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142 Cards in this Set
- Front
- Back
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Purpose of History Taking
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Begins the Diagnostic Process
Helps determine the source of the patient’s problem Guides the future physical examination and treatment Helps determine the prognosis for the patient Establishes possible aggravating/mitigating factors Helps determine if PT is appropriate or not |
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Definition of yellow flags
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A cautionary or warning symptom or sign that signals “slow down” and think about the need or direction for further screening, examination and/or treatment.
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Definition of red flags
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A symptom or sign that requires immediate attention to either pursue further screening or examination or to alter and possibly halt treatment and make an appropriate referral.
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Obstacles to history taking
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44 million Americans are illiterate
Another 35 million are functionally illiterate Even more individuals are health information illiterate Compounded by the number of individuals where English is a second language Complicated by: Cultural Differences Communication styles Health beliefs and behaviors Fear/anxiety - hard to focus/understand, more earwax, repetition is important Sometimes people will tell you too much, others too little Terminology - "leaders" = tendons |
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Good history taking "Do's"
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Do’s
Be prepared Use a private area Use forms when possible Sit-down if possible Limit interruptions Start with open-ended questions Ask 1 question at a time Listen (Let the patient finish) Consider patient’s level of understanding Repeat/Re-state information Encourage patient to ask questions |
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Good history taking "don't's"
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Don’t’s
Don’t forget that communication is also through facial expressions Don’t be in a hurry Don’t ask “leading” questions Don’t jump to premature conclusions Don’t interrupt or take over the conversation Don’t use professional or medical jargon Don’t overreact to their answers |
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components of PT examination
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History
-Personal and Family Medical History -Core Interview -Influencing Factors Review of Systems Review Available Medical Diagnostic Tests Physical Examination |
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Components and methods of Health History and Health Risk Assessment
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Components:
Family/Personal History The Core Interview Influencing Factors Review of Systems Methods: History Medical Chart Patient Intake Form Paper and Pencil Tests Personal Interviews Patient Family Friends |
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Components of a Family/Personal History
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Demographics:
Age Gender Weight (BMI) Race and Ethnicity Level of Education General Health Past Medical and Surgical History Work and living environment (Social History) |
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Family/Personal History: Age
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> 55 years is an automatic “yellow” flag
Most common primary risk factor for: Disease, Falls, and Medication reactions Most Common Symptoms of the Elderly: Acute confusion Depression Falling Incontinence Syncope “old people are sick because they are sick, not because they are old” |
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Family/Personal History: Gender
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Risk factors for health/disease between genders is usually the same. An exception is the effects of alcohol consumption.
Women drink less, but progress more rapidly to dependency (“telescoping”). Women are are less susceptible to alcohol’s sedative effect, but are more susceptible to alcohol’s neurotoxic effects more likely to develop cirrhosis of the liver |
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Family/Personal History: General Health
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Self-assessed health is a strong predictor of mortality and morbidity
Those who rate their health as “Poor” are 4-5 times more likely to die vs. those with an “Excellent” rating Associated with poor surgical outcomes A “Poor” rating is a Red Flag Any “Yes” response related to a history of cancer requires follow-up and possible physician referral |
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Any “Yes” answer in this section warrants:
Further questioning Correlation with objective findings Consideration of referral to the client’s physician |
Any “Yes” answer in this section warrants:
Further questioning Correlation with objective findings Consideration of referral to the client’s physician (yellow flag) |
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Family/Personal History: Personal Medical History
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Previous Illnesses or Infections
Allergies Prior Injuries and/or Surgeries If there is a “Yes” answer, ask… Who in the Family? Age of Onset? Current Status? Outcome? Conditions of Interest: Hypertension Heart Disease Diabetes Cancer |
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Summary of family/personal history yellow flags:
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Yellow Flags:
Age > 55 years BMI > 30 Past Medical Conditions Past Surgeries Family History of Disease Recent (6 weeks) infection |
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Summary of family/personal history red flags:
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Red Flags:
“Poor” self health rating History of Cancer (personal or family) Recent trauma, especially falls in the elderly Minor trauma if older than 60 years Recurrent cyclic pattern of colds or flu Immunosuppression HIV, Steroid use, Organ transplant, etc. |
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Aspects of core interview
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History of Chief Complaint
Prior or ongoing treatment for complaint Medication for complaint Work and Living Environment Nutrition and Social Habits Psychological Issues Fitness and Sleep Habits |
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Core Interview: History of Chief Complaint
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Onset:
“Tell me why you are here today.” or “How did this injury or illness begin?” Systemic Disease = Gradual onset without known cause Location: “Show me exactly where your pain/symptoms are located.” Description: “What does it feel like?” Pattern: “Describe you pain/symptoms from first waking up in the morning to going to bed at night.” “Have you ever experienced anything like this before?” Frequency: “How often does the pain/symptoms occur?” Duration: “How long does the pain/symptom last?” Systemic Disease = Constant Figure out specific definition of "constant" = is it always the same level? Intensity: “How strong is your pain?” (0-10) Systemic Disease = Tends to be intense |
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Core Interview: Prior or ongoing treatment
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Medical Treatment?
