Exam Methods I - Exam 1

Components of the PT Exam

1. Handwashing, Introduction, Informed Consent

2. Review Precautions/Contrainindications

3. History/Patient Interview (subjective)

4. Objective Exam

5. Special Tests

6. Functional Assessment

7. Evaluation, Diagnosis, prognosis, goals, plan of care

Informed Consent

1. Provide information necessary to allow patients to make informed ecisions about care / participate in clinical research

2. empower them in decisions about their healthcare

Red flag vs Yellow flag

Red - signs and symptoms found in the pt history and physical exam that suggest the presence of serious pathology

Yellow - psychological risk factors that may affect prognosis and describe how a person manages their situation with thoughts, feelings, and behaviors

Give examples of some precautions prior to PT

1. weight-bearing status

2. unexplained weight loss?

3. pain that keeps them up at night / night sweats

4. Prescence of the 4 D's - dysarthria, dysphagia, dysmetria, diplopia

5. inability to walk

6. incoordiation

7. facial droop or sudden weakness

8. chest pain, SOB, arm pain, jaw pain

Other than treating a patient, a PT can:

Refer- different service

Consult - professional expert opinion for specialized knowledge

Manage - use of other recognized assistive personelle

Co-manage - collaborate with other professionals

Components of the pt interview

- introduction

- pain levels

- history of present illness

- prior level of function (assistive devices, family suport, typical day in their life)

- home setup

- PATIENT GOALS!!!!!

Goal of the patient history interview?

learn as much about a patient's history, social needs, and environemtn as necessary to direct care in order to maximize safety, comfort, and function

building a therapeutic alliance

Shoulder abduction, shoulder flexion (muscle, nerve, level)

Muscle: deltoid

nerve: axillary nerve

level: C5

Elbow flexion (muscle, nerve, level)

muscle: biceps

nerve: musculocutaneous nerve, C5 and C6

Level: C5, C6

Wrist extension (muscle, nerve, level)

muscle: extensor carpi radialis longus AND extensor carpi radialis brevis

nerve: radial nerve

level: C6

elbow extension (muscle, nerve, level)

muscle: triceps

nerve: radial nerve

Level: C7

Wrist flexion (muscle, nerve, level)

muscle: flexor carpi radialis AND flexor carpi ulnaris

nerve: median and ulnar

level: C7

Systems Review in Lay Persons Terminology

1. Musculoskeletal - problems with muscles, bones, or joints

2. Neuromuscular - pins and needles, numbness, loss of balance, swallowing, hearing

3. Cardiovascular - heart problems, chest pain, swelling

4. Pulmonary - lungs, difficulty breathing, SOB, lightheaded

5. Integumentary - open areas, scratches, redness

6. Internal Organs - sudden weight gain/loss, freq. peeing, stomach issues

Observation/Inspection Portion of Exam

Informal - observe pt walking into clinic, observe them while taking history

Formal - targeted observation

- cognitive assessment

- cranial nerves

- movement analysis

Why do we palpate?

- orient to patient

- determine state of tissues

- variations in temp

- alterations in skin moisture

- referred vs localized pain

- differences in tissue tension

- identify structures and detect abnormalities

Important components of palpation

- properly drape the pt

- be mindful of how you are touching them

- start with uninvolved side

- ensure pt is relaxed

- begin with light pressure

- avoid causing pain

- if structure is still, move hands

- if structure is moving, hands are still

What is a pulse

A rhythmical dilation of an artery by the wave of blood created by contraction of Left Ventricle of the heart

▪ Palpated where superficial artery crosses over a bone

What 3 things should be documented after taking a patients HR

rate, rhythm, intensity

Factors affecting HR

age, gender, emotion, systemic and local heat, medication, activity level

Normal HR

60 - 100

Emergency resting HRs

>100

<30

Emergency resting BP

SBP >180 or <90

DBP >110

What are some emergency signs/symptoms

sudden change in mentation

facial pain with intractable headache

sudden onset of angina or arrythmia

abdominal rebound tenderness

black, tarry, or bloody stools

HR abnormal response to exercise

rise too rapidly, no rise, sudden decrease

BP abnormal response to exercise

systolic hypertension/hypotension, diastolic hypertension

• when top number (systolic) is high but bottom number is low

Respiratory rate abnormal response to exercise

abnormal pattern, rise too rapidly, no rise

Signs/symptoms of abnormal responses to exercise

angina, vertigo, dyspnea, claudication, loss of balance, pallor, cyanosis

HR contraindications to exercise

resting: <40 or >120

exercise: >200

BP contraindications to exercise

SBP >200 OR falls more than 20 mmHg with increasing exercise

DBP >110

RR contraindications to exercise

Resting RR: >30 or <8

Sites for measuring pulse

radial, brachial, temporal, carotid, femoral, popliteal pulse, doralis pedis, posterior tibial pulse

Steps to finding apical pulse

1. Sternal notch

2. angle of louis

3. 2nd ICS - midclavicular line

4. apical pulse location: 5th ICS - midclavicular line

Factors affecting respiratory rate

age, gender, stature, body position, medications, disease, activity level

What to assess when taking a respiratory rate

rate, depth, ryhtym of respirations, deviations from normal breathing patterns

How to count respirations

count a cyle of inspiration + expiration as ONE breath and record for 60 seconds

Difference between the diaphragm and the bell of a stethoscope

Diaphragm: used for BP and high frequency sounds

Bell: used for low frequency sounds

Proper fit of a BP cuff

20% wider than diameter of the limb

Should cover 2 to 2/3 of length of pts proximal limb segment

If the BP cuff is too narrow, what will result?

Abnormally high BP reading

If the BP cuff is too loose, what will result?

