PE1 unit 1

• Patient Examination happens during the examination part of the PMM.
• During the examination, the physical therapist performs tests and measurements.
• The outcomes of tests and measures give direction to the PT through the model.

Evaluation

• A dynamic process where the physical therapist makes clinical judgments based on data gathered during the examination.
• This process may identify possible problems needing consultation with another provider.

Examination

• Obtaining a history, performing a systems review, selecting, as well as administering tests and measures to gather data about the patient/client.
• The initial examination is a comprehensive screening and specific testing process, which leads to a diagnostic classification.
• The examination process may also identify possible problems that require consultation with or referral to another provider.

Diagnosis

• Both the process and the end result of evaluating examination data.
• The physical therapist organizes examination data into defined clusters, syndromes, or categories to help determine the prognosis, including the plan of care, and the most appropriate intervention strategies.

Prognosis (Including Plan of Care)

• Determination of the level of optimal improvement that may be attained through intervention and the amount of time required to reach that level.
• A plan of care specifies the interventions to be used, their timing, and their frequency.

Outcomes

• Results of patient/client management, which includes the impact of physical therapy interventions.
• Domains include: pathology/ pathophysiology, impairments, functional limitations, and disabilities, risk reduction/prevention, health, wellness, and fitness, societal resources, and patient/client satisfaction.

Intervention

• Purposeful and skilled interaction of the physical therapist with the patient/client.
• If appropriate, interaction with other individuals involved in the care of the patient/client, using various physical therapy methods and techniques to produce changes in the condition consistent with the diagnosis and prognosis.
• The physical therapist conducts a reexamination to determine changes in the patient/client status, and to modify or redirect intervention.
• The decision to reexamine may be based on new clinical findings or on a lack of patient/client progress.
• The process of reexamination may also identify the need for consultation with or referral to another provider.

ICF Review

• Examination relates to the body function and structure component of the ICF.
• The ICF includes Health Condition (disorder/disease), Body function & structure (Impairment), Activities (Limitation), Participation (Restriction), Environmental Factors, and Personal Factors.

Clinical Road Map

• Current and prior role functions, such as self-care, domestic tasks, education, work, community, social, and civic life.
• Concerns that led the patient or client to seek the services of a physical therapist.
• Concerns or needs of the patient, or client who requires physical therapy services.
• Current therapeutic interventions and mechanisms of injury or disease, including date of onset and course of events.
• The onset and pattern of symptoms.
• Patient/client, family, significant other, and caregiver expectations and goals for therapeutic interventions.
• Patient/client, family, significant other, and caregiver perceptions of patient’s or client's emotional response to the current clinical situation.
• Previous occurrence of current condition(s) and prior therapeutic interventions.

Examination: History Taking Review

• Includes demographics, general health status, growth and development, living environment, medical and surgical history, medications, other clinical tests, review of systems, as well as social and health habits.

Physical Examination of Tests & Measures

• It is important to pause and self-reflect after each test and measure.
• Important questions include: Am I performing the test/measure adequately?, What is the finding/data from the test & measure?, What does the positive/negative finding tell you?, Should I defer any future tests or measures at this time? Why?, What additional tests and measures do I need to consider/perform? Why?, and How does each test & measure relate back to the initial hypotheses?
• It is important to review the cardiovascular/pulmonary, endocrine, eyes/ears/nose/throat, gastrointestinal, genitourinary/reproductive, hematologic/lymphatic, integumentary, & neurologic/ musculoskeltal systems.
• Social/health habits include behavioral health risks, and level of physical fitness
• Includes Cultural beliefs and behaviors, family and caregiver resources and social interactions, activities, & support systems.

Physical Examination of Tests & Measures Include

• Structural Inspection like posture, skeletal and integument integrity, & anthropometric characteristics.
• Range of Motion: Active & Passive.
• Task Analysis like social & civic life, education, self-care & domestic life, & work & community integration.
• Muscle Performance like strength, power, endurance & length.
• Coordination/Motor Function like balance, gait, mobility.
• Nerves like cranial & peripheral, neuromotor development and sensory processing, pain, reflex integrity, sensory integrity.
• Joint Integrity & Mobility.
• Others like aerobic capacity & endurance, adaptive & assistive technology, circulation, cognitive & mental function, environmental factors,ventilation & respiration.

Conclusion Regarding Examination

• Physical examination includes a foundational understanding of the Patient Management Model, the ICF, and the Clinical Road Map.
• Selecting tests/measures should be based on patient history and clinical presentation.
• Data gathered from tests/measures will serve as a guide for a plan of care and treatment interventions.

Importance of Positioning

• Important for safety, comfort, and to take precautions.