“What medical treatment have you had for this condition?” Surgical Treatment? “Have you had any surgical procedures for this condition?” Other Treatment? “Have you seen other health practitioners for this condition?” Physical Therapy, Chiropractic, Other? Effectiveness? “How effective do you feel the treatment has been?” Red flag if there is no change in symptoms with treatment |
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Core Interview: Medication
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“Are you taking any prescription or over-the-counter medications?”
“How often?” How much? Change in Symptoms: “Have you noticed any change in your symptoms?” Red flag if no improvement in pain “Have you noticed any new symptoms?” Most Common Side Effects of Medication (4-Ds): Dizziness Drowsiness Depression Visual Disturbance |
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Most Common Side Effects of Medication (4-Ds):
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Most Common Side Effects of Medication (4-Ds):
Dizziness Drowsiness Depression Visual Disturbance |
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Family / Personal History: Work and Living Environment
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Occupation
Leisure Activities Living Environment Family/Social Support |
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Family / Personal History: Nutrition and Social Habits
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Better nutrition = better healing
more smoking = worse coffee/caffeine makes perception of pain greater (2 pts on VAS?) |
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Psychosocial Factors: Psychological Factors
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Fear/avoidance: worried it'll hurt, so don't do anything
catastrophizing: blow everything up there are paper/pencil tests for these aspects |
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Core Interview: Current Fitness and Sleep Habits
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what do they do? how often?
encourage, help, motivate health! Sometimes exercise is best possible treatment - fibromyalgia sleep is healing time |
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Core interview: final question
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“Is there anything else you think is important about your condition that we haven’t discussed yet?”
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% of Americans that suffer from either chronic or recurrent pain
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53% of Americans suffer from either chronic or recurrent pain.
25% of those 18-29 years 71% of those 65+ years Back pain is the most prevalent cause. It is the single biggest reason someone seeks medical care. |
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What's wrong with this definition of pain?
Pain is more or less a localized sensation of discomfort or agony resulting from the stimulation of specialized nerve endings |
Ignores the psychological aspect of pain
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Definition of pain with three aspects
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Pain is that sensory experience evoked by stimuli that injures or threatens to destroy tissue, defined introspectively by every person as that which “hurts”
Physiologically triggered Psychologically perceived Multidimensional in nature |
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Characteristics of Cutaneous pain
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Characteristics:
Superficial Well localized (Focal) May occur with both referred and deep somatic pain Dermatomes Pain felt over an area innervated by segmental areas of the spinal cord Myotomes Sclerotome |
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Characteristics of visceral pain
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Poorly Localized
Multisegmental innervation Site corresponds to the dermatome of the organ’s innervation Heart T1-5 Bronchi/Lung T2-4 Stomach T6-10 Gall Bladder T7-9 Spleen T6-10 Kidney T10-L1 Ureter T11-12 |
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Definition of referred pain
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Irritation of cutaneous, deep somatic or visceral structures
Pain experienced at a site other than the anatomical area that is stimulated Well localized, but NOT sharply defined borders in the referred area Muscle hypertonus over the referred area |
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Visceral Local and Referred Pain Patterns: Heart
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left shoulder and down left arm
(I think that pattern is more typical in men than women) |
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Visceral Local and Referred Pain Patterns: lungs and bronchi
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top of left shoulder, mid sternum, mid back
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Visceral Local and Referred Pain Patterns: stomach, pancreas, intestines
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upper right shoulder
patch at midline on front or back, higher or lower |
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Visceral Local and Referred Pain Patterns: gallbladder
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Right upper abdomen, scapula
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Visceral Local and Referred Pain Patterns: colon
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left lower abdomen, sacrum, suprapubic
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Visceral Local and Referred Pain Patterns: liver
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upper right shoulder
various spots below and medial to R scapula Upper R quadrant of abdomen |
