Week 1 Flashcards
1
Q
Should treatment occur if there hasn’t been a thorough physiotherapy specific examination?
A
No
2
Q
What is Screening?
A
- Where you ask questions to determine if a more thorough evaluation for a particular problem is warranted. Does the patient need an assessment. The outcome of your screening will be yes, more assessment or no, no further assessment.
- Little or no special training is needed.
3
Q
What is assessment?
A
- Assessment is a process which involves asking questions, making observations and physical techniques to help to define the nature of a problem and determine diagnosis, develop specific treatment options that meet the individual needs of a patient.
- The outcome is that you gather detailed information that helps you to safely and appropriately manage the client
- Specific training is needed
4
Q
Does patient assessment use observation, judgement and reflection?
A
Yes
5
Q
Does patient assessment stop at all throughout the assessment?
A
No
6
Q
Does patient assessment * provide information needed for diagnosis, selection of treatment techniques and goals, and monitoring the effect of intervention?
A
Yes
7
Q
Is it important that patient assessment is patient centred, if so, why?
A
Yes, because we need to understand the specific problem and also understand the patient as a person
8
Q
Is assessment required in all fields of physiotherapy?
A
Yes
9
Q
What are some fields of physiotherapy?
A
acute care, musculoskeletal, paediatrics, rehabilitation and women’s health
10
Q
Does assessment involve critical thinking and clinical reasoning?
A
Yes
11
Q
What are the hypothesis categories? (ICF Framework)
A
- Activity capability/ restriction
- Participation capability/ restriction
- Patient perspective
- Sources of symptoms
- Pathology
- Impairment in body function and/ or structures
- Contributing factors to:
- Development
- Maintenance of problem - Precautions and contraindications to physical
- Management/ treatment selection and progress
- Prognosis
12
Q
When do you assess a patient?
A
Assessment continues throughout your entire interaction with a patient. Its before you do anything, e.g. Observing the patient walking into the room, reading their notes where you may be reflecting and hypothesizing, throughout the treatment, and as you or the patient is leaving the room.
13
Q
What method does physiotherapy use for assessment?
A
SOAP assessment
14
Q
What does the ‘S’ in SOAP assessment stand for?
A
subjective assessment
15
Q
What does the ‘O’ in SOAP assessment stand for?
A
objective (physical) assessment
16
Q
What does the ‘A’ in SOAP assessment stand for?
A
assessment summary (diagnosis and goals)
17
Q
What does the ‘P’ in SOAP assessment stand for?
A
plan (treatment plan)
18
Q
Which stages of SOAP is documentation between?
A
A + P
19
Q
Where do you source information in subjective assessment?
A
asking the patient questions, case notes, a doctor’s referral letter, a physiotherapist or other health care professional’s letter, talking to a carer, relative, other health care workers e.g. nursing staff.
20
Q
What is the structure of information in subjective assessment?
A
structured in a particular way but customized to a particular patient.
21
Q
are hypotheses generated and tested in subjective assessment?
A
Yes
22
Q
Main Problem (MP)
A
Begin by seeking patient’s perspective of their problem: it is important to get that and document it in the patient’s own words
23
Q
What is the HPC generally? (history of presenting complaint)
A
an overall picture of how they’ve ended up with you today with these symptoms
24
Q
A
25
What are some example questions to ask about HPC?
- What happened at the onset of symptoms?: How did the symptoms start? Was there an incident?
- When did the symptoms start (i.e. time since onset)?
- Have the symptoms changed since the onset?
- Was it a case of insidious onset?
26
What is meant by insidious onset?
did anything out of the ordinary happen around the time the symptoms began?
27
What are some things to consider about acute onset without incident?
- What was noticed first?
- Predisposing factors e.g. activity, sustained posture, unwell, overtired, etc.
28
What is helpful about pattern of progression?
Mx – what/ effect (have they sought any other assistance with the management?,has the other management helped e.g. has heat, cold, or pain relief helped if they have tried these methods)
29
What are some questions that can be asked about acute onset with injury?
- What happened? (mechanism of incident – Moi) they may have to demonstrate this to you (it’s not enough to know that they fell, you need to know how they fell, what position were you in, what happened before you fell, did you feel dizzy before or did you trip over something), if they are capable
- What was noticed first? (did you notice pain straight away or did it come on afterwards, any swelling or bleeding?)
30
What does aggravate mean?
what brings on your symptoms and what time after the aggravating factor do symptoms occur
31
What does ease mean?
what has the patient been doing to ease the symptoms
32
Is it important to track symptoms over 24 hours?
