The Patient-Client Management Model has five components: examination, evaluation, diagnosis, prognosis, and intervention. The end result of this model is effective outcomes.

Examination is the first step of the process. It has three parts: the history, systems review, and tests and measures. The examination should be thorough and use all sources, including the patient, family, medical record, and other health care professionals. The history is an account of past and current health status. It is used to identify health risk factors, health needs, and coexisting health problems. An initial diagnosis is also determined based on the information gleaned from the history. The systems review and tests and measures are then used to rule in or out the initial diagnosis.

A systems review is a very brief, limited exam designed to give you information concerning the general health of the patient; it helps in formulating a diagnosis and prognosis. This is a general screening that should be done as part of every patient’s routine exam. It increases the emphasis on managing the whole person. For an autonomous practitioner, this is the key to good patient care. There are five categories: musculoskeletal, neuromuscular, cardiopulmonary, integumentary, and communication.

The appropriate test and measure is chosen based on the results of the history and systems review. For example, the patient is a 21-year-old male college student who comes into the clinic with the complaint of a painful ankle. If he indicates a particular traumatic incident during the history, you would assume he has a sprained ankle and do anthropometric measurements to assess swelling, joint integrity tests to assess ligamentous integrity, range-of-motion measurement, and gait assessment. If the results of these tests and measures are positive, then a sprained ankle is a reasonable diagnosis. However, if the patient has had no trauma and cannot indicate any activity that would have triggered pain that caused him to seek medical attention, then other diagnoses must be considered. For instance, a history of multiple joint pain and inflammation, and/or a history of recent urinary tract infections and conjunctivitis, may indicate a systemic condition such as Reiter’s syndrome or other rheumatoid diseases. In that case, anthropometric measures, integumentary integrity, joint integrity, range of motion, and gait will all be important to consider before referring back to a physician. A history of an old ankle injury may point toward structural or postural issues that must be carefully examined.

The critical thinking and decision making that follows the examination process is known as the evaluation. It is the most important part of the process, because it leads directly to determination of the diagnosis. Using all the data—including clinical findings, loss of function, social considerations, chronicity of the problem, and patient’s overall health status—the clinician formulates an impression. In the case of the 21-year-old college student, the history of an injury followed by the positive ankle swelling, positive anterior drawer test, decreased range of motion, and antalgic gait all led me to believe that this young man sprained his anterior talofibular ligament.

A diagnosis is a label based on a cluster of signs and symptoms after the collection, organization, and interpretation of information reached through the evaluation process. For the physical therapist, these are generally movement-related impairments or functional limitations. Sometimes, as in the case of the patient with the ankle sprain, the diagnosis is at the pathology level.

Diagnosis by the physical therapist is the key to good intervention planning. The medical diagnosis is often not usefuL. For instance, your patient is a 32-year-old female with a referral that states “chondromalacia patella—evaluate and treat.” As physical therapists, we are not going to treat the actual softening of the cartilage, the pathology of chondromalacia patella. Surgery is generally required to accomplish that. Therefore, that leaves us to explore the multiple possible movement dysfunctions that may be ultimately causing the chondromalacia patella. Only once we discover the key impairment(s) will we know how to organize our treatment approach. Not all patients with chondromalacia patella are treated the same. If the key impairment is muscle weakness of the quadriceps, then the program emphasizes muscle performance. If the patella is not tracking properly because of structural issues, then patella taping may be in order. The mechanics at the foot should be explored, because excessive subtalar and midtarsal joint pronation during gait can increase the torsional forces on the patella femoral joint, causing pain. Treatment in that case would be proper footwear and even orthoses. All of these patients may have an appropriate medical diagnosis of chondromalacia patella, but all require a more specific movement diagnosis for determining the plan of care.

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