Physiotherapy evaluation and examination is a very important process in physiotherapy practice. You become a detective of some sort. It becomes a skill that is sharpened as you see more people requiring physiotherapy evaluation and treatments.
Don't forget to introduce yourself first
Before getting any data from your client, you should always introduce yourself and make him or her comfortable talking to you. If possible, the area should be clear of distractions such as an open door where people are seen passing all the time. In addition, sitting in front of your client without any barrier (a table perhaps) between you and your client may be even better. This could probably make the person more comfortable talking to you.
History of Present Illness
In the history of present illness, or HPI, you will be asking questions that are related to the specific problem of your client. This may include asking:
- What made you come here?
- What did you feel? Please describe to me (Location/Intensity/Duration). What other symptoms did you feel? Please describe them.
- What was your activity at the time your symptoms occurred? / What were you doing when your symptoms occurred?
- What makes your symptoms worse? What makes it better?
- What did you do about your symptoms? (Medications/Consultations and treatments provided including relevant lab works and results if available)
- What other concerns do you have?
If your client's symptoms had been present in the past, ask why he or she decided to have a consultation today.
You might also want to make use of the mnemonics OLD CARTS, which stands for Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity. But, as you become skilled in clinical questioning (with client rapport of course!), questions that your supposed to ask will come in naturally.
Your Clinical Eye
Sometimes, you will know what your client's problem is as he or she enters the evaluation room before the actual evaluation and examination. This is your clinical eye working.
For example, your client is walking with exaggerated right hip and knee bending, lifting the foot to clear it off the ground while walking. Having your clinical eye working, you might expect that he has weakness or paralysis of his ankle dorsiflexors (muscles in front of the leg). Since you know that that may be the case with your client, you can now prepare your questions in your mind.
Past Medical History (PMHx)
Ask about previous medical conditions or other treatments that they are having for another health problem.
Family Medical History
Some conditions are inherited. Sometimes, health problems, such as heart disease or diabetes runs in their family, putting them at risk for the condition, as well.
Tests and Measurements
By doing physiotherapy tests and measurements during the initial encounter / initial evaluation, you will establish a baseline data, which will become your basis for possible change in your physiotherapy treatment plan.
Measurements that are essential in your physiotherapy documentation may include:
- Blood pressure (BP), heart rate (HR), pulse rate (PR) and temperature (To)
- Joint range of motion
- Manual muscle tests (MMT) / Testing for baseline muscle strength
- Other relevant measurements specific for your client's problem. For example, stump measurement for a patient who have had an amputation.
You may also need to perform orthopedic special tests to determine the actual structure affected. For example, the Lachman test, which can be used to test for anterior cruciate ligament injury or the McMurray test for meniscus injuries.
Setting Client / Patient Goals
Setting goals for physiotherapy rehabilitation should involve the person (your client). The goals should be realistic and achievable according to person's condition and problems. By making your client actively participating in setting goals, he or she will feel more comfortable and may be more motivated in achieving those goals, thus, resulting in better outcomes.
Plan of Treatment
Again, in formulating physiotherapy treatment plan, your client should always be involved. Besides, he or she is the most important person in the rehabilitation team. The treatment options to be followed should address the problems that you gathered from your examination and the goals set with your client.Your client should feel that you are putting great importance on what he or she thinks.
Always remember that rehabilitation is a collaboration between you and your client and the rest of the rehab team. Without motivation and active participation of the person (your client), the set goals may be hard to achieve.
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