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Level 1
blank template:
LEVEL 1
Diagnosis:
What condition produces a patient’s symptoms?
An injury was most likely sustained to which structure?
Inference:
What is the most likely contributing factor in the development of this condition?
Confirmation:
What is the most likely clinical presentation?
What laboratory or imaging studies would confirm the diagnosis?
What additional information should be obtained to confirm the diagnosis?
Examination:
What history should be documented?
Important areas to explore include past medical history, medications, family history, current symptoms, current health status, social history and habits, occupation, leisure activities, and social support system.
What tests/measures are most appropriate?
Aerobic capacity and endurance: assessment of vital signs at rest and with activity, perceived exertion scale, pulse oximetry, auscultation of the lungs
Anthropometric characteristics: circumferential measurements
Arousal, attention, and cognition: examine mental status, learning ability, memory and motivation, level of consciousness
Assistive and adaptive devices: analysis of components and safety of a device
Community and work integration: analysis of community, work, and leisure activities
Cranial nerve integrity: assessment of muscle innervation by the cranial nerves, dermatome assessment
Environmental, home, and work barriers: analysis of current and potential barriers or hazards
Ergonomics and body mechanics: analysis of dexterity and coordination
Gait, locomotion, and balance: static and dynamic balance in sitting and standing, safety during gait with/without an assistive device, Berg Functional Balance Scale, Tinetti Performance Oriented Mobility Assessment, Functional Ambulation Profile, analysis of wheelchair management
Integumentary integrity: skin assessment, assessment of sensation
Joint integrity and mobility: assessment of hyper- and hypomobility of a joint, soft tissue swelling and inflammation, assessment of sprain
Motor function: equilibrium and righting reactions, motor assessment scales, coordination, posture and balance in sitting, assessment of sensorimotor integration, physical performance scales
Muscle performance: strength assessment, muscle tone assessment
Neuromotor development and sensory integration: analysis of reflex movement patterns, assessment of involuntary movements, sensory integration tests, gross and fine motor skills
Orthotic, protective, and supportive devices: analysis of components of a device, analysis of movement while wearing a device
Pain: pain perception assessment scale, visual analog scale, assessment of muscle soreness
Posture: analysis of resting and dynamic posture
Prosthetic requirements: analysis and safety of the prosthesis, assessment of alignment, efficiency, and fit of the prosthesis, assessment of residual limb with use of the prosthesis
Range of motion: active and passive range of motion
Reflex integrity: assessment of deep tendon and pathological reflexes (e.g., Babinski, ATNR)
Self-care and home management: assessment of functional capacity, Functional Independence Measure (FIM), Barthel ADL Index, Rankin Scale
Sensory integrity: assessment of proprioception and kinesthesia
Ventilation, respiration, and circulation: assessment of cough and clearance of secretions, breathing patterns, respiratory muscle strength, accessory muscle utilization and vital capacity, perceived exertion scale, pulse oximetry, palpation of pulses, pulmonary function testing, auscultation of the lungs and heart
What additional findings are likely with this patient?
Management:
What is the most effective management of this patient?
What home care regimen should be recommended?
Outcome:
What is the likely outcome of a course in physical therapy?
What are the long-term effects of the patient’s condition?
Comparison:
What are the distinguishing characteristics of a similar condition?
Clinical Scenarios:
Scenario One
Scenario Two
*Adapted from the Academy of Specialty Boards of Physical Therapy