INTRODUCTION TO PT EXAMINATION

April 4, 2021

EXAMINATION PROCESS
PT PROCESS
History Taking • Helps describe the past and
• A series of events that a Physical Therapist performs current nature of the
condition or health status of
to individuals who seek PT services.
the patient.
• It involves the process of: • Requires the ability to
o Examination develop a good
o Evaluation communication or rapport
with the patient or his
o Diagnosis
family.
o Prognosis Systems Review • Brief or limited examination
o Intervention of the cardiovascular,
pulmonary, integumentary,
PATIENT/CLIENT MANAGEMENT MODEL musculoskeletal, and
neuromuscular systems,
• (+) The Guide to Physical Therapist Practice has communication ability,
affect, cognition, language
been instrumental in defining and describing what
and learning style.
PTs do as clinicians. These activities have been • This will guide the PT in
summarized in the patient/client management determining if referral to
model. This model reflects the process of gathering other health professional is
necessary.
information, designing a plan of care, and
Tests and Measures • Rule in or rule out causes of
implementing that plan to result in optimal outcomes impairment in body
for the patient/client. structures and functions,
activity limitations, and
participation restrictions.
• It is necessary to confirm or
reject the most likely cause
of the patient’s condition
and will support the PT in
establishing the diagnosis,
prognosis, and plan of care.

EVALUATION
• All the information gathered from the examination
process are reviewed and the PT makes a clinical
judgement based on this information.
• PT identifies the significance or implications of each
information in patient’s condition.
• In some cases, consulting in some allied health
professionals is necessary to evaluate the results of
the examination.
EXAMINATION
• Gather information about the past and current status DIAGNOSIS
of a patient. • Categorization of findings from the examination
• Composed of history taking, systems review, and through a defined process.
test measures. • After a comprehensive examination and evaluation,
• (+) The initial examination is a comprehensive the PT then makes a diagnosis based on the results
screening and specific testing process that leads to a of the examination.
diagnostic classification. • (+) Established in accordance with a policy adopted
• (+) It may also identify possible problems that require by the House of Delegates of the APTA (Box 2 – 1).
consultation with or referral to another provider.

(+) additional information from the book* 1

PROGNOSIS RESULTS
• After establishing a diagnosis based on the • The results can be seen immediately depending on
examination, the PT then predicts the patient’s their dysfunction, surgery, case.
prognosis or the level of the patient’s improvement
and the time frame to reach that level.
• PTs also design a plan of care integrating the
patient’s goals and expectations.
• Also includes establishing short and long-term goals,
patient’s outcome, interventions, and criteria for
discharge.

INTERVENTION
• Delivery of procedures to establish the goals and
outcomes.
• (+) This component is subdivided into three activities:
o Coordination, Communication, and
Documentation – a consistent exchange of
information, both orally and in writing, is
essential to ensure that all personnel involved
in care of the patient/client are well informed
about his/her status.

FUNCTIONAL MOVEMENT EXAMINATION

ANALYSIS
• To understand the cause of the patient’s impairment
and put together a plan to strengthen their muscles
via therapeutic and corrective exercise.

MANUAL THERAPY
• It can be a massage, joint mobilization, soft tissue
mobilization, and modalities.

LENGTH OF TREATMENT
• Normally, 1 – 3 sessions a week of Physical Therapy
depending whether it is a surgery or on the doctor’s
advice and discretion of the PT on the patient’s
needs.

(+) additional information from the book* 2