Abnormaly low BP reading

Factors that affect BP

Blood volume, diameter/elasticity of arteries, cardiac output, activity, age, valsalva maneuver

Normal BP

<120 / <80

Elevated BP

120 - 129 / <80

Stage I HTN

130 - 139 / 80 - 89

Stage II HTN

>140 / >90

How does BP relate to Korotkoff sounds?

Phase I : the first clear sound which gradullay increases in intensity

Phase V: last sound that is heard: second diastolic, used to record diatolic pressure in adults

BP contraindications

IV, catheder, shunt, fistula, lymphatic removal, pain, fracture, lymphadema

Good rule to follow regarding O2 sat

restrict patient activity when O2 drops below 90% until checking with MD

What may affect reliability of pulse oxs

hypoxemia levels, skin pigment, poor perfusion, anemia, motion

What is goniometry

measurement of angles that are created at joints by the bones of the body

How do we perform goniometry

place the parts of the goniometer along the bones immediately proximal and distal to the joint being measured

Why do we perform goniometry?

important part of a comprehensive examination of joints and surrounding soft tissues

measures and documents the amount of active and passive ROM as well as abnormal fixed joint positions

Goniometric data + other objective measures can provide a basis for the following:

- diagnosis, prognosis, plan of care, treatment goals

- evaluating progress/ lack of progress

- modifying treatment

- motivating the individual

- fabricating orthotics and adaptive equipment

Kinematics

the study of motion without regard for the forces that are creating the motion

Types of motion a bony segment can undergo

translation - linear displacement

rotation - angular displacement

combination - both

Arthokinematics

the movement of joint surfaces

slides, spins, rolls

not measures with goniometry

Convex on concave

roll and slide in opposite directions

Concave on convex

roll and slide in same direction

Osteokinematics

gross movement of the shafts of bony segments

Frontal plane: axis of motion and joint movements

Anterior/Posterior

Abduction/Adduction

Sagittal Plane: axis of motion and joint movements

Medial/Lateral

Flexion/Extension

Transverse Plane: axis of motion and joint movements

Vertical

Internal/External Rotation

LOM

Limitation of motion/ Loss of motion

Degrees of freedom

the number of axis or planes at which the bone in a joint can move

Soft end feel

Soft tissue approximation

ex. knee flexion

Firm end feel

muscular stretch, capsular stretch, ligamentous stretch

ex. hip flexion with knee straight, extension of fingers, forearm supination

Hard end feel

bone contacting bone

ex. elbow extension

What affects ROM?

age, gender, musculoskeletal issues, neuromuscular issues, pain, psychological issues

Example:

Patient with rheumatoid arthritis who presents with a 30 degree right

wrist flexion contracture. That is, she lacks 30 degrees of extension

required to bring her wrist up to the neutral position. In addition, she can

only flex her wrist to 65 degrees

what is her total joint ROM?

35 degrees

• contracture: shortening of tissues or tightening limiting ROM which could be caused from injury or scarring or prolonged use

Precautions to ROM and muscle length testing

joint dislocation/subluxation

unstable bone fracture

rupture of tendon or ligament

infectious or acute inflammatory process

severe osteoporosis

acute injury or recent surgery

prescence of pain / muscle spasms

immobilized joints

Where to stabilize when goniometry testing

stabilize proximal joint segment so motion can be isolated to the joint being examined

Normal hip flexion angle

100 - 120

Normal hip extension angle

20 - 30

Normal hip abduction angle

40

Normal hip adduction angle

20

Normal Hip Medial Rotation angle

40 - 45

Normal Hip Lateral Rotation Angle

45 - 50

Normal Knee flexion angle

140

Make test

Not true MMT

- application of resistance against an actively contracting muscle

• ex: hand grip dynanometry

Break test

True MMT

- resistance is applied at end range (mid range for 2 joint muscles)

- patient is asked to hold position and "don't let me move you"

0/5 MMT grade

no visible or palpable muscle contraction

"zero"

1/5 MMT grade

muscle contraction detectable visibly or through palpation, no movement produced

"trace"

2/5 MMT grade

able to move through full available ROM in a gravity-eliminated plane ( horizonal plane)

"Poor"

3/5 MMT grade

able to move through full available ROM in an anti-gravity position (vertical plane)

"Fair"

4/5 MMT grade

Able to maintain contraction against a moderate amount of resistance after completeing full anti-gravity ROM

"breaks" with more than moderate resistance

"Good"

5/5 MMT grade

Able to maintain contraction against a maximal resistance after completion of full AGAINST gravity ROM - doesn't break

"Normal"

grades 0-2 in MMT, they are mostly

A. Objective

B. Subjective

Objective

grades 3-5 in MMT, they are mostly

A. Objective

B. Subjective

Subjective

1+ / 5 MMT grade

movement in gravity-eliminated plane with ≤ 1/2 of full available ROM

2- / 5 MMT grade

movement in gravity - eliminated plane with ≥ 1/2 of full available ROM

2+ / 5 MMT grade

initiation against gravity for ≤ 1/2 full available ROM

3 - / 5 MMT grade

movement against gravity plane for ≥ 1/2 full available ROM

3+ / 5 MMT grade

able to withstand a minimal amount of pressure

- breaks with greater than minimum pressure

4- / 5 MMT grade

Able to withstand a minimal to moderate amount of pressure

4+ / 5 MMT grade

able to withstand a moderate --> maximal amount of pressure

Below 3/5 MMT grades are based on

amount of ROM, and gravity-eliminated

Above 3/5 MMT grades are based on

amount of resistance that they can withstand

Normal shoulder flexion ROM

180

Normal shoulder extension ROM

60

Normal shoulder abduction ROM

180

Normal shoulder medial rotation ROM

70