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Visceral Local and Referred Pain Patterns: kidney, ureter, bladder
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left shoulder
band across low back left low back, wrapping around to front and down groin |
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Patterns of pain
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Pattern of Pain
Peripheral: peripheral Segmental: spinal nerve or root or vertebral segment Bilateral: spinal cord Hemilateral: brainstem or cortex Facial: trigeminal Perioral: brainstem or thalmus Stocking/glove: neurological, vascular, psycho |
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Potential sources for pain at rest
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Pain at Rest:
Neoplasms Compressive Neuropathies Tendon tears Burning or acute throbbing |
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Potential sources for pain with activity
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Activity Pain
Vascular Claudication Ischemic pain: sharp or dull Angina Typically 5-10 min post activity = visceral lesion During Activity = musculoskeletal problem |
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Potentially involved structures for diffuse/dull pain
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Diffuse - Dull
Visceral Structures Vertebral Disc Bone Tendon * Ligament * Fascia * Fat * Muscle * * Becomes sharp and localized with movement or palpation |
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Potentially involved structures for Localized - Sharp pain
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Localized - Sharp
Periosteum Skin |
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Potentially involved structures for Burning - Radiating pain
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Burning - Radiating
Nerve Fascia Skin Acute Inflammation |
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Arterial, Pleural, and Tracheal Pain
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Arterial, Pleural, and Tracheal Pain
Throbbing pain with increases in systolic pressure (e.g. exercise) Vascular headaches (migraines) Arteritis (inflammation of arteries) |
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Gastrointestinal Pain
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Gastrointestinal Pain
Increases with eating and peristaltic activity Exception is ulcers which are relieved with food |
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Methods of Pain assessment
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Simple Description
Pain Pattern Diagrams Frequency, Duration, and Intensity Standardized and Non-Standardized tests Aggravating /Relieving Factors |
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Pain pattern? Questions to ask to Gather information about current symptoms and if they have changed:
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Gather information about current symptoms and if they have changed:
Ever had this pain before? When does it hurt? What is the pain like during the course of the day? |
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Asking about frequency/duration of pain
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Constant
Intermittent? How Often? Word Descriptors: Continuous or Steady Constant or Brief Momentary or Transient Rhythmic Intermittent Periodic |
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Determining Intensity of pain
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Word Descriptors
Unidemensional Measures -Visual Analog Scale (VAS) Multidimensional Measures -McGill Pain Questionnaire (MPQ) |
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Common Characteristics of Chronic Pain
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Any pain that persists past the expected physiological time of healing
Multidimensional Pain out of proportion to lesion Behavioral changes: depression, anxiety, neuroses Poorly defined Emotional Overlay Secondary Gain |
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Aspects of patient's movement to observe
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Patient’s Movement
Facial Expressions Ease Willingness or avoidance Compensations Gait Transfers |
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Observation of Pallor could indicate
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Pallor (pale)
Anemia, Lead poisoning, Chronic bleeding |
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Observation of cyanosis could indicate
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Cyanosis (blue)
Cold exposure, Vasomotor instability, Poor circulation |
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Observation of yellow skin could indicate
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Jaundice (yellow)
Liver disease, Hepatitis, Gallstone |
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Observation of gray skin could indicate
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Gray
Increased iron or silver |
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Observation of brown (spots on?) skin could indicate
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Hyperpigmentation (brown)
Adrenal or pituitary problems |
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Observation of red skin could indicate
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Red
Local infection or inflammation Hyperemic |
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Observation of thin,shiny skin could indicate?
loss of hair? |
Thin, Shiny
Skin ischemia Loss of Hair Compromised circulation (diabetes) Rapid hair loss, or if does not begin in the frontoparietal scalp should cause concern |
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Follow-up questions for skin lesions
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“Can you tell me about this?”