Dependent Positioning Versus Treatment

• Positioning for treatment is short lived.
• Dependent positioning is longer term.
• Use where there are CNS related impairments.
• Use where there are Limb impairments.
• Use where there is an Injury.

Precautions for Positioning

• Maintain Head/Neck in Neutral.
• Extremities supported.
• Follow diagnosis specific precautions.

Prevention: General Items to Avoid

• Spinal/Thorax Rotation, Bending, Forward head, and Chest compression.
• Upper extremities Scapular abduction, Adduction and internal rotation at the GH joint.
• Lower extremities Plantar flexion at the ankles, Knee flexion and hyperextension, and Hip adduction or internal/external rotation.

Patient Positions

• Include Supine, Prone, Sidelying, Semi-Fowler's, Fowler's, Sims', and Trendelenberg.

Conclusion

• Understanding proper patient positioning enhances safety and patient comfort throughout the Physical Therapy Plan of Care.
• Recognize when precautions and/or contraindications influence how you should position a patient before treatment.
• Understanding workplace posture/ergonomics will help you, as a therapist, maintain career longevity.

Safe Patient Handling

• Prevent medical errors; ensure you have the correct person, place, time.
• Maintain Hand hygiene and use personal protective equipment.
• Use Proper and safe equipment.
• Ensure the environment is free from hazards.
• Use proper body mechanics.
• .Never leave patient unattended.
• Ensure Proper training and competent personnel.

Preparation for Patient Handling

• Scan the environment, the patient and assess the situation.
• Assure appropriate draping.
• Gather equipment.
• Secure the surfaces.
• Communicate and Coordinate.
• Position and prepare the surfaces.
• Assure appropriate body mechanics.
• Position patient safely and assure items are within reach.

Body Mechanics

• Consider proper body mechanics when handling patients.

Gait/Transfer Belt

• Used for safety during mobility tasks
• Positioned at waist or above as needed.
• Is not a substitute for body mechanics.

Applying the Gait Belt

• Communicate with you patient.
• Put the belt around the patient.
• "Teeth" first.
• Must Be snug but not tight.

Gripping a Gait Belt

• Use Underhand grip.
• Usually behind the patient.

Summary of Patient Handling

• It begins with preparation.
• Includes: scanning environment, patient, situation; checking lines/tubes, equipment; setting up equipment including wheelchairs; using proper body mechanics; and gait belt considerations.

Body Mechanics Introduction

• It is critical for safe patient handling, for longevity as a PT, for anyone involved in patient care, and to conserve energy, reduce injury risk plus reduce stress & strain.

Body Mechanics and Trunk Stabilization

• Essential for safe, energy conserving/efficient movement.
• Requires balance,control, bracing vs hollowing.
• Valsalva can be potentially harmful.

Two Requirements for Body Mechanics

• Having a Center of Gravity (COG) and Base of Support (BOS).

Lifting Principles

• Visualize and plan.
• Use Short lever arms, be close to the center of gravity and maintain a gravity line.
• Use stabilizing muscles, maintain normal lumbar lordosis; avoid trunk rotation and flexion.
• Warm up.
• Take your time.
• Direct and ensure cooperation as well as instruction.

Therapist Positions for Examination Skills

• Consider the test and measure you are going to perform.
• How much effort will it take you to perform the technique.
• Position your feet in staggered stance in the direction of the motion.
• Avoid power stance when test and measures require the therapist to move.

Lift Types

• Include: Deep Squat Lift, Power Lift, Straight Leg Lift, One-Leg Stance Lift ("Golfer's Lift"), Half-Kneeling Lift, Traditional Lift, Stoop Lift.

Pushing and Pulling

• Similar principles to lifting.
• Parallel force to line of movement.
• Use Multiple techniques for redirection.
• Face the object square.
• Be in a straight line when possible.
• With Arms partially flexed.

Reaching and Carrying

• Raise your position to an object overhead.
• Move object closer before reaching or carrying.
• Carry on the waist or the back.
• Balance the load.
• When in hands, alternate hands when possible.
• Use Shoulder carry for heavy or bulky items.

Conclusion

• Body Mechanics is important for patient safety and career longevity.
• Understanding the position of your Center of Gravity (COG) and Base of Support (BOS) can reduce load on your spine.
• Preparing the environment can facilitate increased safety for you, your patients and other members of the healthcare team.

Objectives of the Review of Systems

• Understand the Review of Systems and its part in the physical therapy examination.
• Understand the Systems Review and its part in the physical therapy examination

Review of Systems Versus Systems Review

• Review: Part of history taking (subjective), screening major body systems, directs the systems review.
• Systems: Includes "DOING” something to test the system (objective), directs further tests and measures.

