Patient Assessment Overview

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is the primary focus of the objective guidelines as described?

Patient's subjective experience of pain

Patient's exercise routine

Treatment methods used in therapy

Physical therapist's observations and measurements (correct)

Which of the following best categorizes the types of information relevant to the physical therapy session?

Observations, interventions, and responses to treatment (correct)

Demographics and insurance information

Injuries and historical records of the patient

Personal and family medical history

What does the measurement '0-175º' under Flex for the date 10/19/20XX indicate?

Flexion has significantly improved with no pain (correct)

Flexion has significantly decreased

Patient was not able to perform the measurement

Flexion is unchanged from previous observations

What should the objective findings include according to the guidelines?

Physical measurements and therapist’s observations Signup and view all the answers

Which statement accurately reflects a consistent patient report during the assessment?

Improvement in neck pain after sessions Signup and view all the answers

What does the term 'CGA' refer to in the context of patient gait?

Contact Guard Assistance Signup and view all the answers

Which of the following descriptions is true regarding Internal Rotation (IR) at the latest measurement?

Continued pain was reported at the end range Signup and view all the answers

What does the term 'flow sheet' refer to in the context of formatting patient's information?

A standard table of measurements Signup and view all the answers

What is the first step in the Patient Client Management Model?

History Signup and view all the answers

Which of the following is NOT included in the Patient Client Management Model?

Treatment Planning Signup and view all the answers

What role does the Patient Client Management Model play in physical therapy?

It guides decision-making processes. Signup and view all the answers

Which of the following steps comes after the Systems Review in the Patient Client Management Model?

Tests & Measures Signup and view all the answers

What is indicated by the phrase 'Hypotheses' in the context of the Patient Client Management Model?

Potential diagnoses based on gathered information. Signup and view all the answers

In the context of physical therapy, what does observation & assessment of movement primarily involve?

Evaluating the patient's range of motion. Signup and view all the answers

Which of the following conditions might be identified during the Tests & Measures step?

Kidney Issues Signup and view all the answers

What is the expected outcome mentioned for the patient in the Patient Client Management Model?

The patient will successfully bend forward without limitations in 4 weeks. Signup and view all the answers

What is the primary reason why the patient is seeking physical therapy?

For right knee pain and stiffness Signup and view all the answers

What is the intensity level of the patient's low back pain at its worst according to the provided information?

8/10 Signup and view all the answers

Which factor is identified as aggravating the patient's low back pain?

Bending Signup and view all the answers

How often does the patient experience their low back pain according to the symptom behavior documentation?

Constantly Signup and view all the answers

What method does the patient use to ease their low back pain?

Heating pad Signup and view all the answers

What type of information should the PT provide regarding future services?

Specific plans including education and potential changes Signup and view all the answers

What is one indicated reason for the continuation of PT for the patient?

The patient still experiences knee pain and limitations in gait Signup and view all the answers

What does the follow-up plan need to include?

Comprehensive details about adjustments in treatments Signup and view all the answers

Which of the following actions does NOT represent mutual understanding between therapist and client?

Cease all treatments without discussing future plans Signup and view all the answers

Which statement best reflects the patient's current progress?

The patient has improved pain management but continues to struggle with certain physical activities Signup and view all the answers

What might be included in the discharge visit's final plan?

Patient will continue with a home exercise program independently Signup and view all the answers

What improvement was noted in the patient's exercise tolerance?

Increase in time on recumbent bike Signup and view all the answers

What is a key component of the patient's current treatment plan?

Active participation in physical therapy to improve function Signup and view all the answers

What is included in the demographics section of the subjective portion of a SOAP note?

Name, date of birth, and medical diagnosis Signup and view all the answers

Which element represents the patient's primary concern in the subjective section of the SOAP note?

Chief concern Signup and view all the answers

What type of information should NOT be documented in the subjective section of a SOAP note?

Physical exam findings Signup and view all the answers

Which of the following components is part of conducting a comprehensive subjective exam?

Identifying medical history Signup and view all the answers

Which statement accurately describes symptom behavior during the subjective portion of a SOAP note?

The personal experience and description of symptoms Signup and view all the answers

What is the purpose of gathering social history in the subjective section?

To understand the patient’s living conditions and support systems Signup and view all the answers

In the subjective section, how should patient information be documented?

With direct quotes from the patient Signup and view all the answers

What type of data is least likely to be collected from other health care providers during the subjective portion?

Patient’s demographics Signup and view all the answers

Study Notes

Patient Assessment and Progress

Patient reports neck pain at 2/10 while turning head right, with significant improvements since last session.
Pain and limited motion affect daily activities, such as backing up the car.
Consistent home exercise routine enhances motion and reduces pain.

Objective Assessment

Gait noted: Patient moved from FWW to SPC, ambulating 225 feet with CGA and cueing for cane usage.
Range of Motion (ROM) measurements indicate progressive improvement over several weeks with noted pain levels.

Range of Motion (ROM) Measurements

Flexion improved from 0-165º with pain to 0-175º without pain.
Abduction increased from 0-170º to 0-180º, with no complaints.
Internal rotation showed improvement from 0-20º to 0-45º, pain persists at end range.
External rotation improved from 0-70º to 0-82º.

Interventions and Response

Patient management includes thorough clarity and accuracy on assessments and interventions performed.
Overall improvement observed with decreased pain levels and enhanced exercise performance.
Continued issues with right knee pain impacting stairs and gait noted for further attention.

Patient Client Management Model

Key components: History, Systems Review, and Tests & Measures inform treatment planning.
Observations must be integrated into overall assessment and treatment effectiveness.

Future Planning

Treatment plans should specify goals, patient education, frequency, and potential adjustments.
Emphasis on mutual understanding between therapist and patient regarding treatment actions, whether continuing without changes, with changes, or reassessment.

Subjective Examination Components

Subjective data collected from patient and caregiver statements, including demographic information, current condition, medical history, and patient goals.
Chief concern details should accurately reflect why the patient seeks therapy and contain symptom history and behaviors.

Gathering Subjective Data

Demographics include name, date of birth, medical diagnosis, and gender.
Current conditions should document symptom location, description, intensity, aggravating and easing factors, and frequency/duration.
Insightful patient interviews and careful documentation are critical to capturing complete information.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

This quiz focuses on the assessment and progress of a patient dealing with neck pain and limited motion. Participants will explore the objective assessments, range of motion measurements, and the patient's response to interventions over several weeks. Perfect for healthcare professionals looking to refine their patient evaluation skills.