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Flashcards in Components of the Subjective Exam Deck (29):
1

Where does the Subjective Exam fall?

Evaluation and Examination

2

What is the Primary Objective of the Initial PT visit?

Phase 1 differential Diagnosis- Does this patient belong in my clinic?

3

What is the Steps in the Subjective Exam Flow?

1. Review Baseline Information/ Chart Review
2. Establish Rapport
3. Gather General Information
4. Analyze information/ Hypothesis Generation
5. Gather Specific Information
6. Plan objective Exam

4

____% of the information needed to determine to make a diagnosis is contained in the subjective exam.

80%

5

Step 1: Review Baseline Information/Chart Review

Provides needed information:
* General Health Status
* Imaging Findings
* Operative reports
* Past Medical History and/or treatments
* Medications

6

Step 2: Establishing Rapport

* Welcoming Introduction
* Establish effective communication and rapport
* Explanation of perspective
*clarification of patient expectations
*Sequence of first session- exam process and patient's role

7

Step 3: Gather General Information

* Patient profile
* Chief Complaint
*Body Chart
* Present Episode
* Past History
* Aggravating/ Easing Factors
* Relationship between regions
*24 hours behavior
* Patient goals
* Patient Expectations

8

Body Chart- Problem Area Characteristics

Location- of each area of pain/ symptoms
quality- type of symptoms
depth- of symptoms
frequency- constancy of symptoms
Relationships- between areas of symptoms
clearing- relevant areas

9

Body Chart- Rating pain

Numerical Pain Rating Scale (NPRS)- on a scale of 0 to 10...
Visual Analog Scale (VAS) for pain

10

Radicular Symptoms

direct stimulation of a nerve root results in a sharp, lancinating pain, well-localized to the dermatome.

11

Visceral Referral

Kidney, pancreas, cardia etc. can mimic or masquerade as musculoskeletal pain

12

Somatic referral

symptoms that arise from referral of a musculoskeletal structure (i.e. facet jt.)

13

Trigger Point

hypersensitive spot typically in skeletal muscle that can be associated with a taut band

14

Step 4: Analyze Information/ Hypothesis Generation

Hypothesis generation--> Hypothesis Refinement--> Primary Hypothesis

15

Step 5: Gather Specific Information

Date of onset?
Mode of onset? (Gradual or sudden onset)
Immediate or delayed symptoms after injury? (Pain and Swelling)
Are symptoms getting better, worse, or status quo?
Any treatment to date? Effects?
24- Hour Behavior

16

Step 5: Gather Specific Information

Behavior of Symptoms- Aggravating Factors or Easing Factors

17

Red Flags

Signs and/ or symptoms that may warrant immediate communication with the referring provider or... May warrant a referral/ consultation to another healthcare practictioner

18

Red Flags: Category 1

Factors that require immediate Medical Attention

19

Red Flags: Category 2

Factors that require subjective questioning and precautionary examination and treatment procedures

20

Red Flags: Category 3

Factors that require further physical testing and differential analysis

21

Yellow Flags

May warrant a referral/ consultation to a mental health practioner

22

SINSS

Severity
Irritability
Nature
Stage
Stability

23

Severity

Minimal, Moderate, High

24

Iritability

Low, Moderate, High

25

Nature

Musculoskeletal vs. Non-Musculoskeletal/ Sinister

26

Stage

Acute, Subacute, Chronic

27

Stability

Worse, Better, Staying the Same

28

High Severity & Irritability

Limit exam, don't make patient worse

29

Low irritability

No limits to exam, want to reproduce symptoms