“How long have you had this”? “Is your physician aware of this?” if so, “what did he/she say about it?” “Has it recently changed in terms of”: Size? Color? Shape or surface appearance? |
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Patient palpation
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Identification of areas of tenderness
Identification of anatomical structures involved Lumps or Masses Enlarged Thyroid Submandibular glands Local Lymph nodes Supraclavicular fossa Pancoast’s Tumor Infraclavicular fossa May appear as the absence of a notch or body concavity rather than a lump |
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Follow-up questions from palpation
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“Is it painful to palpate here?”
“Is this similar to the pain you have been having?” For Lumps or Masses: “Have you noticed this lump?” “Has a physician examined this area? If so, what did the physician say?” “Has the lump changed in terms of”: Size, Consistency, Shape or surface appearance? |
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Disorders of muscle
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Strains & Contusions
Myofascial Pain Fibromyalgia Polymyalgia Rheumatica |
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Disorders of Joints
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Sprains
Adhesive Capsulitis Subacromial Impingement Meniscal Tears Labral Tears Joint Hypermobility (Ehlers Danlos) |
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Signs and Symptoms of Strains, Tendonitis & Tendonosis
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Joint Hypomobility
Overuse / Overload / Overstretch Mechanism Acute or Chronic Onset Muscle Weakness and Spasm Swelling Pain on Isometric Contraction and Stretch Normal Joint Play Palpable Tenderness |
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Myofascial pain
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Regional pain disorder characterized by trigger points
Cause: Sudden overload or overstretch of muscle, contusion, postural faults, psychological stress or chronic repetitive or sustained muscle activity Clinical Manifestations: Taut muscle Palpable trigger points Absence of systemic signs |
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Myofascial pain syndrome
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Not the same as Fibromyalgia
Clinical entity vs pathological entity Signs and Symptoms: Painful Trigger Points Regional rather than widespread |
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Common features of trigger points
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Common Features:
Increased Metabolism Decreased Circulation Predictable and reproducible areas of referred symptoms Most common in postural muscles Irritability may vary over time |
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Trigger points are aggravated by
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Aggravated by:
Strenuous physical activity Quick passive stretch Prolonged activity in the same posture Cold drafts Viral infections Nervous tension |
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Trigger points are alleviated by
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Alleviated by:
Short periods of rest Slow passive stretch Light physical activity Heat / Cold |
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Etiology of trigger points
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Etiology
Acute Overload Direct Trauma Overwork with Fatigue Other Trigger Points Chilling of the Muscle Over Stretch of Muscle |
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Predisposing factors for trigger points
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Predisposing Factors
Muscle Imbalance Posture Infection Quick Chill Lack of Physical Activity Stress |
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What has a trigger point in the ear?
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Masseter
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What m. tends to have trigger points in a horizontal band above the ear
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splenius capitus
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Trapezius trigger points
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down shoulder blade
upper trap does ram's horn |
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What muscles have common trigger points down the shoulder and arm?
