAP) includes:

A
  • understanding the client
  • understand the demands or stresses, training schedules, functional requirements
  • allows patient to explain in their own words the CC
  • primary history info of CC
  • perceptions: severity, pain, MOI
  • demographics
  • level of functional activity
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24
Q

Objective (of SOAP) includes:

A
  • the evaluator’s findings
  • findings that are observable and measurable
  • observation (looking for)
  • ROM
  • palpation
  • tests
  • functional ability
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25
Q

Assessment (of SOAP) includes:

A
  • the evaluator’s impression of the injury

- develops a probable impression of problem, including site of injury, structure involved, and severity rating

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26
Q

Plan (of SOAP) includes:

A
  • the treatment plan
  • can include: first aid, referral, treatment, rehab
  • goals (short and long term)
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27
Q

3 parts of subjective assessment:

A
  1. injury history
  2. personal history
  3. sport/activity history
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28
Q

In the subjective assessment, we establish …

A
  • the patient’s problem or CC
  • a probable impression of the injury (site, structure, severity)
  • comfort and trust through sequential dialogue
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29
Q

Subjective assessment requires…

A

effective and efficient communication techniques

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30
Q

The medical history is actually a story of the individual, where we are the journalist and are meant to…

A

edit and organize the patient’s spontaneous report into a formal, organized presentation

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31
Q

7 parts of part 1 (injury history):

A
  • CC
  • MOI
  • sounds and sensations
  • at the time of onset
  • pain
  • management (treatment) to date
  • past medical history = previous injuries
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32
Q

3 parts of chief complaint (CC):

A
  • client’s impression of the problem
  • date of injury (DOI)
  • location of the injury
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33
Q

Client’s impression of the problem consists of:

A
  • asking what’s the problem
  • what brings you in today?
  • who/what/when/where/why
34
Q

DOI consists of:

A
  • did injury occur immediately (acute)
  • was injury brought on overtime (chronic)
  • don’t know? (insidious onset)
35
Q

Location of the injury consists of:

A
  • where does the pain hurt? site, location
  • local: can point with 1 finger
  • global: generally area or region or joint
  • left or right
  • anterior or posterior or lateral
  • superficial or deep
36
Q

2 parts of mechanism of injury (MOI):

A
  • asking questions to understand the exact method the patient got injured
  • how did the injury occur?
37
Q

Asking questions to understand the exact methods of injury includes:

A
  • identify the nature of forces acting on the body

- how this relates to anatomical tissue stress = yield point

38
Q

Figuring out how the injury occurred includes:

A
  • identify body position and limb position
  • direction of applied force
  • magnitude of applied force and point of application
  • was it a single traumatic force (macrotrauma) vs an accumulation of repeated forces (microtrauma)
39
Q

Injury results from ….

A

forces acting on the anatomical structures causing tissue stress or failure (structure)

40
Q

Sounds and sensations include:

A
  • unusual sounds/sensations
  • pop
  • crack
  • snap
  • grating
  • clicking
  • cracks
  • creaking
  • grinding
  • crepitus
  • tearing
  • locking
  • giving way
  • buckling
  • shifting
41
Q

At time of onset (when happened) includes questions on:

A
  • swelling?
  • bruising?
  • altered or limited function?
  • pain?
42
Q

Pain is _____. It’s manifestations are …

A
  • subjective

- unique to each individual

43
Q

Pain should be described based on….

A
  • history of pain
  • use the same pain scale to record and document every time
  • # /10
44
Q

OPQRST stands for:

A
  • onset
  • provocation & pallative
  • quality
  • region
  • refer pain or radiate
  • severity
  • time
45
Q

Onset of pain:

A

date of injury (may have already asked)

46
Q

Provocation & pallative of pain:

A
  • what aggravates or provokes?
  • what eases or alleviates?
  • understanding the functional movements that cause pain
  • inc./dec. with activity
  • constant, periodic, episodic
  • associated with rest, activity
47
Q

Quality of pain:

A
  • sensation
  • description of pain
  • sharp
  • dull
  • aching
  • burning
  • stabbing
  • pins & needles
48
Q

Region of pain:

A
  • site or location
  • deep or superficial
  • left or right
  • anterior or posterior
49
Q

Refer pain or radiate:

A
  • pain travelling to different parts of the body
  • pins/needles
  • changes in sensation, lack of sensation
50
Q

Severity of pain:

A
  • intensity of pain (rating scale 1-10)
  • at time of injury?
  • now?
  • before, during, after sport/activity?
51
Q

Time of pain:

