Name Sajjad Ahamd
Class DPT 10th
Subject SCP
Submitted to Dr Samara.
What is clinical reasoning?
Clinical reasoning is a complex cognitive process that is essential to evaluate and manage a
patient’s medical problem. Clinical Reasoning is the process by which a therapist interacts with
a patient, collecting information, generating and testing hypotheses, and determining optimal
diagnosis and treatment based on the information obtained. It has been defined as “an
inferential process used by
practitioners to collect and evaluate data and to make judgments about the diagnosis and
management of patient problems.
1. It includes the diagnosis of the patient problem, making a therapeutic decision and
estimating the prognosis for the patient.
2. In describing the importance of clinical reasoning, it has been acknowledged that clinical
reasoning is the central part of physician competence.
3. And stands at the heart of the clinical practice.
4. It has an important role in physicians’ abilities to make diagnoses and decisions
5. Clinical reasoning has been the subject of academic and scientific research for decades
Clinical decision making:
Clinical decision-making (CDM) is a contextual, continuous and evolving process where data is
gathered, interpreted and evaluated to select an evidence-based action.
● The CDM process is a highly complex, multi-faceted skill that is developmental in nature
and requires a substantial amount of practice with realistic patients to develop” i.e.
learnt behaviour.
● The understanding of CDM is still evolving and is largely based on research in
psychology, medicine and nursing.
● It involves multiple types of reasoning.
Clinical decision making has three integrated phases:
(1) diagnosis
(2) assessment of severity
(3) management.
What is ICF model?
The International Classification of Functioning, Disability and Health (ICF) is a framework for
describing and
organising information on functioning and disability. It provides a standard language and a
conceptual basis
for the definition and measurement of health and disability.
The ICF was approved for use by the World Health Assembly in 2001, after extensive testing
across the
world involving people with disabilities and people from a range of relevant disciplines
Aims
The ICF is a multipurpose classification system designed to serve various disciplines and sectors
for
example in education and transportation as well as in health and community services and
across
different countries and cultures.
The aims of the ICF are to:
● provide a scientific basis for understanding and studying health and health-related
states, outcomes,
determinants, and changes in health status and functioning;
● establish a common language for describing health and health-related states in order to
improve
communication between different users, such as health care workers, researchers, policy-
makers
and the public, including people with disabilities;
• permit comparison of data across countries, health care disciplines, services and time; and
• provide a systematic coding scheme for health information systems.
Assessment form
DEPARTMENT OF PHYSICAL THERAPY & REHABILITATION
Name: M.ali S/D/O: M.Ahmad
Age: 33 Gender: Male.
Marital status: Married Language: Urdu
Occupation: Housewife Address: Gulshan Ravi
Mode of Admission: OPD Date of Admission: 8/June/23
Medical Diagnosis:
Hypotention
History of present illness:
Patient comes up in fainting conditions followed by sweating
Past medical history:
Surgeries
Family history:
Mother have HTN positive
ADL deficiencies:
N/A
Posture:
Lying
Sitting
Standing
Pain:
Onset
Type/Frequency of Pain: Constant Intermittent Other
Nature Aching Burning Cramping Crushing Dull Numbness Pins & Needles
Sharp Shooting Throbbing Other, describe :
Radiating
Aggravating factor
Relieving factor
Severity (VAS)
Associated symptoms
Inspection:
Swelling Erythema Joint Deformity Muscle wasting
ON PALPATION: Temperature Tenderness Edema Inflammatory sign
Muscle wasting Contractures Crepitations
ON EXAMINATION
Range of movement
o Active
o Passive
Joint Effusion measurement
Muscle girth
Limb length
End feel:
Capsular
Non-capsular
MMT:
NORMAL
Specialized test:
Gait assessment
Neurological test
Dermatomes
Myotomes
Reflexes
Lab Test:
Blood test
X-ray
CT scan
MRI
Management:
Short Term Goals:
1. maintain blood pressure
2.
3.
Long Term Goals:
1. diet planning
2.managmemt to control BP
3.
Intervention:
N/A
Home plan:
Patient advised to take good care of diet, and maintain blood pressure, exercise daily.______________
___________________________________________________________________________.
Name of the Student:Sajjad ahmad
Registration No: 060285
Program: DPT
Signature of student:sajj
Supervisor’s Signature___________.
