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LECTURE 8 - Clinical Assessment-F17-4610 PDF
LECTURE 8 - Clinical Assessment-F17-4610 PDF
LECTURE 8 - Clinical Assessment-F17-4610 PDF
What is a Medical
History?
• Structured/systematic evaluation of the
patient to gain insight into the patient’s
health status.
• Includes:
• Current health issues
• Past health issues
• General health status
• Other factors (health, socioeconomic,
lifestyle) that may impact their current
condition and/or response to
treatment
• Family history
• OBJECTIVE: determine the problem and
develop:
• Patient perspective/goals
• “ICE”: ideas, concerns,
expectations
• primary diagnosis
• differential diagnosis
• Identify yellow/red flags
• prognosis
• plan of management
Tips for conducting a good clinical history
• Ensure privacy
• Establish rapport‐smile, approachable
• Patients are worried, apprehensive
• More likely to open up to you if they feel comfortable
• Non‐judgmental
• Demonstrate respect/sensitivity for the patient’s
condition
• Eye contact
• Begin by asking the patient to identify their reason for
the visit
• Encourage patient to do most of talking
• Open questions
• Encourage expression of feelings
• “ICE”: ideas, concerns, expectations
• Easy to understand language, clear, concise – minimize
jargon
• Communicate to patient what you plan to do every step
of the way
• Close the consultation with summary and offer one last
opportunity for patient to add anything to the discussion
Comprehensive History:
Chief complaint, Systems Review,
Personal History, Family History
Chief Complaint: “LoDrFicara”
• Indicators for urgent attention
and further testing/referral
• Age over 65 years
• Unresponsive to treatment or
worse at rest
• Night pain, fever, chills,
unexplained weight loss
• Trauma
• Significant neurological deficit
Yellow Flags
• Risk factors for chronic
disease/illness including:
• Psychosocial factors: Negative
coping behaviour, poor self‐
efficacy, Fear avoidance
behaviour
• Other factors: duration of
condition, job demands, visiting
many practitioners, reliance on
passive care, compensation
claim
• Management – Education,
active care, possibly co‐
management with counselor
Differential Diagnosis
• “CATBITES”
• Congenital
• Arthrotide
• Tumour
• Bone
• Infection
• Trauma
• Endocrine
• Soft tissue
• Mechanical vs non‐mechanical
pain?
• Plan Physical Exam
Physical
Examination
• Purpose:
Diagnosis/Exclusion
• Focuses on problem
identification/reproduci
ng pain
• Test ‘normal’ side to
establish baseline
• Includes:
• Observation
• Palpation
• Functional Tests
• Neurologic exam
• Orthopedic/special
tests
Observation
• Posture
• Gait
• Bony contours/deviations
• Asymmetry
• Colour/texture of skin
• Pain areas v normal
• Trophic skin changes (loss of
elasticity, shiny, hair loss,pitting
edema)
• Redness/swelling/edema
• Facial expressions, guarded
movement
Tissue Palpation
•Used to isolate the pathologic source
• Must differentiate from referred pain
• character of pain, localized/not localized.
• localized/point tenderness usually isolates the precise location of
the tear/bruise, etc..
• To palpate properly, keep area relaxed, if possible.
• Effective palpation will detect:
• Differences in tissue tension/texture
• Temperature
• Moisture/dryness
• Abnormal/increased sensation
• trigger points
Functional Tests
• Range of Motion:
• Active Range of Motion (AROM)
• Passive ROM (PROM)
• Joint Play
• Strength
• Manual Muscle Tests (MMT)
• Resisted
Joint Play
• Joint dysfunction signifies
a loss of joint play movement.
• Paraphysiologic space
• Normal joint play is necessary
for full, pain‐free function of
the joint.
• Prior to muscle strengthening regime.
• To regain full ROM, normal joint
play must be restored to the joint
• Mobilization/manipulation
Neurological
Examination
• Examines for nerve/nerve
root lesions
• Observe for:
• Muscle wasting/atrophy
• Loss of secretions (sweat)
• Loss of pilomotor response
• Sensory testing ‐ dermatomal
• Myotomal testing
• Paralysis
• Paresis: partial paralysis
• Reflex testing
• Upper/lower MN disease/injury
Grading of Muscle and Reflex Responses
• Look for asymmetry
• Sensory – symmetry and discrimination
• Motor – 0 (none) to 5 (resistance against gravity) grading
• Reflexes
Strength of contraction measured
from 0‐5
0=no contraction visible
1=cannot contract against gravity
2=can contract if gravity eliminated
5=normal contraction
Orthopedic tests
• ‘reproduce the pain’
• Joint provocation
• Resisted muscle testing
• Test for:
• Joint function/dysfunction
• macro‐tissue injury – e.g.
muscle/ligament tear
• Inflammation
• Nerve impingement
• Most orthopedic tests are
variations of ROM and joint play
manoevres
• Eg Kemps test
Special Tests
• X‐Rays
• MRI
• CT Scan
• Ultrasound
• Bone Scan (bone
scintigraphy)
• Blood Tests
• Electrophysiology
• EMG
Note taking
• Soap Notes
•Subjective: how is
patient presenting?
•Objective: results
of your examination,
testing
•Assessment:
evaluation of your
findings
•Prognosis: follow
up recommendations
References/Suggested Readings
• Bates’ Guide to Physical Examination and History Taking ~ L.S. Bickley
• Orthopedic Physical Assessment ~ D. J. Magee