The Clinical Assessment

Flashcards covering key vocabulary and concepts from the clinical assessment lecture.

Medical History

A structured/systematic evaluation of the patient to gain insight into the patient’s health status, including current and past health issues.

ICE

Ideas, Concerns, Expectations; a framework used to understand the patient's perspective and goals in clinical assessment.

Chief Complaint

A description of the patient's primary issue or symptom, typically expressed using the acronym LOCDRIFACAR.

Red Flags

Indicators for urgent attention and/or further testing/referral, such as age over 65, unresponsive to treatment, or unexplained weight loss.

Yellow Flags

Risk factors for chronic disease/illness, such as negative coping behavior and job demands.

Differential Diagnosis

A systematic diagnostic process to determine which disease may be causing a patient's symptoms, using the acronym CATBITES.

Physical Examination

The process of diagnosing or excluding a condition by identifying and reproducing pain through observation, palpation, and functional tests.

Neurological Examination

An examination aimed at detecting nerve/nerve root lesions through muscle testing, sensory assessments, and reflex testing.

SOAP Notes

A method of documentation in clinical settings that covers Subjective, Objective, Assessment, and Prognosis.

Functional Tests

Tests assessing the patient's range of motion, strength, and joint play to identify functional limitations.