Evaluation and Health Examination
Evaluation and Health Examination
Evaluation and Examination
The evaluation process broadly involves interviewing the patient and reviewing medical and test reports such as X-rays, MRI CT scan reports. Any medical evaluation involves a series of interrelated steps that help a physiotherapist to make clinical decisions and set a goal for treatment. A physical therapist’s plan based on this data is an effective treatment suited to the patient’s needs and goals.
The evaluation procedures are as follows:
Collection of basic information such as name, age, gender, address and occupation is important for documentation.
But, address and occupation have their other values because it gives us an idea of what could be the possible cause of the current disease. We can also correlate current illness or disability with the occupation of the person.
The main complaint is the most important complaint that a patient is presenting to us. It should be documented in the exact words or ideas presented by the person.
History is a very important part of orthopedic evaluation for physiotherapists, because during history physiotherapists actually interview or interact with the patient, it gives us an opportunity to establish a relationship with the patient. The way we put our question is more an art than a science.
During this time we should be comfortable with him/her and allow him/her to express his/her opinion about pain in their own words.
History of present illness:
It includes a collection of data related to current complaints or diseases. We ask the following questions to extract information:
History of Treatment
We ask if he/she has received any medicines, any kind of treatment or underwent any physiotherapy treatment. What type of physiotherapy treatment was received?
Then review all the medical reports of the previous treatment, its X-ray report, MRI report, CT scan report.
History of previous illness
In many cases, we have to go through the ills of the past to make connections with the present complaints. We may need to ask for a similar illness or related illness in the previous year / previous years, and treatment can be obtained for it.
Many cases like rheumatoid arthritis, osteoarthritis, osteoporosis all travel in the family. So it is sometimes worth looking at family history.
Under observation, we have to document everything that we have seen for a patient since entering the department.
We have to develop a target treatment plan based on the diagnosis, patient complaints, need of the patients.
We classify targets into two types:
Short-term goals – A goal that patients want to meet soon, which means today, this week, this month or even this year.
Long-term goals – A long-term goal is something you want to achieve in the future which requires time and proper planning.
Pain is assessed by: detecting and describing pain to help in the diagnosis process; Understand the cause of pain to help determine the best treatment; We monitor pain to determine whether the disease or disorder is improving , remaining the same or worsening, and whether pain treatment is working.
Pain is personal and subjective differing from person to person; Therefore, the patient’s self-report of pain is the most reliable gauge of experience. The components of pain assessment include:
- History and Physical Assessment
- Functional Evaluation
- Psychosocial Evaluation
- Multidimensional Evaluation
History and Physical Assessment
Areas of focus include pain, the site of the musculoskeletal system and the neurological system. Other components of history and physical assessment include:
Functional and Psychosocial Evaluation
Overview of Patient's Behavior while Performing Functional Tasks
Several tools are available for an intensive, multidisciplinary pain assessment. It is specifically important with patients who have chronic pain, mixed pain (both acute and chronic), or complex
Common examples of these devices include:
General Pain Scale
For patients with newborns through advanced age, there are varieties of pain scales for pain assessment.
Era of Pain
When assessing pain, it is important to differentiate between acute and persistent / chronic pain and the implications of patient assessment and management:
A comprehensive evaluation using reliable and validated instruments to prevent the onset of acute chronic disease is of extreme importance in acute pain stage performance.
Persistent / Chronic – When pain is persistent, it is important to gather all the information and understand the factors that contribute to the persistence of pain.
When assessing pain we use a biopsychosical approach to the assessment of pain and disability because it accounts for the multidimensional nature of pain in domains relevant to physical therapy practice.
Despite the inherent difficulty in measuring pain, there are several accepted tools for tracking pain-related treatment outcomes. Commonly used measures for various pain dimensions include:
Chronic pain has many effects on patients, so the results cover several domains:
What is posture
Posture is defined by the approach either by the body with support during muscle activity, or as a result of coordinated action performed by a group of muscles working to maintain stability.
There are two types
Dynamic Posture is something when you are moving your body, like walking, running, or bending over to pick something up. Muscles and non-contractile structures have to work to adapt to changing conditions.
Static Posture is something that you hold yourself when you are not moving, such as sitting, standing, or sleeping. The body segment is aligned and placed in a fixed position. This is achieved by coordination and interaction of muscle groups that are working to counter gravity and other forces.
It is important to make sure that you have a good moving and stable posture.
When evaluating posture, symmetry and rotation / bending should be seen in anterior, lateral and posterior views.
Posture and Health
Poor Posture can be bad for your health. Slouching / slowing can confuse your musculoskeletal system. It increases pressure on the spine, making it at risk of injury and degeneration, all of which cause neck, shoulder and back pain and reduces flexibility. Poor posture affects joint movements, affects balance and increases the risk of a fall. This makes the digestive system to work slowly. It also affects breathing patterns (harder to breathe).
Physiotherapists can identify the posture and provide hands-on treatments, there are posture correction exercises and helpful home exercises to achieve great alignment of body. Some objectives are listed below: