The Evaluation Process Pt. 1 Flashcards
1
Q
4 parts of the evaluation process:
A
- recognition
- evaluation
- rehabilitation
- re-evaluation
2
Q
_____ is the foundation of rehabilitation.
A
evaluation
3
Q
2 things to determine in the evaluation process:
A
- a client’s chief complaint (CC)
- a client’s needs
4
Q
The evaluation must be…
A
- systematic
- valid & reliable
- reproducible
5
Q
Common _______ _______ techniques is useful in helping the examiner to solve a problem.
A
assessment recording
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
7
Q
Evaluate consists of:
A
accurately diagnose or gather an index of suspicion (IOS)
8
Q
When determining rehabilitation plan, consider…
A
- severity
- irritability
- nature
- stage of injury
9
Q
Re-evaluation consists of:
A
monitor progress at every visit
10
Q
3 types of evaluations:
A
- pre-participation physical evaluation
- primary and secondary survey
- health care provider notes and evaluations
11
Q
Pre-participation physical evaluations include:
A
- medicals for sport
- examination for MV operators
12
Q
Primary and secondary survey includes:
A
HOPS (for first aider or first responder, done at time of injury) (History, Observation, Palpation)
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
14
Q
Documentation must be _____, _____ and _____.
A
- clear
- concise
- accurate
15
Q
Common assessment recording technique:
A
medical records
16
Q
Why are medical records helpful?
A
- legal reasons
- for insurance, for third party billing
17
Q
Challenges of documentation:
A
- cumbersome and time consuming
- becoming proficient
- generate accurate records (inter, intra evaluator reliability)
18
Q
4 keys to successful evaltation:
A
- sequential approach (thorough)
- systematic approach
- reproducible
- correct diagnosis
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
20
Q
SOAP is a _____, _____, _____ and ______ evaluation process.
A
- systematic
- sequential
- developing
- differential
21
Q
SOAP stands for:
A
- subjective
- objective
- assessment
- plan
22
Q
SOAP is an _____ ____ technique and a method of _____.
A
- assessment recording
- documentation
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
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
25
Assessment (of SOAP) includes:
- the evaluator's impression of the injury
| - develops a probable impression of problem, including site of injury, structure involved, and severity rating
26
Plan (of SOAP) includes:
- the treatment plan
- can include: first aid, referral, treatment, rehab
- goals (short and long term)
27
3 parts of subjective assessment:
1. injury history
2. personal history
3. sport/activity history
28
In the subjective assessment, we establish ...
- the patient's problem or CC
- a probable impression of the injury (site, structure, severity)
- comfort and trust through sequential dialogue
29
Subjective assessment requires...
effective and efficient communication techniques
30
The medical history is actually a story of the individual, where we are the journalist and are meant to...
edit and organize the patient's spontaneous report into a formal, organized presentation
31
7 parts of part 1 (injury history):
- CC
- MOI
- sounds and sensations
- at the time of onset
- pain
- management (treatment) to date
- past medical history = previous injuries
32
3 parts of chief complaint (CC):
- client's impression of the problem
- date of injury (DOI)
- location of the injury
33
Client's impression of the problem consists of:
- asking what's the problem
- what brings you in today?
- who/what/when/where/why
34
DOI consists of:
- did injury occur immediately (acute)
- was injury brought on overtime (chronic)
- don't know? (insidious onset)
35
Location of the injury consists of:
- 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
2 parts of mechanism of injury (MOI):
- asking questions to understand the exact method the patient got injured
- how did the injury occur?
37
Asking questions to understand the exact methods of injury includes:
- identify the nature of forces acting on the body
| - how this relates to anatomical tissue stress = yield point
38
Figuring out how the injury occurred includes:
- 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
Injury results from ....
forces acting on the anatomical structures causing tissue stress or failure (structure)
40
Sounds and sensations include:
- unusual sounds/sensations
- pop
- crack
- snap
- grating
- clicking
- cracks
- creaking
- grinding
- crepitus
- tearing
- locking
- giving way
- buckling
- shifting
41
At time of onset (when happened) includes questions on:
- swelling?
