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SOAP

Subjective Information/Patient History

Other medical conditions/co-morbidities (Systems Review)


Social/health habits; living environment; employment status (Systems Review)
Any medical testing reported in the patients medical record (Systems Review)
History of the current complaint (previous interventions for this problem)
Patient knowledge of the problem (helps with education) (Subjective)
Site and intensity of the symptoms (PAIN DATA) (Subjective)
Behavior of the symptoms over 24 hours (Subjective)
Patient goals (Subjective)

Objective Patient Data


What Gives a Better Quality Measurement?(In terms of predicting outcomes and directing the POC)

Assessment: Diagnosis

Relate:
impairments (body functions and structure) and pain TO...
e.g.
decreased AROM of c spine
inflammation of facet jones
limited control of postural ms
altered head posture
functional limitations (activity restrictions)
upright positioning with driving
lifting and carrying
Examples:
restricted neck mobility and soft tissue disruption limiting Pt ability to turn his head to drive his
truck
decreased muscular endurance limiting Pt ability to sit upright for greater than 5 mins
pain with activities that require compressive forces to the patella including walking and
squatting.
poor quadriceps control during ambulation with patient using a circumducted gait pattern
Occupation: Truck Driver
Dx: Impaired postural control of head and neck with upright positions greater than 5
minutes as the result of flexion/extension injury limiting performance of upright job
related responsibilities.
Occupation: Outside salesman
Dx: Impaired cervical mobility required to drive a car as a result of soft tissue
shortening and long term postural malalignment.
Occupation: Unemployed, helps elderly parent at home
Dx: Impairment of lower extremity and trunk strength limiting weight bearing ADLs
secondary to recent exacerbation of MS.

Assessment/Prognosis: Long Term Goals


tip = Seymour does long term goal first, then she breaks it into short(er) term goals
hinges on when patient completes therapy with you, personally, so its discrete

What is it?
FUNCTIONAL Outcome Expected at Completion of Treatment
There are five parts
Audience/subject
typically patient or patients family member
Behavior
what youll look at, evaluate, and measure
Standard
whats the acceptable level of performance
Condition
what are the conditions that the patient will complete long term goal
is it completion in clinic or at work? in the community?
Time Span
how long will it take for them to accomplish long term goal?

Assessment: Short Term Goals

Include all the same components of the LTG


Interim Objectives starting with simple and moving to more complex tasks
Example 65 year-old s/p TKR beginning outpatient Rx 6 weeks post surgery
LTG: ambulate in community over rough and smooth surfaces, with normal cadence
and control for mile or up to 20 minutes, after 6 weeks of treatment.
Initial STG: Improve AROM 0-90 degrees flexion and LE strength to 4/5 to allow for
ambulation 600 feet with normal cadence and control on smooth surfaces using single
tipped cane after two weeks Rx.
Interim STG: Full AROM and 4+/5 strength of quads to allow for ambulation of 1200
feet without assistive device on smooth surface after four weeks Rx.

Plan of Care

Need to include specific information;


Frequency (i.e. 2 X week)
Amount of treatment (i.e. duration = 6 weeks)
Time Required (30 minutes)
Delegation of Rx (PT or PTA)
Any equipment and specifications of how equipment will be used (i.e. with US continuous, at 1.8
w/cm2 X 10 minutes with 3 Mhz 2 inch sound-head)
Type of Rx: (i.e. exercise, gait training, massage, stretching, etc)
Treatment progression (break Rx into acute, sub-acute and return to function phases)
Referral to others (i.e. OT, Speech, Podiatry, etc.)
Education (i.e. safety, posture)
Self management (i.e. use of ice after exercise, HEP)
724 Joint Surgery and Postoperative Management

TABLE 20.3 Features of Traditional (Conventional) Surgical Approaches for THA and Potential Impact
on Postoperative Function
Involvement of Hip Muscles Impact on Postoperative
Surgical Approach and Other Soft Tissues Function