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supraspinatus - farthest down
coracobrachialis long head of biceps |
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Fibromyalgia
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Complex, chronic condition characterized by widespread pain and fatigue
Widespread = left & right, upper & lower extremities Chronic fatigue syndrome 4-6 million Americans affected 80% women 20-60 years old Not synonymous with Myofascial Pain Syndrome (MFPS) |
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Myofascial vs Fibromyalgia Pain - Etiology
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Etiology:
Overuse Repetitive motions Reduced muscle activity Posture Muscle imbalance Etiology: Neurohormonal imbalance Autonomic dysfunction CNS dysfunction |
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Muscle feel tense with restricted ROM
vs Muscle feels soft and doughy |
Myofascial vs Fibromyalgia Pain
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Myofascial vs Fibromyalgia Pain: trigger points
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Focal Trigger points
Widespread Tender points 72% also have trigger points |
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Myofascial vs Fibromyalgia Pain: pain distribution
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Regional pain
Widespread pain |
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Myofascial vs Fibromyalgia Pain: Gender ratio
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Male = Female
Female > Male (4-9 times) |
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Myofascial vs Fibromyalgia Pain: Associated s/s
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No associated signs and symptoms
Wide array of associated signs and symptoms Systemic condition |
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Polymyalgia Rheumatica: incidence and cause
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Widespread pain and stiffness in multiple muscles
Incidence: 5:1000 Female 2:1 Age > 50 years Whites > all others Cause: Unknown, but suspect genetic factors, infection or autoimmune malfunction |
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Clinical Manifestations of polymyalgia rheumatica:
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Clinical Manifestations:
Sudden onset of stiffness and pain Often bilateral and symmetric Neck, SC joint, shoulders, hips, LB and buttocks Peripheral joints involved 50% of cases 15-20% develop giant cell arteritis |
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Treatment/Management of polymyalgia rheumatica:
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Treatment/Management:
Responds dramatically to glucocorticoids (prednisone) Alteration of Diet Allergies? Physical Therapy to Improve Function Conservation of Energy The disease is generally self-limiting within 1-2 yrs Recurrence , however, is 30% |
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Sprains and Connective Tissue Trauma
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Trauma to ligament, capsule or tendon caused by direct trauma, overuse, overload, or overstretch:
First Degree = Tear of a few fibers Second Degree = Tear of approximately ½ Third Degree = Complete rupture |
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S/S of ligamentous injury
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Acute onset
Overload / Overstretch mechanism Disuse muscle weakness Swelling Loss of function Minor to Major Pain on stretch of the injured tissue Altered joint play and/or ROM Hypermobility or Hypomobility Capsular Pattern Palpable Tenderness over the injured tissue |
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An Ankle X-Ray is Indicated If…
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An Ankle X-Ray is Indicated If…
Bone Tenderness at A (posterior edge or tip of lateral malleolus) OR Bone Tenderness at B (posterior edge or tip of medial malleolus) OR Unable to Bear Weight Immediately and in ED |
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A Foot X-Ray is Indicated If…
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A Foot X-Ray is Indicated If…
Bone Tenderness at C (base of 5th metatarsal) OR Bone Tenderness at D (navicular)OR Unable to Bear Weight Immediately and in ED |
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Effectiveness of ankle clinical prediction rules
(Ottowa?) |
Sensitivity = 1.00
Specificity = .77 Reduced Ankle X-Rays by 28% and Foot X-Rays by 14% |
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Clinical manifestations of adhesive capsulitis
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Frozen shoulder
Clinical Manifestations: Severe restriction of Movement Capsular pattern Swelling Pain with PROM Little or No pain with isometric contraction Unknown Cause |
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Capsular and non-capsular patterns
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A unique pattern of proportional limitation of a synovial joint secondary to trauma, inflammation or immobilization
indicates that the capsule is involved in its entirety Accompanied by muscle spasm Non-capsular pattern Ligamentous adhesions Internal derangement Extra-articular lesions |
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Common capsular patterns
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Cervical, Thoracic, and Lumbar Spine
Lat Flexion = Rotation > Extension Glenohumeral External Rotation > Abduction > Internal Rotation Wrist Flexion = Extension Hip Flexion > Abduction > Internal Rotation Knee Flexion > Extension Talocrural Plantar Flexion > Dorsiflexion 1st MTP Extension > Flexion |
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Risk factors for adhesive capsulitis
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Risk Factors:
Joint and muscle hypermobility Diabetes Stroke Cardiopulmonary Disease Female Over 40 years of age |
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Clinical manifestations of subacromial impingement
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Clinical Manifestations:
History of overuse Pain with overhead activities Positive impingement tests Painful Arch Speeds Kennedy-Hawkins Cause: Anatomical Functional |
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General joint hypermobility testing
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Beighton Index (0-9 pts)
Hyperextension of 5th MCP > 90o (0-2 pts) Hyperextension of elbows (0-2 pts) Touch thumb to volar surface of forearm (0-2pts) Hyperextension of knees (0-2 pts) Touch palms to floor with knee extended (0-1 pt) Normals: 61% of Individuals <= 3 10% of Individuals >= 6 |
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EDS - Ehlers Danlos Syndrome
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Rare genetic disorder involving collagen synthesis
Autosomal dominant Clinical Signs and Symptoms: Joint Hypermobility and instability Prone to subluxation / dislocation Fragile skin and poor healing Life Threatening if vasculature is involved |
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Screening for Cervical Radiculopathy: Clinical Prediction Rule
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Upper limb tension test
Cervical Rotation Less Than 60 degrees Spurlings Test Cervical Distraction Test Two Positive Tests Sn = .39; Sp = .56 Post-test Probability = 21% Three Positive Tests Sn = .39; Sp = .94 Post-test Probability = 65% All Four Tests Positive Sn = .24; Sp = .99 Post-test Probability = 90% |
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Describe review of systems and its purpose
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Series of Checklists of common symptoms relevant to major body systems.
