EXAMINATION

By Carolyn Kisner PT, MS and Lynn Allen Colby PT, MS on January 28th 2009

Examination is the evaluation of the patient with pulmonary dysfunction and determination of a diagnosis, prognosis, and intervention plan are based on the findings derived from a comprehensive examination, including a history, systems review, and specific tests and measures.

Components of the Examination

A comprehensive examination of a patient with known or suspected dysfunction related to primary and secondary pulmonary or chest disorders has many elements. The examination procedures described in this section are those often used by a therapist during an initial evaluation to establish a therapy-related diagnosis or during subsequent assessments for modification of therapeutic interventions. Additional examination procedures not described in this section but integral to the management of a patient with pulmonary dysfunction are radiography, evaluation of blood gases, tomography, bronchoscopy, and hematological tests.

History and Systems Review

The examination process begins with a patient’s history including an interview with the patient and sometimes family members if they are available. During the interview a therapist can identify a patient’s and/or family members’ perception of any functional limitations or disabilities and determine a patient’s chief complaints and why he or she is seeking treatment. In preparation for the interview, the medical history and any medical diagnoses are obtained from the patient’s medical record, if available, or more generally, from the patient or family. Relevant occupational and social history are obtained; particularly important are on-the-job physical demands, the environment of the workplace, and social habits that affect a person’s well-being, such as tobacco or alcohol use. Assessment of the home or family environment might include a patient’s family responsibilities, the housing situation, and available family support systems. A brief systems review should follow the history.

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Tags: Evaluation, Examination, Respiratory

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