Posterior or Posterolateral34,39,54,66,75,96,97

Gluteus maximus divided in line with Possible earlier recovery of a


its fibers with a posterior approach normal gait pattern because
Interval between the gluteus gluteus medius and TFL left
maximus and medius divided in a intact
posterolateral approach Highest risk of dislocation or

Short external rotators and piriformis subluxation of prosthetic hip


released and repaired
Gluteus maximus tendon possibly

released from femur; repaired at


conclusion
Posterior capsule incised and repaired

Gluteus medius and TFL left intact

Direct Lateral34, 54

Longitudinal division of the TFL Weakness of the hip abductors


Release of up to one-half of the Possible pelvic obliquity
proximal insertion of the gluteus Delayed recovery of

medius and minimus; reattached symmetrical gait


prior to closure
Longitudinal splitting of the vastus

lateralis
Capsulotomy and repair

Anterolateral34,54,66,81,89

Incision centered over the greater Weakness of the hip abductors


trochanter and lateral to the TFL Delayed recovery of gait
Anterior one-third of the gluteus symmetry
medius and minimus and sometimes Lower incidence of hip

the vastus lateralis released; dislocation than posterior


reattached prior to closure approach
External rotators usually remain intact

Anterior capsulotomy and repair

Direct Anterior34,54,81

Incision made anterior and distal to Weight bearing as tolerated


the ASIS, slightly anterior to the greater immediately after surgery
trochanter, and medial to the TFL More rapid recovery of hip

No muscles incised or detached, but muscle strength and normal


rectus femoris and sartorius retracted gait pattern compared with
medially to access the joint anterolateral approach
Anterior capsulotomy and repair

Transtrochanteric34,54,66

Osteotomy of the greater trochanter Extended period of nonweight


at the insertion of the gluteus bearing on the operated
medius and minimus extremity
Anterior capsulotomy and Necessity for abduction

dislocation precautions
Greater trochanter reattached Possible pain due to irritation

