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44 Cards in this Set
- Front
- Back
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What are you screening for?
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-yet to be dx condition which is responisble for the pts symptoms.
-yet to be dx condition which is not responsible for the pts symptoms -exisitng clinically stable medical condition -existing clinically UNstable medical condition |
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what are the goals for screening
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-ID the pts at risk
-atypical sxs -correlation of symptoms with signs -Review of symptoms (GH and individual systems) |
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what is cultural competence
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-fostering communication that is sensitive to: socioeconomic status, racism, accultration, values, beliefs and behaviors
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Name ways you can ensure that you are being culturally sensitive
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-ask your pt open ended questions
-ask your pt about their culture/way of life -inspire your pt to be open and honest through your line of questioning |
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generally speaking what are the euro-american values
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-individualism/privacy
-personal control over environment -time dominates -doing, working, achieving -self-help -human equality -informality -direct, open, honest -values youth -materialistic |
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generally speaking what are cross-cultural
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-group welfare
-fate -human interaction dominates -being -birthright inheritance/inequity of sexes -formality -indirect, ritual -values elders -spirtualistic |
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what are some important considerations to understand when trying to create a POC and goals
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-who is the pt (cultural competence)
-what does pt want from you -How does this pt experience illness -what are the pts perceptions about the disorder (px, intervention) -what are the pts feelings about the disorder (px, intervention) |
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what are some questions that build empathy?
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-would you tell me more about that
-what has this been like for you - is there anything else |
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what are some ways to clarify that build empathy
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-let me see if I have this right
-I want to make sure I understand you - You let me know if I am off track, OK |
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what are some responses that build empathy
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-that sounds tough
-I imagine you might feel.. -I can see that you are... |
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what are the broad categories of history taking
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-pt demographics
-pt social history -personal medical history (past & present) -Social habits -family history |
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what should be asked about the pt personal history
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-can you describe your condition to me?
- Are you currently receiving care or is it something from the past that has completely resolved? -What are your current symptoms and do they change - How is the condition being managed |
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what are yellow flags
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cautionary sxs"I should think about this in the context of my tx.
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what are the categories of red flags
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-PMH
-Risk factors -clinical representation -pain pattern -associated signs and symptoms |
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What are Red flags in the: PMH
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-cancer
-recent infection when followed by joint or back pain -recent cold/flu cyclical pattern -Hx of trauma -Hx of immunosuppression -Hx of injection drug use |
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What are Red flags in the: Risk factors
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-substance abuse
-age -gender -BMI -Exposure to radiation -race/ethnicity -domestic violence -sedentary lifestyle -hysterectomy/oophorectomy -occupation |
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What are Red flags in the: Clinical presentation
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-no known cause
-PT doesn't help with sxs -significant weight change -cyclical pattern of worse, better, worse -unrelieved by position change -sxs out of proportion to injury -no pattern to sxs -B sxs |
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What are Red flags in the:
Pain presentation |
-inconsistent
-night pain -constant & intense pain -worse with activity & relieved by rest -throbbing knife like, boring, deep aching -poorly localized or comes & goes -associated with viscera -changes with food intake or medication use |
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What are Red flags in the:
Associated signs or symptoms |
-recent confusion
-constitutional sxs -proximal mm weakness -joint pain & skin rashes/nodules -clusters of sxs associated with an organ system -unusual menstrual changes |
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What are constitutional sxs/signs
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-fever
-diaphoresis -night sweats -N & V -Diarrhea -Pallor -Dizziness/Syncope -Fatigue -Weight loss |
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what are the "presenting complaint" questions
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-location
-pain characteristics -functional limitations -mechanism of injury |
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what are the general guidelines for MD referral
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-a lack of progress with PT
-unknown cause -discovery of significant PMH not known by MD -development of constitutional signs -abnormal vital signs |
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What are the immediate referral guidelines
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-unstable
-angina with sweating, N & V -Bowel/bladder -anaphylactic shock -detectable irregular mass -inadequate ventilation -diabetic with changes in mental function -acute appendicitis -signs of thromboembolism -signs of AAA -changes in size, tenderness of lymph nodes |
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what are the contraindications for PT
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-uncontrolled CHF or pulmonary edema
-Acute myocarditis -RHR > 120bpm -SBP > 180-200 mmHg -DBP>no mmHg -dizziness/syncope -marked dyspnea -unusual fatigue -unsteadiness -irregular pulse -Signs of DVT -unstable glucose (<100 or >250) |
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what are some things to ask in order to clear most systems
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-fatigue
-malaise -fever/chills/sweats -Nausea -mentation -weight change -parathesias -weakness -dizziness |
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what do you do if the pt answers "yes" to one of the items that you ask in order to clear systems
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-is there an explanation
-has the pt mentioned it to the MD -Has it worsened/changed |
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what are techniques that PTs use in order to screen
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-ausculation
-palpation -inspection -percussion |
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what is in a screening kit
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-stethoscope
-blood pressure cuff -thermometer -pulse oximeter -reflex hammer -pen light -safety pin -cotton ball -tuning fork -2 test tubes -familiar objects -gloves -tape measure -goni |
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Vital signs important to screen:
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-HR
-BP -Body temp -RR -O2 stats -Pain |
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what is the system wide checklist for neuro
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-pain
-numbness -weakness |
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how do you screen the neuro system
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-inspection
-mental and emotional status -CN exam -motor and sensory -reflexes -neural tension |
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what is the CV-P checklist
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-dyspnea
-palpitations -syncope -pain with sweats -cough -peripheral edema -cold hands/feet -open wounds -skin discoloration |
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How do you screen for CV/P
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-inspection
-vitals -palpation -auscultation |
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what is the musculoskeletal checklist
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-insidious onset
-atypical pain pattern -night pain -inadequate relief with rest or rehab -inability to reproduce or alter sxs during PT exam -impairments do not match functional limitations -atypical findings during physical exam |
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How do you screen musculoskeletal system
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-B joint inspection
-End feel and ROM -strength -palpation -provocative/composite motions -special tests |
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What is the Visceral/GI checklist
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-swallowing difficulties
-indigestion/heartburn -food intolerance -bowel dysfunction (color, caliber of stool, constipation, diarrhea, difficulty initiating, incontinence) |
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How do you screen GI
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-palpation
-Auscultation -inspection |
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What is the GU checklist?
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-urination (color, caliber, flow frequency, urgency, output, retention, difficulty initiating, incontinent)
-male/female reproduction (discharge, sexual dysfunction, pregnancy, menses/menapause) |
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How do you screen the GU
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-usually referral
-could use inspection -could use sxs reproduction during positioning |
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what is part of the integumentary checklist
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notable changes in the:
-hair -skin -nails -wounds |
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How do I screen Integumentary system
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-inspection
-palpation |
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what are the 2 "tricky" systems
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-Endocrine and psychological
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What sxs do you look in regards to the endocrine system
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-insidous onset
-atypical pattern |
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what are the "guidelines" for the clinical decision making
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Take into account:
PMH, risk factor assessment, clinical presentation, associated sxs, ROS |
