The physical therapist integrates the five elements of patient/client management:
Examination of the patient
Evaluation of the data and identification of problems
Determination of the diagnosis
Determination of the prognosis and plan of care (POC)
Implementation of the POC (intervention).1
The examination (Figure 3-1) consists of three components of equal importance:
- The history
- The systems review
- The tests and measures
Components of the examination and their interrelationships.
The history, systems review, and tests and measures are closely related, in that they often occur concurrently. One further element, observation, occurs throughout.
The history (Table 3-1) usually precedes the systems review and the tests and measures components of the examination, but it may also occur concurrently.
Table 3-1 Data Generated from the Patient History ||Download (.pdf)
Table 3-1 Data Generated from the Patient History
|Growth and development|
|History of current condition|
|Functional status and activity level|
|Other test and measures|
|Past history of current condition|
|Past medical/surgical history|
|Social habits (past and present)|
It is estimated that 80% of the necessary information to explain the presenting patient problem can be provided by a thorough history.
Neutral questions should be used whenever possible. These questions are structured in such a way so as not to lead the patient into giving a particular response.
- Open-ended questions, such as “tell me why you are here” encourage the patient to provide narrative information and decrease the opportunity for biasing on the part of the clinician.2
- Close-ended questions are more specific and are asked as the examination proceeds. The specific questions help to focus the examination and deter irrelevant information. Examples include the following:
- Is the pain becoming worse, better, or is it relatively stable?
- Does the pain wake you up at night or prevent sleep?
- Have you experienced any loss of bowel or bladder function?
A sudden onset of pain, associated with trauma, could indicate the presence of an acute injury such as a tear or fracture, whereas immediate pain and “locking” is most likely to result from an intra-articular block (Table 3-2).
Table 3-2 Pain Descriptions and Potentially Related Structures ||Download (.pdf)
Table 3-2 Pain Descriptions and Potentially Related Structures
|Type of Pain||Potential Source|
|Cramping, dull, sore, aching||Muscle|
|Dull, aching||Ligament, joint capsule|
|Sharp, shooting, pinching, gnawing||Nerve root|
|Sharp, burning, shooting||Nerve|
|Burning, pressure like, sting, smarting||Sympathetic nerve|
|Deep, nagging, dull||Bone|
|Sharp, severe, ...|