and wired in place prior to of soft tissues from internal


closure fixation device

ASIS=anterior superior iliac spine; TFL= tensor fasciae latae


History Algorithm for the Dizzy Patient
The following algorithm is designed to be a basic guide in the taking of a history from a dizzy patient. First the dizzy patient must have their
chief complaint specified into: vertigo (true spinning), light headed (sense of feeling faint, or passing out), or imbalanced (unsteady or tipsy). A
few of the most common diagnostic criteria are then provided to differentiate conditions. Finally the most common conditions are found at the end
of each branch. This is not a substitution for a thorough history and exam.
-Orthostatic hypotension
Orthostatic changes -dehydration
of position -adverse effect of cardio-vascular medication
-cardiac dysfunction
Lightheaded
Spontaneous -Arrhythmia -Labryinthitis
yes
Hearing Loss
no
Preceding -Vestibular neuronitis
no
spontaneous -Anterior vestibular artery stroke
vertiginous episode yes
Associated dysarthria,
Head motion
diplopia, headache,
induced
no
limb discoordination
yes
-Consider CNS
Imbalanced -Bilateral vestibular loss disorder
Persistent with -Acoustic neuroma
gait/station
Review of Consider non-vestibular cause:
Positional systems screen -cerebellar
Complaints -sensory loss (neuropathy, vision loss)
-weakness
Continued on page 2
Created by Colin OBrien SPT University of Wisconsin with advisement from Jeff Walter PT, DPT, NCS 1
History Algorithm for the Dizzy Patient
Cont. from page 1 -BPPV (canalithiasis)
<1 min -Migraine variant dizziness
duration/episode -Vestibular paroxysmia
-Phobic positional vertigo
Positional
-Vestibular paroxysmia
Complaints
>1 min -Migraine variant dizziness
duration/episode -BPPV (cupulolithiasis)
-Phobic positional vertigo
Persistent Non-otologic in nature
>1 week
Vertigo
yes Recurrent Menieres disease
Hearing Loss
Spontaneous
Single Episode Labryinthitis
no
Hour(s)- -Vestibular neuronitis
Day(s) -Anterior vestibular artery stroke
Preceding history of migraine headaches and
associated light, sound, odor sensitivity with yes
Minutes/Seconds vertigo -Migraine variant dizziness
no
-TIA/Stroke
Induced by -Superior canal dehiscence
Sound and/or -Perilymphatic fistula
Pressure
Created by Colin OBrien SPT University of Wisconsin with advisement from Jeff Walter PT, DPT, NCS 2
BPPV Flowchart < minute Right posterior Modified Epley Brandt Exercises
(History suggestive of positional vertigo) canal canalithiasis or Semont if Epley/Semont is ineffective,
(common) consider canal plugging if
Upbeating unresponsive to maneuvers
Positive: Right > minute Right posterior Ipsilateral > 6 months
torsional nystagmus canal cupulolithiasis Brandt or Semont
(rare)
< minute Right anterior Contralateral
Downbeating canal canalithiasis Deep Hallpike
(rare) to rapid sit?
Hallpike or Sidelying Positive: > minute Right anterior canal
test 1)Pure upbeating cupulolithiasis Brandt protocol or
2)Pure downbeating Likely Central (rare) or Semont with head rotated ipsilateral
3)Pure torsion Central
Mixed horizontal/ Unilateral peripheral vestibular
torsional nystagmus hypofunction?
Left posterior Modified Epley Brandt Exercises
Negative or < minute canal canalithiasis or Semont if Epley/Semont is ineffective,
Horizontal nystagmus Upbeating (common) consider canal plugging if
unresponsive to maneuvers
> minute Left posterior canal Ipsilateral > 6 months
cupulolithiasis (rare) Brandt?
Positive: Left
torsional nystagmus Contralateral
< minute Left anterior canal Deep Hallpike
canalithiasis (rare) to rapid sit?
Downbeating
> minute Left anterior
canal cupulolithiasis Brandt Daroff or
(rare) or central Semont with nose head rotated ipsilateral
from page #2
< minute Horizontal canal Gufoni's a
canalithiasis [Symptoms Maneuver
more severe to affected side] (Appiani 2001)
(Common) or
Geotropic 270 degree roll
nystagmus maneuver
Conversion to
geotropic
nystagmus
> minute Central,?
Not BPPV
Gufoni's b
Roll test Positive Ageotropic variant, Maneuver
Horizontal canal (Appiani 2005)
< minute canalithiasis [Symptoms
more intense to unaffected
side] Yes
Ageotropic
nystagmus Ageotropic nystagmus
Negative < minute
1) No BPPV Horizontal canal No
2) Inactive BPPV cupulolithiasis
[Symptoms more intense
to unaffected side, null
> minute point with head positioned
10 degrees to affected side Rapid sidelying
with roll test] to the affected
or ear with head
central tilted forward
Log Symptom Response to Brandt Daroff 20 degrees
or refer back to MD
MS lab - elbow, wrist, and hand: goni, MMT, joint mobs,
special tests
Study online at quizlet.com/_3av0dw

1. elbow special test: median nerve test: 2. elbow special test: radial nerve test:

patient supine
patient supine
therapist depresses Pt shoulder girdle, slightly abducts
shoulder, extends elbow, laterally rotates arm, and supinates therapist depresses Pt shoulder girdle, slightly abducts
forearm shoulder, extends elbow, medially rotates arm, pronates
forearm
add: wrist, finger, thumb extension
add: wrist, finger, thumb flexion
add: more shoulder abduction
add: ulnar deviation of wrist
add: contralateral cervical lateral flexion
add: contralateral cervical lateral flexion
shoulder: depress, abduct
elbow: extend, ER, supinate shoulder: depress, abduct
wrist, finger, thumb EXT elbow: extend, IR, pronate
CL cervical LAT FLEXION wrist, finger, thumb FLEX
CL cervical LAT FLEXION
3. elbow special test: ulnar nerve test:

to detect tension along ulnar n

patient supine

therapist extends Pt wrist and fingers, supinates forearm, fully flexes elbow

add: shoulder girdle depression

add: shoulder lateral rotation and abduction so Pt hand is near ear with fingers pointing posteriorly (like waiter carrying heavy tray)

add: contralateral cervical lateral flexion

make the tray


tray in front of anterior delt
depress
tray at middle delt
tray at ear
CL cervical LAT FLEXION
Special test Test motion Positive finding =
Cause of PIP flexion limitation:

