Term
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Definition
-observations
-palpations
-auscultations
-smell
-Tests and measures
-outcome measures |
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Term
| objective tests and measures |
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Definition
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Term
| subjective information gathering |
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Definition
-direct and specific questioning of patient
-from caregivers, family |
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Term
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Definition
-Disease (acute or chronic)
-Disorder
-Injury (acute or chronic)
-Trauma
-Infections
-Metabolic imbalances
-Degenerative disease processes
-Other |
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Term
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Definition
| considerations, but not what we are treating |
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Term
| current condition (medical diagnosis) |
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Definition
| provide accurate picture of patients medical condition that warrants Physical Therapy |
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Term
answering the questions
"Why was the patient referred?" |
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Definition
-Go beyond simply restating previously determined diagnosis
-Describe precipitating incident or mechanism of injury |
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Term
| 3 key elements when assessing/reporting current condition of the patient |
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Definition
-underlying disease process
-location
-time course |
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Term
| diagnosis and direct access |
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Definition
-include medical info from history and chart review in the beginning
-perform reasonable differential diagnosis
-PT's final diagnosis is documented in "Assessment" |
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Term
| demographics to document/discuss |
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Definition
-Age
-Sex/gender
-Race/ethnicity
-Language/Communication
-Education |
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Term
| race/ethnicity information to obtain? |
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Definition
| anything about your culture, beliefs, or background, that I should be aware of? |
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Term
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Definition
| literacy, ability to interpret information |
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Term
| when there are more than one concerns? |
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Definition
-ask the patient to prioritize
-only one eval per episode of care unless two separate diagnosis are present |
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Term
good question to begin with....
Progress to... |
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Definition
-open ended
"how can I help you today?"
-then, 'how' and 'when'
mechanism of injury, mech. or onset |
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Term
mechanism of onset
-reason known questions? |
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Definition
-date of injury
-"would you share with me how you were inj?"
-"how and when did the pain start"
-"do you remember what you were doing the moment the pain started?" |
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Term
Mechanism of onset
-reason unknown questions? |
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Definition
-"can you think of any reason why the pain may have started?"
-"any life/work changes around the time the pain started?
-"did the pain begin suddenly or slowly over several days or weeks?" |
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Term
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Definition
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Term
| burning, piercing, shooting pain |
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Definition
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Term
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Definition
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Term
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Definition
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Term
| sharp, stabbing, pinching |
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Definition
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Term
| symptom location questions |
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Definition
"would you point to where your pain is located?"
-"does your pain move to any other area?" |
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Term
intensity
-methods of documenting |
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Definition
-numerical rating scale (0-10)
-visual analog scale (10cm)
-verbal rating scale
(none, mild, moderate, severe) |
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|
Term
symptom behavior
-constancy questions
-what can it reveal |
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Definition
"does pain ever go away completely, even for short periods?"
-can reveal patient's hypervigilant |
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Term
symptom behavior
-irritability questions |
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Definition
| "after pain is aggravated , how long does it take to calm down?" |
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Term
symptom behavior
-24 hour pattern questions? |
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Definition
-"take me through a typical day; describe how your symptoms change"
-"does the condition affect how you sleep at night?"
-"does condition behave differently on a workday versus your off days?" |
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Term
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Definition
Severity(pain scale)
Irritability
Nature (stabbing, shooting, aching)
Stage (acute, subacute...) |
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Term
| associated symptoms considerations |
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Definition
-patient may not consider symptoms relevant
-maintain control of the conversation
-focus on symptoms that support or negate your hypothesis |
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Term
aggravating or easing factors
-Gravity |
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Definition
“Is your pain different when you sit versus when you lie down?”
“Do you feel better is you are at rest or if you are moving?” |
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Term
aggravating or easing factors
-Extension vs Flexion |
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Definition
| “Is your pain better when you are standing or sitting?” |
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Term
aggravating or easing factors
Posture |
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Definition
| “What positions or activities seem to increase (decrease) your pain?” |
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Term
current interventions
"questions to ask" |
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Definition
“Are you seeing anyone else for this condition?”
---“What treatments are they using? Are they helping?”
“Are you trying anything besides physical therapy to treat this condition on your own?" |
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Term
| medications - considerations |
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Definition
-can suggest conditions the patient left out
-is it used appropriately? does it help?
-side effect considerations |
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Term
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Definition
| side effects mimic MSK conditions |
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Term
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Definition
Corticosteroids
β-blockers |
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Term
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Definition
used to identify depression - in your own word....
-“During the past month, have you often been bothered by feeling down, depressed, or hopeless?”
-“During the past month, have you often been bothered by little interest or pleasure in doing things?” |
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Term
| patients impression of their own health |
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Definition
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Term
CAGE questionnaire
-what for
-questions? |
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Definition
-to assess alcoholism
-"Have you ever felt you needed to cut down on your drinking?"
-"Have people annoyed you by criticizing your drinking?"
-"Have you ever felt guilty about drinking?"
-"Have you ever felt you needed a drink first thin in the morning to steady your nerves or get rid of a hangover?" |
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