Review of Systems

• Includes questions in the patient history
• Identifies signs and symptoms beyond the PT scope
• Observation
• Seek information relevant to major body systems.
• Ask questions
• Refer to other healthcare professionals as needed.

Review of Systems - Major Body Systems

• Cardiopulmonary, Endocrine, Gastrointestinal, Hematologic/lymphatic, Immune, Nervous, Musculoskeletal,Integumentary, and Genitourinary systems.

Systems Review

• The physical exam begins with a systems review
• Includes components such as: Cardiovascular, integumentary and surface anatomy, musculoskeletal, neurological.
• Includes Communication, Cognition, Movement.

Neuro Screen Characteristics

• Assesses function of CNS/PNS.
• Guides for more in-depth testing.
• Is patient specific, not all tests are for all patients.

Review of Systems : Musculoskeletal/Neurologic

• Asks about symptoms such as : Joint pain; Frequent headaches; Vision change; Vertigo; Paresthesias; Muscle tone changes; Weakness/ Atrophy; Abnormal reflexes, Issues with Co-ordination; Tremors; Loss of Consciousness; Memory Problems; Paralysis; Mood swings

Observation

• Motor control
• Balance
• Fluidity

Patient Subjective Reports:

• Very important to consider because...

Cranial Nerve Screen

• Depends highly on patient history and review of systems.
• Need to include all 12 cranial nerves only if there is concern.

Coordination Screen

• Dysdiadochokinesia
• Heel-to-shin

Reflex Screen

• Assess if: Absent, present, exaggerated.

Summary

• Observation is key.
• Patient reports and history guide the extent of screening
• Usually involves coordination and reflex testing
• May involve cranial nerve testing

Objectives of Integumentary Screen Includes:

• Understanding techniques for safe patient handling, recognizing typical and atypical characteristics of the integumentary system, and demonstrating a general integumentary assessment including girth measurements.

Safe Patient Handling includes

• Standard, contact and droplet precautions.
• Hand sanitization and hygiene.
• The use of gloves and taking into account latex allergies

Review of Systems - Integumentary (Includes Skin, Hair, and Nails)

• You should ask about recent rashes, nodules or other skin changes, unusual hair loss or breakage, increased hair growth.
• Ask about change in nail beds, and itching

Screening Characteristics include

• Color
• Palpation
• Symmetry
• Moisture
• Texture
• Firmness
• Shape
• Elasticity
• Temperatures

Integumentary: Skin Coloration, Rashes, Lesions, Incisions and Wounds

Edema

• Use of "Volumetric Measures/Displacement" to use for it.
• Also use patient dips to measure depth, for charting.

Palpation

• Assessment includes:texture, firmness, turgor, mobility, temperature

Capillary Refill

Summary: Integumentary System

Objectives of Musculoskeletal Observation:

• Discussion on typical and atypical observations about the patient's musculoskeletal system, posture, and positioning.
• Understand the parts of the musculoskeletal screening observation.

The Components of the MSK System Include

• Tissues, shape, size, muscle groups, proportions.

System Review, Includes:

• part of patient history; neuro-musculoskeletal overview.

Observation of the Musculoskeletal System. Pay close attention to:

• bony contours, alignment, symmetry, posture, positions/ movements.

MSK: Gross UE and LE ROM Screening

• AROM across cardinal planes for a given joint, against gravity.
• Goal: to determine if the patient has a ROM limitation that could limit their function.Bed mobility, the use of an assistive device, grooming, getting dressed, reaching, walking.

Orthopedic MSK setting, the MSK screen is part of the examination. Apply overpressure to feel the quality and quantity of tissue resistance, if pain free or as therapist desire. Considering Quantity as compared to a normative value , Symmetry and Symptom production is helpful when screening.

Muscle Strength Screening

• Quick general assessment on muscle strength Only test major muscle group. Not a specific test. Not a break test.

Cardiopulmonary Observation- Cardiovascular Disease (CVD)

• CVD main cause of mobility decline.
• Cardio Observation, almost half of adults in the United States get this CVD.
• It could save lives with the 10% improvement.

How to Perform Cardiopulmonary Observation

• Perform subjective systems review, Objective measurement of the system as well.

Cardiopulmonary Review of Systems include Questions About:

• Chest pains, any Discomfort, Any palpitations, Limb pain during activity, Discolored or painful feet, Pulsating or throbbing pain, Sudden weight gain.

Systems Review includes questions regarding:

• Any Persistent cough, Fatigue.

Vitals include:

• HR, RR, BP,. SPO2

Chart Information should Include:

• Vitals, Labs, Comorbidities and Testing results.