-ED: PIP remains limited in flexion with MCP flexed / less limitation
with MCP extended
Passively flex and extend MCP joint, check
Bunnel-Lettler Test
ROM of PIP flexion -Intrinsics: PIP remains limited in flexion with MCP extended / less
limitation with MCP flexed

-Joint capsule OR all of the above: no change in PIP limited flexion


with extension/flexion of MCP
Cause of DIP flexion limitation:

-ED: DIP remains limited in flexion with PIP flexed / less limitation
with PIP extended
Passively flex and extend PIP joint, check
Wrist and Hand Special Tests

Retinacular Test
ROM of DIP flexion -Retinacular: DIP remains limited in flexion with PIP extended / less
limitation with PIP flexed

-Joint capsule OR all of the above: no change in DIP limited flexion


with extension/flexion of PIP
Reproduction of symptoms, such as tingling in median distribution
Flex patient's wrist to full ROM and hold for 1+
Phalen's Test
minute
Carpal tunnel syndrome
Pt makes fist with thumb tucked inside
Sharp pain in area of 1st extensor tunnel (APL, EPB)
Finkelstein Test
Stabilize forearm and passively ulnarlly deviate
De Quervain's disease/stenosing tenosynovitis
wrist
Pt opens and closes first quickly several times,
then squeezes first tightly and holds
Hand does not regain color, or regains color slowly
Allen Test Occlude radial and ulnar artery
Complete or partial occlusion of artery
Release pressure one of the two arteries, then
repeat test on other one
Unable to touch fingers together
Fingers extended, pt attempts to adduct 5th
Wartenberg's Sign
digit towards 4th Ulnar nerve injury: extensor digiti minimi unopposed by palmar
interossei and FDP
IP joint of thumb flexes
Pt actively laterally pinches thumb and index
Froment's Sign
finger Ulnar nerve injury: adductor pollicis and 1st dorsal interossei weak,
substituted with FPL
Test: Purpose: Indications: Procedure:

Tight rectus: knee moves into


extension or knee is flexed and
hip extension is limited supine, with pelvis level and
Tight sartorius: hip will move square to trunk, the pt brings
Detects flexion contractures of
Thomas Test into abduction and knee flexion his thigh to their trunk and
the hip and evaluate hip ROM
Tight TFL: hip moves into allow contralateral leg to hang
abduction and medial rotation off table.
Tight adductors: hip moves into
adduction

side lying with involved leg on


top. Abduct leg as far as
Detects contractures of the IT If the TFL or IT band is tight, the possible and flex the knee to 90
Ober Test
band or TFL thigh will remain abducted degrees while keeping hip in
neutral position to relax IT tract
then release the abducted leg.
HIP Special Tests

standing behind the pt, observe


Evaluates strength of the If contralateral hip drops there dimples over posterior superior
Trendelenburg Test
gluteus medius is glut med pathology iliac spine. Ask pt to stand on
one leg
if straight leg raising is painful:
Determines if cause of back and supine, lift leg upward and
hamstring pain and all the way
Straight Leg Raise test leg pain is from the sciatic support pt calcaneus, while
down thigh indicates scatic
nerve/spinal cord knee is straight.
pain.

