Physical Therapy Exam and Eval - Class 1 Flashcards

1
Q

2 rules to remember when performing an exam

A
  1. it is a continuous process that is always updated during treatment of the pt
  2. never let one positive finding stop you from completing your eval –> that finding should be confirmed by alternate techniques or methods
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2
Q

evaluation

A

to determine or fix the value of something

to examine and judge concerning the worth, quality, significance, amount, degree or condition of something

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3
Q

PT exam

A

process that includes taking the history, conducting a systems review and administering tests and measures to identify potential and existing problems

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4
Q

history

A

an account of past and present health status

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5
Q

what does history include

A

identification of complaints

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6
Q

what does the history provide

A

provides the initial source of info about the pt/client

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7
Q

what does the history suggest

A

individual’s ability to benefit from PT

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8
Q

what does the PT do while taking the history

A

identifies health-risk factors, health restoration and prevention needs and co-existing health problems that have implications for intervention

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9
Q

how is history obtained

A

through gathering of data from the pt/client, family, SO, caregivers and other interested persons

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10
Q

who else could we speak to to obtain history

A

through consultation w/ other members of the health care team

review of the medical chart

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11
Q

systems review

A

brief or limited examination that provides additional info about the general health of the pt/client

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12
Q

what does the systems review help the PT do

A

formulate dx, prognosis and POC and select direct interventions

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13
Q

how else does the systems review assist the PT

A

identifying possible health problems that require consultation w/ or referral to another health care provider

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14
Q

systems review helps answer

A

what should I do next?

what do I need to examine in depth?

what don’t I need to do?

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15
Q

when do you do tests and measures

A

after analyzing the info gathered from the history and review of systems

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16
Q

tests and measures

A

therapists will select tests and measures to elicit additional info

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17
Q

PT evaluation

A

done to establish dx and px by synthesizing the exam data

putting together the parts

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18
Q

purpose of a PT eval (1-3)

A

identify the specific lesion responsible for the pt’s chief complaint of pain and fxnal impairment

to assess the integrity and performance of the involved tissues and structures that we have identified

to determine the pts baseline fxnal abilities during … so future measurements may be compared

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19
Q

identify the specific lesion responsible for the pt’s chief complaint of pain and fxnal impairment –> purpose

A

so we could direct our interventions towards that

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20
Q

to determine the pts baseline fxnal abilities during … so future measurements may be compared –> purpose

A

ADLs

occupational activities

recreational activities

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21
Q

purpose of PT eval (4-5)

A

documentation to prove to insurance companies that PT is working and helping the pt to improve

to ensure that each pt is an appropriate candidate for PT

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22
Q

to ensure that each pt is an appropriate candidate for PT –> purpose

A

part of this process is screening for medical dz

23
Q

PT dx

A

term that names the primary dysfxn toward which the PT directs treatment

24
Q

how is the dysfxn identified by the PT

A

based on info obtained through

-history
-S&S
-examination
-tests the therapist performs or requests

25
Q

what happened in 1984

A

PT may establish a dx w/in the scope of their knowledge, experience and expertise

26
Q

dx

A

label encompassing a cluster of S&S, syndromes or categories

27
Q

dx is a

A

decisions

reached as a result of the dx process

28
Q

dx process

A

evaluating the info obtained through the exa–> organizing it into clusters, syndromes or categories and interpreting it

29
Q

dx is giving the pt a

A

label

30
Q

2 aspects of a dx

A

label is given to the condition

label provides characteristics of the conditions when it is communicated w/ others

31
Q

what must PT must establish

A

diagnostic categories

32
Q

diagnostic categories

A

direct treatment prescriptions

provide a means of communication both w/in the profession and w/ other practitioners and consumers about the conditions that require their particular expertise for effective treatment

33
Q

PTs must not use diagnostic labels that

A

they cannot confirm through their own recognized examination and testing methods

34
Q

dx could be made possible if

A

physical exam showed visual or manual evidence

35
Q

PTs do not make

A

differential dx to identify a specific dz

36
Q

what do PT dx and diagnostic categories help with

A

clinical decision making about the most appropriate intervention

37
Q

what exist on PTs making a dx

A

legal limitations

38
Q

clinical dx will help

A

make treatment plan

39
Q

a PT dx

A

encompasses the pt’s impairments, activity limitation and participation restriction

leads our treatment

40
Q

differential dx

A

comparison of sxs of similar dzs

41
Q

why do we do a differential dx

A

so that a correct assessment of the pt’s actual problem can be made

42
Q

rule-out concept

A

similar meaning to differential dx

means to “check out”

helps you arrive at a differential dx

43
Q

initial exam and eval is done at

A

first visit

44
Q

what does the initial exam/eval include

A

history of past illness

PMH

Dx tests

physical exam

evaluations

POC

setting anticipated goals

expected outcomes

px

duration of tx

45
Q

most difficult part of initial visit

A

prognosis

46
Q

prognosis is determined once

A

dx has been established

47
Q

what is a px

A

determination of the predicted optimal level of improvement in fx and the amount of time needed to reach that level

48
Q

what else may a px include

A

prediction of levels of improvement that may be reached at various intervals during the course of therapy

49
Q

px is a

A

complicated process

50
Q

what does a px require

A

both clinical experience and academic knowledge

51
Q

reexamination is done

A

on a regular basis

52
Q

discharge eval or summary is done to determine

A

the status of the pt at time of discharge

have they met all goals of PT?

53
Q

what foes the discharge eval or summary help with

A

determine the type of follow-up plane or continued care to be recommended