A
  • time of/since onset (how long has the pain been going on)
  • time of day (am, pm, night pain, all the time)
  • timing of pain (intermittent or constant, activity related, increases with movement)
52
Q

Activity related pain examples:

A
  • pain but reduces with activity
  • pain that worsens with activity
  • pain at rest and worst at beginning of activity
  • pain is not influenced by activity
53
Q

Pain that increases with a movement includes…

A

at the joint, or within the kinetic chain (ie. spinal flexion, extension, or rotation)

54
Q

4 parts of management (treatment) to date:

A
  • type of injury management to date (ice, heat, massage etc.)
  • any & type of medications (prescribed or OTC, last taken)
  • any health care professional consulted (HCP)
  • any diagnostics or any laboratory tests
55
Q

Past medical history =

A

previous injuries

56
Q

2 parts of past medical history:

A
  • to the joint of the CC

- previous injury to other joints

57
Q

Previous injury to other joints include 3 relevant areas:

A
  • from same side (ipsilateral) extremity, joints above and below CC
  • from other side (contralateral) extremity, all joints
  • from spine
58
Q

Follow up questions for previous injury to relevant areas:

A
  • DOI
  • previous diagnosis
  • treatment, care & management
  • full return to activity?
59
Q

Which joints are relevant for previous injuries?

A
  • same side: ipsilateral
  • other side: contralateral
  • look at joints above or below
60
Q

7 parts of part 2 - personal history:

A
  • patient profile
  • red flags
  • previous surgeries, MVA
  • allergies
  • medications (OTC, prescribed)
  • activity pattern & ADL
  • lifestyle behaviours
61
Q

Patient profile consists of:

A
  • name
  • age
  • gender vs sex
  • occupation/jobs
  • dominant limbs (arms, legs)
  • overall general health status currently or recently
  • personal history of illness (or injury if needed)
  • family history of illness and injury (specific to CC)
62
Q

What are red flag questions?

A
  • personal history questions related to health
  • need to know if there is something else going on that is unrelated to CC
  • not your job to determine what the sum of those symptoms mean
63
Q

Flag findings are S/S that….

A
  • indicate the problem is not a musculoskeletal one or a more serious problem that needs referral
  • may denote problems that may be more severe, involve more than 1 area requiring more examination
  • may relate to cautions and contraindications to treatments that might have to be considered
64
Q

Activity pattern and ADL includes:

A
  • daily activity
  • sports
  • recreation
  • hobbies
  • physical job
65
Q

Lifestyle behaviours includes:

A
  • smoking
  • sleep habits
  • nutrition
  • stress/workload
66
Q

ADLs =

A
  • BATTED
  • Bathing
  • Ambulation
  • Toileting
  • Transfers
  • Eating
  • Dressing
67
Q

Components of part 3: activity history:

A
  • identify type of activity of participation
  • how long have they been participating in activity
  • position = specificity of movements
  • level of participation
  • identify functional movements required for needed for activity, concerns
  • volume of activity
  • equipment
  • activity surface and training surface
68
Q

Identify type of activity of participation:

A
  • sport
  • play
  • recreation
  • leisure
  • hobby
  • exercise
69
Q

Level of participation:

A
  • work of job
  • fun
  • casual
  • competitive
  • high performance
70
Q

Identify functional movements required or needed for activity, concerns:

A
  • what can’t they do?
  • pain?
  • what are restrictions or limitations?
71
Q

Volume of activity:

A
  • FITT
  • frequency (in and out of season, next competition)
  • intensity of activity
  • time or how often
72
Q

Equipment used:

A
  • shoes
  • footware
  • sport or protective equipment
73
Q

Activity surface and training surface:

A
  • indoor
  • outdoor
  • trails
  • clay/dirt
  • tracks
74
Q

Part 3 - sport/activity history: changes or alterations to…

A
  • volume of training (changes to FITT)
  • activity surface
  • anthropometrics
  • equipment
  • biomechanics
75
Q

Part 3 - sport/activity history: goals:

A
  • ask what client wants from treatment
  • what does the client want to do that can’t currently do?
  • short term/long term
76
Q

IOS =

A

index of suspicion

77
Q

IOS is not a _____ until….

A
  • diagnosis

- objective is completed

78
Q

____ ____ is especially important for making a correct diagnosis.

A

history taking

79
Q

To improve the diagnostic reasoning skills, medical students should be trained in methods for….

A

inferring the correct diagnosis from the case history

80
Q

Correct history assessment:

A
  • even if the diagnosis is obvious, take time
  • will help determine the cause
  • provides valuable info
  • decrease assumptions
  • establishes relationship with client

KIN 440 (10 decks)

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