- bruising?
- altered or limited function?
- pain?
42
Pain is _____. It's manifestations are ...
- subjective
| - unique to each individual
43
Pain should be described based on....
- history of pain
- use the same pain scale to record and document every time
- #/10
44
OPQRST stands for:
- onset
- provocation & pallative
- quality
- region
- refer pain or radiate
- severity
- time
45
Onset of pain:
date of injury (may have already asked)
46
Provocation & pallative of pain:
- 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
Quality of pain:
- sensation
- description of pain
- sharp
- dull
- aching
- burning
- stabbing
- pins & needles
48
Region of pain:
- site or location
- deep or superficial
- left or right
- anterior or posterior
49
Refer pain or radiate:
- pain travelling to different parts of the body
- pins/needles
- changes in sensation, lack of sensation
50
Severity of pain:
- intensity of pain (rating scale 1-10)
- at time of injury?
- now?
- before, during, after sport/activity?
51
Time of pain:
- 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
Activity related pain examples:
- 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
Pain that increases with a movement includes...
at the joint, or within the kinetic chain (ie. spinal flexion, extension, or rotation)
54
4 parts of management (treatment) to date:
- 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
Past medical history =
previous injuries
56
2 parts of past medical history:
- to the joint of the CC
| - previous injury to other joints
57
Previous injury to other joints include 3 relevant areas:
- from same side (ipsilateral) extremity, joints above and below CC
- from other side (contralateral) extremity, all joints
- from spine
58
Follow up questions for previous injury to relevant areas:
- DOI
- previous diagnosis
- treatment, care & management
- full return to activity?
59
Which joints are relevant for previous injuries?
- same side: ipsilateral
- other side: contralateral
- look at joints above or below
60
7 parts of part 2 - personal history:
- patient profile
- red flags
- previous surgeries, MVA
- allergies
- medications (OTC, prescribed)
- activity pattern & ADL
- lifestyle behaviours
61
Patient profile consists of:
- 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
What are red flag questions?
- 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
Flag findings are S/S that....
- 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
Activity pattern and ADL includes:
- daily activity
- sports
- recreation
- hobbies
- physical job
65
Lifestyle behaviours includes:
- smoking
- sleep habits
- nutrition
- stress/workload
66
ADLs =
- BATTED
- Bathing
- Ambulation
- Toileting
- Transfers
- Eating
- Dressing
67
Components of part 3: activity history:
- 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
Identify type of activity of participation:
- sport
- play
- recreation
- leisure
- hobby
- exercise
69
Level of participation:
- work of job
- fun
- casual
- competitive
- high performance
70
Identify functional movements required or needed for activity, concerns:
- what can't they do?
- pain?
- what are restrictions or limitations?
71
Volume of activity:
- FITT
- frequency (in and out of season, next competition)
- intensity of activity
- time or how often
72
Equipment used:
- shoes
- footware
- sport or protective equipment
73
Activity surface and training surface:
- indoor
- outdoor
- trails
- clay/dirt
- tracks
74
Part 3 - sport/activity history: changes or alterations to...
- volume of training (changes to FITT)
- activity surface
- anthropometrics
- equipment
- biomechanics
75
Part 3 - sport/activity history: goals:
- ask what client wants from treatment
- what does the client want to do that can't currently do?
- short term/long term
76
IOS =
index of suspicion
77
IOS is not a _____ until....
- diagnosis
| - objective is completed
78
____ ____ is especially important for making a correct diagnosis.
history taking
79
To improve the diagnostic reasoning skills, medical students should be trained in methods for....
inferring the correct diagnosis from the case history
80
Correct history assessment:
- even if the diagnosis is obvious, take time
- will help determine the cause
- provides valuable info
- decrease assumptions
- establishes relationship with client