Yes (AM, DD, PM)
33
Should it be checked that the symptoms don't cause sleep disturbances?
Yes
34
What are some past history questions that can be asked about the presentation?
- Previous history of the same presentation:
- Has this happened before?
- How often has it happened?
Is each episode the same? (are they worsening/ improving, becoming more/ less frequent/ longer etc.)
- What was the history of the first episode?
- How is it usually managed/ treated?
35
General Health and Medical Question Examples:
* Any medical conditions (may seem irrelevant to the patient)
* ALWAYS ask about asthma, diabetes, CVD and any heart or lung problems
* ALWAYS ask about medications (may seem irrelevant to the patient)
* ALWAYS ask about smoking
* ALWAYS ask about a past history of cancer
* Recent illnesses (within past 6 weeks)
36
Is family history important?
Yes, because medical conditions in the family that have genetic association and can contribute to the presentation
37
Occupation as a part of social history example
if they retired ask them, what did you used to do for a living, as this can give you some background as to why they are presenting with the symptoms
38
Social History Examples
* Marital status/ living situation/ home environment (i.e steps, ramps) – living alone/ living with someone, this information will help with discharge and management planning, is their house one or two stories, do they steps at any doors, do they have a shower that is easy to get into, do they have gravel or sealed pathways?
* Hobbies/ sports/ activities/ interests – is there anything you are finding you are unable to do at the moment that you would like to get back to?
* Physical activity level (i.e. do they meet the guidelines)
* Sleep – good/bad sleepers – ask what position they sleep in
39
INV (Investigations), are they important?
- Have any investigations been preformed? (i.e. x-ray, MRI, CT, blood tests)
- What were the findings?
40
What are some special questions that need to be asked?
* Bilateral symptoms (especially P+N, numbness)? – in both arms or both legs, the reason this is important is because it could be an indication of spinal cord symptoms
* VBI symptoms? – vertebral bretella insufficiency, symptoms of this include dizziness, lightheadedness, flicking of the eyes
* Cauda equina symptoms? (i.e. saddle paresthesia- around the genital region)
* Any unexpected weight loss/ gain in recent months?
* PLUS, different body areas have extra SQs (i.e. grating, clicking, locking – knee) that suggest particular pathologies
41
What are some red flags and signs of serious pathology in physiotherapy?
CE, syndrome, #, tumour, unremitting night pain, sudden weight loss, incontinence, PHx Ca
42
What are some orange flags or psychiatric symptoms in physiotherapy?
clinical depression, personality disorder
43
What are some yellow flags, or beliefs, appraisals and judgements, emotional responses and advanced behaviours in physiotherapy?
Unhelpful beliefs about pain, expectations of poor treatment outcome. Worry, fears, anxiety. Advance of activities due to expectations of pain and re-injury. Over-reliance on passive treatments
44
What are some blue flags, or perceptions about the relationship between work and health?
Belief that work is too onerous and likely to cause further injury. Belief that workplace supervisor/ workmates are unsupportive
45
What are some black flags, or system or contextual obstacles in physiotherapy?
Legislation restricting options for return to work. Conflict with insurance staff over injury claim.
46
What are some red flags in physiotherapy?
* Drug use e.g. alcohol, narcotics (especially IV)
* Steroid use
* Patient is >55 years or <20 years, onset of pain
* Severe, unremitting pain
* Pain that gets worse when laying down
* Bowel or bladder symptoms (CE)
* Bilateral P+N in hands or feet, ataxic gait (SC)
* Significant trauma including falls from a height/high energy MVA
* Unintended weight loss
* History or possibility of cancer/malignancy
* Osteoporosis
* Fever/chills/malaise/night sweats
* Neurological deficit (esp if worsening)
* Pulmonary or neurovascular compromise
* Unexplained deformity/ swelling
* HIV infection, immunosuppression, prolonged use of corticosteroids
* Dizziness and/or nausea
* Tinnitus, dysphagia, dysarthria, diplopia, drop-attack, facial numbness, HAs i.e. vertebro-basilar insufficiency (VBI)
47
if you note a red flag what do you do?
you need to determine whether it needs immediate attention
48
What are asterisk signs?
Can be in the objective assessment and in the physical assessment. They are things that stand out to us, that we can use in ongoing assessment of the patient to indicate whether they are staying the same, getting better or getting worse. Overall they indicate how they are going because after the initial assessment of a patient you don’t do a full assessment every time you see them from then onwards
49
Why are asterisk signs important?
