Documenting the Assessment: Summary and Diagnosis

Dr. S M ALI ZAIDI

Assistant Professor
University Institute of Physical Therapy
University of Lahore
Diagnosis

Diagnosis as a process
 Investigation or analysis of the cause/ problem

Diagnosis as a Product
 is a statement or conclusion from such an analysis

Diagnosis – The Process

 Inductive methods
 Hypothetico-deductive methods
 Pattern recognition methods

Inductive methods
 Inductive reasoning
The process of deriving general principles from specific facts or instances
Clinician infers diagnosis from specific signs and symptoms

Hypothetico-deductive methods
 Deductive reasoning
A conclusion follows necessarily from stated premises, inferring specific instances from general
principles
Hypothesis
A tentative explanation, a conclusion taken to be true for the sake of argument or
investigation, an assumption
  Clinician tests whether deduced signs or symptoms are actually present

Pattern recognition methods

 Associative memory
Learned knowledge and experience with other patients

The Process for Physical Therapists to Develop a Diagnosis

Participation (or Potential Disability)

 Identify disability or potential disability

Activity Limitations
 Identify functional problems – critical functional activities

Impairments in Body Structures and Functions

 Identify causes of the functional problems
 and contributing factors

Health Condition

 Identify clarifications of medical diagnosis, recovery stage, and requirements for

prevention
Three Components of the Assessment

 Summary statement
 Diagnosis
 Potential to benefit from physical therapy

PHYSICAL THERAPY DIAGNOSTIC SYSTEMS

Muskuloskeletal

 Prevention of demineralization
 Impaired posture
 Impaired muscle performance
 Impaired connective tissue
 Localized inflammation
 Spinal disorders
 Fracture
 Joint Arthoplasty
 Bone/tissue surgery
 Amputation
Neuromuscular
Falls: Prevention
Impaired neuromotor development
Nonprogressive CNS—congenital
Nonprogressive CNS—adult
Progressive CNS
Peripheral nerve injury
Acute/chronic polyneuropathy
Nonprogressive spinal cord
Coma

Cardiovascular Pulmonary
Prevention of CP disorders
Deconditioning
Impaired airway clearance
Impaired CV pump
Impaired ventilatory pump
Respiratory failure—adult
Respiratory failure—neonate
Impaired lymph

Integumentary

Prevention of integumentary disorders

Prevention of superficial skin disorders
Partial-thickness scar
Full-thickness star
Impaired bone, fascia, and muscle

Examples of Diagnosis by Physical Therapist

COPD TO EMPHYSEMA WITH ACUTE PNEUMONIA
Acute: impaired coughing ability resulting in inadequate clearance of airway secretions with
potential for fluid accumulation in lungs and infection

chronic: impaired expiratory control resulting in poor endurance during upper extremity
functional activities, esp. dressing

S/P Medial meniscal tear R knee

Acute: joint effusion, pain, and limitation in RoM of right knee resulting in potential muscle
atrophy and prolongation of healing

chronic: pain and limitation of RoM of right knee, knee extensor weakness resulting in difficulty
in walking and climbing stairs.
s/p of THR in RLE secondary to Osteoarthritis
Acute: general weakness; decreased transfer and walking skills with immediate risk of
complications due to inadequate mobilization

chronic: longstanding limitation in hip RoM and strength; habitual trendelenburg-type gait
deviation with resulting poor endurance and limited maneuverability in walking.

L MCA Stroke
Left-sided stroke with 1° impairment of residual force production deficit resulting in impaired
mobility and standing balance

R Shoulder pain, Supraspinatus Tendinosis

 Pain
 RoM
 Impingement
 Crepitus
 Overhead Acitivities and Difficulty in Sleeping

LBP with L4-L5 Disc herniation

L4-5 hypermobility with hip joint hypomobility; exacerbation of pain symptoms with flexion
movements;

muscle spasms and pain limit patient’s sitting tolerance and prevent patient from working in full
capacity.

treatment-based classification:
extension syndrome.
Common pitfalls in assessment Documentation
WRONG
 Pt. has decrease strength and ROM, which is leading to limitations in ADL.
RIGHT
 Weakness in knee and hip extensors and limitation in hip extension PROM prevent Pt.
from being able to perform bed mobility and transfers independently
RIGHT
 Pt. requires 6-8 sessions of strengthening exercises and functional training to become
sufficiently skilled in transfers and self-care to function independently at home
RIGHT
 Pt. is no longer showing improvement in walking velocity and will therefore not benefit
from further therapy related to this functional goal.

Case 1: Outpatient
 59 y.o. man, s/p R THR 2° to osteoarthritis, 3 wk previous. Pt. past acute stage; no
significant pain or swelling; incision well healed.

 PARTICIPATION: Sales representative, travels by car, unable to work since surgery

 ACTIVITY LIMITATIONS: Needs assist for transfers into car, walks slowly with walker, up
to 100 ft at a time, needs assist on steps.

 IMPAIRMENTS: Weakness in R hip flexors, abductors, and extensors; habitual gait

deviations from preop antalgic gait. R hip √ and abduction ROM limited.
Case 2: Outpatient
 43 y.o. female with MS diagnosed 3 yr previous; recovering from recent exacerbation.

 PARTICIPATION: Clerical worker in major downtown office building; rides train and bus
to work; resists using cane. Pt. is fearful of falling during commute and needs extra time
during commute.

 ACTIVITY LIMITATIONS: Requires assist to go up and down steps; walks slowly; walking
difficulties exacerbated in crowded places.

 IMPAIRMENTS: Only DECREASED weakness; standing balance easily disturbed, esp.

when patient is distracted