Not intended to identify or rule out specific diseases Purpose: See whether other systems are involved Identify symptoms that may have been overlooked Identify symptoms related to principle complaint Identify existing co-morbid conditions – diabetes,etc. Identify occult disease – hidden, no one has realized Identify adverse drug reactions – medications causing symptoms Not designed to make diagnosis |
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Comprehensiveness and use of checklists for review of systems
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The checklists become comprehensive when combined with the patient’s medical history and the physical examination
Do not need to use every checklist (except General), only those that are appropriate Appropriateness is based on location, history and the subsequent examination Want to be selective, figure out what's appropriate based on above Could wait and do them at the end after physical exam |
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Review of systems: what are the systems?
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General Health
Cardiovascular System Pulmonary System Gastrointestinal System Genitourinary System Nervous System Integumentary* Endocrine System Psychological* Musculoskeletal * * Typically Covered by the General Health Review, Symptom Investigation Stage, Observation, or the Physical Examination. |
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When Do You Perform a Review of Systems?
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Always do the General Health Screen
Do one or more of the other screens, if… patient’s medical history or health risk reveals several “RED” flags. unable to determine that the source of the symptoms are mechanical. Interesting... patient does not respond appropriately to the developed plan of care. Hm, thought treatment would work, but maybe other things are involved something changes during the course of the treatment making it appropriate. Things change! Wasn't active before, but now it is |
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Review of Systems: General Health Screen
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Fatigue?
Malaise? Fever/chills/sweats? (> 99.5o for > 2 weeks) Unexplained weight loss/gain? (5-10% of BW) Nausea/vomiting? Dizziness/lightheadedness? Paresthesia/numbness? Muscle Weakness? Change in mentation/cognitive abilities? |
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General Health Screen: Fatigue
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Results in 10 million office visits/yr in the U.S.
A common symptom in many disorders Psychological (depression, anxiety, etc.) Endocrine/Metabolic (DM, thyroid conditions, etc.) Infections (TB, HIV, mononucleosis, hepatitis, etc.) Neoplasms Cardiopulmonary (CHF, COPD, etc.) Sleep Disturbances Medications (e.g. antihistamines, muscle relaxants) Lots of things can make you tired (“none of these involve my lectures”) |
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Fatigue becomes a “RED” flag when…
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Fatigue becomes a “RED” flag when…
It interferes with the patient’s ability to carry out typical daily activities at home, work, social settings, school, or rehabilitation It lasts for 2 to 4 weeks or more So, it's ok to be tired unless it becomes debilitating or long term |
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General Health Screen: Malaise
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Sense of uneasiness or general discomfort, an “out of sorts” feeling
(order a sandwich – hold the malaise) Don't use this term – no good definition Many patients will not know if they feel malaise, but may say something like… “I have felt like I am coming down with the flu for weeks, but haven’t yet become ill”. Have to gather this sort of info indirectly |
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General Health Screen: Fever / Chills / Sweats
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Symptom of a systemic illness such as infection, cancer, rheumatoid arthritis, etc.
