Subjective Eval Flashcards by Tori Chatman

PT Evaluation Process

-exam
-evaluation
-diagnosis
-Prognosis
-POC
-Management

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Exam

-Pt Hx (meds, current interventions, imaging)
-subjective interview
-tests and measures

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Evaluation

-synthesize all data
-what does it mean

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Diagnosis

-what clinical pattern does the Pt fall in?

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Prognosis

-what is the expected level of improvement based on physical, emotional, and social factors

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Plan of Care/Management

-How will we proceed
-Interventions
-assessments
-goals

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Subjective Interview

-establish relationship and trust
-Determine understanding of PT
-Determine understanding of condition
-search for clues about condition
-determine current interventions from other clinicians
-Medications
-look for red flags
-determine what to examine
-formulate hypothesis

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Biopsychosocial Model

Biology: how does their body work

Psychology: current mindset

Social: what do they do, what is around them, who is around them

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Open-Ended questions

-use at the beginning
-use when difficulty opening up
-use when clarifying any missing information

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Close-Ended questions

-clarify questions
-get specific answers

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Graded-Response questions

-quantify experience with a range
-clarify vague answers
-use for goal setting

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Multiple-Option Questions

-often visual
-use for patients with difficulty describing
-identify patterns

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Pre-Interview

-review chart and Hx
-observe patient’s posture, demeanor, company, movements
-establish first impression

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Chief Complaint

-Onset
-Location
-Description/Duration
-Intensity
-Behavior

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Injury Descriptions: Aching

Muscular

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Injury Descriptions: Burning

Muscular or neural

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Injury Descriptions: Shooting, lightning, electrical

Nerve root irritation

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Injury Descriptions: Coldness

Blood flow issues

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Injury Descriptions: Hotness

inflammation or infection

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Injury Descriptions: Clicking, snapping, popping

ligament or tendon dysfunction

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Injury Descriptions: Joint locking

Cartilage tear, looseness, misalignment

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Injury Descriptions: Global weakness or fatigue

Cardio or pulmonary dysfunction

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Injury Descriptions: Whole body pain

Study These Flashcards

-central somatization: chronic pain

Injury Onset: Acute

Study These Flashcards

-quick

Injury Onset: Subacute

-has no timeline, but not chronic

Injury Onset: Chronic

-long term

Injury Onset: Episodic

-Chronic with recent exacerbation

Injury Onset: Insidious

- no plausible explanation

Injury Location

-show location -describe any movement

Injury Intensity

-pain tools/scales -numbers

Injury Behaviors

-exacerbating factors -Alleviating factors -changes in 24h

24h Pain Pattern

-"Over the course of 24h how does your pain change?" -joint and back pain -how does it effect sleep -how often do you think about your pain

Jt pain worse in AM

-inflammatory -Ex: RA

Jt pain worse with movement

-degenerative -OA

Back pain worse in AM and then again in late PM

Disc

Red Flag for Malignancy

Constant intense pain, worse PM, awakes from sleep without relief

Red Flags Requiring Immediate Attention

-anginal pain no relieved in 10-20min -angina with sweating, nausea, vomiting -Diabetic client that is confused or lethargic -onset of incontinence or saddle anesthesia -anaphylactic shock

Yellow Flags

-proceed with caution -psychological

ABCs of Radiographs

A: alignment or structures B: Bone density and textures C: Cartilage S: soft tissues

Patient History

-Determine understanding of condition -determine current interventions from other clinicians (current and other conditions) -prior level of function -health habits/risks -Medications -past PT experiences -Family Hx

Patient Environment

-Physical environment -Living environment/Assistance -Work/recreation/social/school/sport

Mental Orientation Assessment

-AOx3 -Name, location, current date

Patient goals

-not always the same as clinician -specific functional tasks that are not obtainable at present -can be planned

Vital Signs

-HR, BP, O2 Saturation, Respiration rate, temp, pain

Nominal Measures

-categorized -one or the other

Ordinal Measures

-order/rank is important

Interval Measures

-real numbers that can be manipulated -have no real 0 ex: ankle circumference

Ratio Measures

-real numbers that can be manipulated -real 0 ex: goniometer reading, pain scale

Test-Restest Reliability

-reliable accurately and consistently -stability over time

Intra-Rater Reliability

-reliable accurately and consistently -same for the same person

Inter-Rater Reliability

-reliable accurately and consistently -Same for all raters

Face Validity

-does it measure what it claims to -Does a scale measure weight?

Content Validity

-does it measure the full construct -Does an ADL insttrument include all ADLs

BATTED

-ADLS: activities of daily living -Bathing -Ambulation -Toileting -Transfers -Eating -Dressing

MDC

-Minimal detectable change -amount of change that must be achieved to reflect true statistical difference

MCID

-Minimal clinically important difference -smallest difference in a measured variable that signifies and importance

Global Disability/QoL

-measures overall disability and quality of life -patient perceptions of how conditions affects their role in society -broad range of health

Subjective Eval Flashcards

(57 cards)