For us to be able to know how the person is going
50
How do physiotherapists use asterisk signs?
Used in subsequent follow ups with the patient, this can be during treatment and after treatment
51
What is important is establishing the patient profile?
* Problem in context of the person not just the problem
* Goals – both your goals as the physiotherapist and the goals of the patient
* Intervention
* Where does the info come from: demographics, SHx, MHx, GH
52
What are some dominant pain mechanisms?
* Inflammatory
* Nociceptive/ mechanical
* Ischemic
* Sensitization (central, peripheral)
* Neurogenic
* Infection
* OR dominant mechanisms for other conditions e.g. SOB
* Inflammatory
* Surgery
* Infection
* Pain
* Neurogenic
* Obstruction
* Decreased oxygen
53
Is it important to identify anatomical structures when establishing the patient profile?
Yes
54
What generally is intensity?
how much pain/ SOB/ other symptoms the person is in
55
What generally is severity?
‘the activity that causes the symptoms has to be interrupted because of the intensity of the pain’
56
What is an example of explaining the difference between severity and intensity?
For example – someone might walk ten meters and get extreme shortness of breath, the intensity here is extreme but the severity is not very severe because they are only walking ten meters to get an extremely intense symptoms
57
What is pain severity assessed by most commonly?
VAS-pain scale
58
How do you assess the severity of something other than pain?
Use a relevant scale
SOB – modified Borg scale
59
60
What does irritable mean?
'a little activity causing severe pain, discomfort, paresthesia or numbness, which takes relatively long subside’
61
How is irritability assessed?
Irritability is assessed by judging:
1. The vigor of activity required to provoke a patient’s symptoms
2. The severity of those symptoms
3. The time it takes for the symptoms to subside once aggravated (i.e. pain persistence)
62
Do you always want to reproduce symptoms in the physical assessment?
No, In your physical examination you want to reproduce the symptoms to have an idea of what is causing them, but only within reason, e.g. do not cause symptoms that will last for hours afterwards
63
How do you determine a diagnosis?
Consider your initial hypotheses about the:
* Source(s) of symptoms
* Dominant pain mechanisms
* Pathobiology of the prescription
* Does it fit with any recognizable diagnosis or clinical pattern?
64
What needs to be considered when you are determining a prognosis?
Consider:
* What was the mechanism of injury?
* What is the severity and irritability?
* Does the patient have any flags or risk factors (i.e. smoking, comorbidities)?
* Contributing factors?
* ‘normal’ rate of recovery?
* Recurring injury?
65
Why do we want information?
* Clinical reasoning
* Develop hypotheses from the S/E that relates to ICF categories, e.g. potential anatomical structures, pain mechanisms, diagnosis and prognosis, leads to…
* Planning
66
subjective assessment in MSK (outpatient)
* In MSK we are often looking to make a diagnosis, make sure there are no sinister pathologies, plan an assessment and decide on a treatment
* We often start by working at the impairment level to achieve functional improvements
* We move to the functional level often to address contributing factors to a patient’s presentation.
67
subjective assessment for acute care (inpatient)
In acute care (inpatient) we are often not looking to make a diagnosis (i.e. they will already have seen medical staff, had investigations etc.)
68
The purpose of subjective examination is?
- Determine the person’s current mental and physical capability, their mobility and discharge needs to ensure a safe discharge to their discharge destination wherever that may be
- identify any sinister pathologies that may have been undetected
- plan a physical assessment and treatment
69
what is some important acute care information to gather? (from patient, medical records, family member)
- diagnosis (reason for admission)
- past medical history – no. of admissions, time since diagnosis etc.
- social history – living arrangements, home assistance, smoking history, use of oxygen – important that you have detailed social history
- orientation – TPP (time, person and place)
70
What is some general information that is important to gather?
other important information to gather:
cough – dry/moist, frequency and time of day
septum clearance – amount, colour, recent changes, difficulty
shortness of breath – associated with rest, activity? Effect on walking/ talking?
Wheeze – present or not, triggers
Pain – distribution (e.g. rib fracture, drain site, angina) aggravating/ easing factors
Mobility – prior to episode, gait aids etc.
Home environment – for discharge planning – single/ double story, steps, pets etc
71
In acute care, do we operate at the impairment?