It is a “RED” flag if… > 99.50 F (37.50 C) > 2 weeks without seeing MD (feel ok if someone is dealing with it) > 102 degrees F (390 C) The lack of a fever does not preclude the possibility of infection (e.g. pneumonia) – not necessarily a fever! |
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General Health Screen: Unexplained Weight Change
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Unexplained weight loss/gain
5-10% of body weight Weight loss is associated with: Depression (18%) Cancer (16%) Gastrointestinal disease (11%) Weight gain is associated with fluid retention Kidney, CHF, Liver, etc. Can gain weight by eating a lot, but it's gotta be dramatic to gain weight quickly |
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General Health Checklist: Nausea / Vomiting
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Low-level nausea may go unreported or is masked by over-the-counter medication – side effect is often nausea, can prevent someone from being concerned with it
Associated with many diseases/conditions other than the gastrointestinal system Cardiac, pregnancy, headaches, CVA, etc. It is a “RED” flag if… Physician is not aware Symptoms worsened since last visit Unexplained cause |
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General Health Screen: Dizziness/Lightheadedness
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Associated with most body systems as well as adverse drug reactions, including:
Neurologic disorders Cardiovascular disorders Diabetes Hypoxia Cervical spondylosis Anxiety Psychosis And, living in Victorian Era – corsets If present, get precise description of symptom: Lightheaded or faint? Spinning sensation? Associated with specific postures or movements Upright postures worsen with Cardiovascular problems Associated with nausea, vomiting, diaphoresis (sweating)? Associated with hearing loss, visual disturbances, or tinnitus? History of falls, fallen? |
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General Health Screen: Paresthesia / Numbness
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Most commonly associated with neurologic disorders
It is a “RED” flag if associated with… “Stocking-and-Glove” distribution. Systemic condition “Saddle” distribution. - whatever would be touching the saddle – numb/altered sensation, can't feel yourself go to the bathroom progressive deficits. - getting worse Urinary/bowel problems (retention, increased frequency, incontinence). bilateral extremity deficits or UE/LE combination. |
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General Health Screen: Muscle Weakness
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Associated with neurologic conditions as well as disuse and immobilization
It is a “RED” flag if associated with… progressive deficits. - I think I'm getting weaker urinary problems (retention, increased frequency, incontinence). bilateral extremity deficits or UE/LE combination. concurrent sensory and/or neurologic deficits |
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General Health Screen: Change in Mentation / Cognition
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If present, examination should include:
Level of consciousness (alertness) Attention (ability to focus) Memory (short-term vs long-term)- short usually goes, while long is preserved Orientation (person, place, time) – where you are and why you're here, don't ask about the President Thought Process (logical & coherent) – make sense? Do you trust them to keep precautions, etc. Judgment (evaluate alternatives & follow appropriate values while choosing a course) Safety is the primary issue Don't walk yet by yourself, etc. Speech therapist came down to PT – evaluated Mrs. So-and-so – “where is your nose? Ear?...” “oh, honey, I don't know, my sister packed everything” |
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Onset of confusion or disorientation or a change in these symptoms can be manifestations of:
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Onset of confusion or disorientation or a change in these symptoms can be manifestations of:
Delirium or Dementia Head injury Adverse drug reactions Systemic Infection If deficits are pre-existing, the MD knows of them, and they have not worsened, it is a “YELLOW” flag Who else knows about this? |
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Review of Systems: Cardiovascular System Screen
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Dyspnea? Use appropriate terminology (don't call it dyspnea or SOB)
Palpitations? Syncope? fainting Diaphoresis (pain with sweating)? No good reason Chronic Cough? Peripheral Edema? pitting Cold Hands/Feet? But warm heart :) Open Wounds? Skin Discoloration? |
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Cardiovascular System Screen: Dyspnea (SOB)
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Is difficulty breathing related to:
Activity, Exertion or Body position Orthopnea = difficulty breathing when recumbent CHF Mitral Valve disease Treponea = difficulty breathing, eased with side lying CHF Platypnea = difficulty breathing when upright Neurological diseases S/P pneumoectomy |
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Cardiovascular System Screen: Dyspnea (SOB)
Follow-up Questions: |
Follow-up Questions:
When did the SOB begin? Did the SOB begin suddenly or slowly? Is the SOB constant? Does SOB occur with exertion only? Does your SOB change with a change in position? Do you wake up suddenly at night with severe SOB? (haha!) |
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Cardiovascular System Screen: Palpitations
