Clinical Assessment and Diagnosis

Clinical Assessment

The examination process: To determine the patient’s primary reason for seeking assistance, identify damaged or impaired tissue/structures, the extent or severity of the urgency of the situation, and patient goals so that an appropriate plan can be devised

Diagnosis

The nature of the problem, condition, or disease

Diagnostic Symptoms

Information provided by the patient regarding their perception of the problem

Diagnostic Signs

An objective, measurable, physical finding regarding the patient’s condition

Determining the scope of assessment

• Urgency of the situation

• Reason - initial assessment vs. follow up

Diagnosis

A term designating a specific health condition with criteria agreed upon by the medical community

Differential Diagnosis

List of possible diagnoses

Working diagnosis

Current plan until…

HOPS/HIPS

History, observation, palpation, special tests

SOAP

Subjective, objective, assessment, planning

HPE

History, physical examination

History

Subjective, primary complaint, mechanism of injury, characteristics of symptoms, and patient medical history

OPS

Objective evaluation using measurable findings relative to the patient’s condition

• Observation/inspection

• Palpation

• Special tests

ICD

International Classification of Diseases

Somatic

Deep/Superficial

Visceral

• Deep, nagging, and pressing

• Nausea

• Injury to internal organ

• Referred pain

SANE

Singe Assessment Numeric Evaluation

Observation

Body language, symmetry, appearance, motor function

Inspection

Bilateral Comparison & Factors seen at the injury site

Palpation

Gentle, circular pressure, followed by gradual, deeper pressure. Begin away from the injured site and work toward the injury.

Bilateral Palpation

Look for swelling, temp, tenderness, deformity, spasms, and pulse.

AROM

Active Range Of Motion; Moved voluntarily by patient

PROM

Passive Range of Motion; Moved by AT without help from the patient; Distinguishes injury to contractive tissue or noncontractile tissue or inert tissue

MMT

Manual Muscle Testing

Stress Tests

Joints

Neurological Testing

Nerve Roots

CNS

Assesses dermatomes, myotomes, and reflexes

Dermatome

Area of skin supplied by a single nerve root

Myotome

A group of muscles primarily innervated by a single nerve root

Reflexes

DTR (Deep tendon reflexes), Superficial, Pathological

Peripheral Nerve Testing

Manual muscle testing, cutaneous sensation testing, and special compression tests

Activity-Specific Functional Testing

Strength, agility, flexibility, joint stability, endurance, coordination, balance, sport-specific skill performance

Radiographs (x-ray)

Fractures, infections, and neoplasms

Radiopaque Dyes

Myelogram and arthrogram

CT (computed tomography) Scans

Reveals abnormalities in bone, fat, and soft tissue; detects tendon and ligament injuries

MRI (Magnetic Resonance Imaging)

Soft-tissue, space occupying lesions in the brain, and joint damage

Radionuclide Scintigraphy (Bone scan)

Stress fractures of long bones and vertebrae, degenerative diseases, and infections/tumors in bone

Ultrasonic Imaging

Tendon and soft tissue

Electromyography

Denervated muscles, nerve root compression injuries, and muscle diseases

Use of HOPS vs. HPE

HOPS is used for orthopedic purposes HPE is used for medical assessment