used to detect shortening of the less than 70 degrees indicates prone, flex hip and then extend
Distal hamstring test
hamstring muscles hamstring tightness knee to measure knee ROM
determines shortening of the knee should measure at least
Elys test prone, flex knee
rectus femoris 135 degrees
supine, with hip flexed and
detects pathology of hip or SI
pain indicates hip or SI abducted and externally
Patrick/ Faber test joint depending on location of
pathology rotated, press on ASIS and
pain
flexed knee
holding pts knee in flexion, flex
pain, apprehension, crepitus, or
and adduct hip toward opposite
detects irregularities of the catching sensation indicates hip
shoulder and apply axial
Scouring Test femoral head and or impingement, labral tear or
compression along thigh while
acetabulum. acetabular/femoral head
slowly externally/internally
abnormalities
rotating the hip.
Test: Purpose: Indications: Procedure:
stabilize sup border and have pt
Patella Grind Test Observe crepitations, roughness, or pain subpatellar pathology
contract quads
move patella lat and look for
Apprehension test if you suspect common dislocation may indicate risk of dislocation
apprehension
push down on knee cap for minor
joint major and minor effusion To look for fluid under patella effusion, major or minor
and from sides for major
compress along long axis of tibia
apleys compression To look for med/lat pain menisucs tears
with medial and lateral rotation

distract on long axis of tiboia with


apleys distraction look for med or lat pain ligament damage
med/lat rotation, look for pain

Medial: apply valgus stress to knee


and externally rotate while
extending the knee from full flexion.
McMurray Test pain with valgus or varus stress medial or lateral meniscus damage
Lateral: apply varus stress to knee
and internally rotate while
extending the knee from full flexion
Knee Special Tests

Lat/med glide: distance from center


of patella to med/lat condyle
lat/med tilt: compare lat/med
borders of patella
McConnell Eval of Patella To evaluate patella orientation Will show malpositioning of patella
ER/IR: compare angle of patella and
femur (usually 5) to spot bw asis and
greater trochanter.
AP Tilt: compare sup/inf borders

Varus stress test To evaluate the functionoing of the lateral in supine, with knee fully extended,
may indicate damage to lat capsule,
knee structures (lat capsule, ligaments, place hand on medial joint line and
Varus stress test in 25-30 flexion ligaments or PCL
PCL) --> hamstrings relaxed with flexoin pts ankle, apply varus stress -->
in supine, with knee fully extended,
Valgus stress test in full extension To evaluate medial joint structures (MCL,
May indicate damage to MCL, medial place hand on medial joint line and
medial capsule, PCL) --> hamstrings
capsule or PCL pts ankle, apply varus stress -->
relaxed with flexion
Valgus stress test in 25-30 flexion compare to other knee and see
supine with hip flexed to 45
degrees, knees flexed at 90 and feet
To evaluate stability of knee joint and flat on table, sit on pts foot (on edge
structures (PCL, oblique popliteal, arcuate May indicate damage to pcl, oblique to stabilize) and push tibia
Posterior drawer test popliteal) popliteal, arcuate popliteal posteriorly
pt supine, with knee flexed at 20
degrees, place hand around distal
femur above condyle and other
hand around proximal tibia just
evaluate stability of knee joint and below tib plateau and move tibia
Lachmans test structures (ACL) may indicate ACL damage anteriorly
Test: Purpose: Indications: Procedure:

sitting on edge of table, knee


flexed to 90 degrees, place
one hand on the anterior
Anterior stability may indicate tear of anterior aspect of lower tibia and fibula
(anterior drawer sign) talofibular ligament to stabilize. Grasp posterior
calcaneus and talus with other
hand and apply anterior force,
compare to other side

To test stability of ankle pt on EOB, grasp calcaneus


Ankle Special Tests

May indicate tear to anterior and and place other hand around
Lateral stability test posterior talofibular and medial aspect of tibia, push
calcaneofibular ligaments the calcaneus and talus into a
varus position (inversion)

sitting on EOB, grasp


calcaneus in one hand and
Medial stability test May indicate deltoid ligament tear place other around lateral
aspect of fibula and tibia while
pushing into valgus (eversion)
may indicate DVT if pain deep in
Homans sign DVT passively dorsiflex the pts foot
calf
squeeze belly of gastroc soleus
for rupture of the achilles tendon
Thompsons test stability of ankle complex, normal is plantar
(if fooot does not plantarflex)
flexion of foot
may indicate impingment within tap fingers over medial aspect
Tinels sign tarsal tunnel syndrome th etarsal tunnel (if pain or of ankle where tibial nerve I
tingling) smost superficial