Yes. In acute care we operate at the impairment (i.e. airflow obstruction) level as well as at the functional level (i.e. unable to mobilize) level to achieve safe discharge for patients
72
paediatric subjective assessment (often in an outpatient setting)
S/E will often occur with the patient(s) and the ‘patient’ themselves
Additional considerations with children:
- stress and anxiety over a child’s illness/ delay (s/e often preformed more conversationally, probing for more information rather than direct questioning)
we are often looking to make a diagnosis, make sure there are no sinister pathologies, plan an assessment and decide on a treatment (similar to MSK)
unlike MSK, we often work at the functional level to achieve improvements (rather than the impairment level)
73
subjective assessment on rehabilitation patient (in or out patient)
In rehabilitation we may or may not be involved in diagnosis. In an in-patient rehab environment, information sources will be similar to acute care, whereas outpatient environments will rely more on the patient themselves (more like MSK and paediatrics)
In rehabilitation we work at the impairment and functional levels
74
What are the week 1 Key take home messages?
In different disciplines, there are specific focusses of the S/E that will influence how you go about it
Sources of information may vary
They key thing is to keep in mind what you’re trying to do – always plan a P/E, always to determine the need for treatment – so you need enough information to allow this to happen
Sometimes (i.e. outpatient environments) you will also need to make a diagnosis
75
What are some examples of medical documentation?
Case notes, referrals, discharge information, letters, exercise sheets and personalized information sheets and investigation reports
76
What are the medico-legal requirements of physio documentation?
* The national law requires physiotherapists to keep accurate and detailed records of all patient encounters (this includes meetings with a patient over the phone, this needs to be documented)
* Patient records can be either in paper or electronic form
* A separate patient record is required each time the patient attends a service
* The date of the service must be clearly identifiable
* The documentation should be completed as soon as practicable following the service, because this is when you can best remember what you have done
* The patient and therapist must be clearly identifiable, you need to sign at the end of each entry as well
* Sufficient detail is required so that another practitioner could continue the patients’ ongoing care using only the notes provided
* The type of service that you have provided must be clear
* Patient records must be written legibly, factually and accurately
* Blue or black pen must be used for paper-based records
* There should be minimal ‘white space’ available so that the later entries are prevented (adding to/ altering the notes afterwards).
* Errors or amendments must be initialed and dated with the original entry still visible
* Records must be kept and maintained for a minimum of 7 years
77
What are some professional considerations that we need to effectively work with patients?
- a baseline of their presentation
- a record of their evolving narrative
- to know the effect of our treatment
- to be accountable for our decisions and actions
- a record of what we have done to facilitate safe and responsive care
- the act of writing out clinical notes provides an opportunity to reflect on patient encounter and our clinical reasoning
- clinical notes safeguards us from having to remember each patient, their presentation, their goals and our management plan
- accurate clinical notes means that another person can conduct the service on holidays, if we are unwell etc.
- clinical notes help us to demonstrate the effectiveness of our intervention (and therefore our profession)
78
how to record SOAP
subjective data – information from the patient/ accompanying person, through interviewing techniques or medical records
objective data – results of the physical testing of the patient (i.e. physical examination findings)
assessment – main impression of the patients’ problem, through clinical reasoning (i.e. working diagnosis)
plan – outline of management of the patient and any further assessment
79
When recording information what are some things that will help make it easier for yourself?
* use the patient's words where possible
* be clear and precise
* Use Medical Terminology
* be thorough
* be concise and use standard abbreviations
* maintain confidentiality
80
What to record in SOAP
* ensure each entry has the patients’ name, the date, and your signature
* subjective examination findings
* physical examination findings
* consent
* assessment of the patient's presentation (i.e. working diagnosis)
* treatment/s
* reassessment findings
* plan
81
What to record asterisk signs
* highlight main findings in S/E and P/E by marking with an asterisk (*) on notes
* allows easier recognition of main issues and therefore planning of goals and treatment
* allows easier reassessment at future visits
* remember that * signs will change as the patient’s presentation changes
82
How to record - subjective examination (SOAP)
* use your body chart to record the area, severity, nature and depth of symptoms
* Where there is more than one symptom, use different colours to differentiate
* Where there is more than one area, use numbers to differentiate
* Some people will also record their screening questions on a body chart as a ‘one-stop’ shop for critical information
83
How to record - assessment in SOAP
* Includes the main impression/ hypotheses from S/E and the O/E findings
* i.e. hypermobile C4/5 facet joint secondary to poor sleeping position. Should clear up in 2 treatments
* needs full rotation to cycle safely
84
How to record - Plan (SOAP)
* be detailed – the best time to record your plan is immediately after your session as this is when it is the most clear in your mind
* record the treatment you preformed
* any further assessment you plan to preform in the next session
* when you want to review next
