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Exam (elaborations)

Intro to Patient Exam IRA 1- Patient History

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Intro to Patient Exam IRA 1- Patient History

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Intro to Patient Exam IRA 1: Patient
History



examination - Answer--patient history and systems review

-tests and measures



evaluation - Answer--interpret and synthesize data from examination

-diagnosis and prognosis



establish plan of care - Answer--determine interventions and outcome measures



Patient Evaluation and Management - Answer-examination

evaluation

establish plan of care

management



initial interview - Answer-Health or subjective history

Most important component of patient examination

Can be therapeutic for patient

Focus the physical examination

, Extremely important interview!!!



purpose of initial interview - Answer--establish trusting therapeutic relationship

-determine unique aspects of every patient

-determine patient's understanding of PT

-determine patient's understanding of the condition

-determine if condition has changed since PT referral was written

-search for clues to possible underlying condition

-listen for red flags

-determine what should be explored in exam

-determine how intense exam can be

-formulate early hypotheses about how patient might respond to PT



open-ended questions - Answer--invite patient to answer w a narrative response

-begin the interview or new topics



close-ended questions - Answer--require a definitive Y or N response

-obtain more specific info or clarify a response



graded response questions - Answer--provide a better illustration of patient's condition or ability

-specific numerical response that can be measured ie rate pain on a scale of 0-10

-follow up questions



multiple option questions - Answer--offer options to help patient better describe condition

-ex type of pain (throbbing, vascular, shooting/stinging)

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