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Uncomfortable sensations in the chest that are associated with a variety of arrhythmias
Described as: “fluttering”, “jumping”, or “pounding” “stopping” or “skipping” Not the same as being twitterpated Follow-up questions should focus on: Frequency and Duration Associated signs (chest pain, syncope, lightheadedness, dyspnea, etc.) |
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Cardiovascular System Screen: Syncope (fainting)
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Sudden loss of consciousness
Usually caused by reduced blood flow to the brain Also associated with metabolic and psychogenic causes Increased incidence over age 70 |
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Cardiovascular System Screen: Diaphoresis (sweating)
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Unexplained sweating
Common with myocardial infarction, women and the Elderly Most serious when accompanied with pain in: Chest Lower Extremities Neck, Jaw, Teeth Right Shoulder Epigastrium or mid-thoracic |
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Cardiovascular System Screen: Chronic Cough
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Usually associated with cigarette smoking, but may also be associated with:
Asthma, Pneumonia or Heart failure Follow-up questions should focus on: Onset Duration and Frequency Altered by position Associated signs & symptoms |
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Cardiovascular System Screen: Peripheral Edema (pitting)
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Seen with:
Venous insufficiency CHF DVT Pulmonary thrombosis If present, asses for: DVT Local tenderness Associated signs & symptoms |
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Cardiovascular System Screen: Integumentary Signs
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Cold Hands / Feet
Poor circulation Open Wounds Venous insufficiency Diabetes Skin Discoloration Venous insufficiency Diabetes Poor circulation |
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Deep Vein Thrombosis (DVT)
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Vascular disease that manifests as DVT or pulmonary embolism (PE)
May be symptomatic or asymptomatic More than 250,000 hospitalizations annually 0.56 – 1.82:1000 17% three month mortality rate Most common in the lower extremities Popliteal and thigh veins (proximal) Tibial and calf veins (distal) |
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Review of Systems: Pulmonary System Screen
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Dyspnea
Chronic Cough Wheezing/Stridor Audible abnormal respiratory sounds High-pitched noise from partial obstruction of the airway Clubbing of the nails |
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Gastrointestinal Screen: Dysphasia (Difficulty Swallowing)
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Loss of coordinated local muscle control:
Myasthenia Gravis Multiple Sclerosis Amyotrophic Lateral Sclerosis Parkinson's Disease Stroke Mechanical Obstruction: Tumors Thyroid Goiter Cervical Osteophytes Aortic Aneurysm |
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Gastrointestinal Screen: Dyspepsia (Indigestion / Heartburn)
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Food Intolerance
E.g.. fatty foods Indigestion/Heartburn (dyspepsia) Follow-up Questions: Duration and Frequency? Constant vs Intermittent? Known Cause? Current Treatment? Associated Signs? |
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Gastrointestinal Screen: Bowel Dysfunction
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Color of stool?
Melena (black, tarry) = Blood in upper GI Hematochezia = Blood in lower GI Shape/Caliber of stool? Pencil thin or Flat & Ribbon-like = mechanical obstruction (e.g. colon cancer) Constipation? Difficulty Initiating? Incontinence? Follow-Up Questions: Onset? Change? MD Aware? |
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Genitourinary Screen: Urination – kidney, bladder, diabetes...
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Frequency (most common)
“Nocturia” = urination at night (2-3 times is upper limit) Urgency = infection / irritation Output Increased (“Polyuria”) eg. Diabetes Decreased = dehydration Retention “Dysuria” (painful urination) inflammation, infection, distension Reduced Caliber or Force of urination or Difficulty initiating urine stream Associated with obstructive disorders (eg. prostate hyperplasia) Incontinence Color Red/Brown (“Hematuria”) = blood in urine |
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Review of Systems: Central Nervous System
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Gross movement patterns
Altered Gait Altered Balance Tremors Asymmetric facial features: Pupil dilation Ptosis Facial contour Altered Hearing |
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Review of Systems: Endocrine System Screen
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General Health Screen
Fatigue/Weakness Weight Change Gastrointestinal Screen Nausea/Vomiting Dysphasia Diarrhea/Constipation Urogenital Screen Impotence Urination problems Neurological Screen Paresthesia Numbness Entrapment neuropathies Integumentary Screen Foot ulcerations Edema Dry/Coarse skin Impaired wound healing |
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Review of Systems: Endocrine System (cont.)
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Musculoskeletal Screen
Muscle weakness/stiffness Arthralgias Myalgias Stiffness Bone pain Psychological Screen Memory loss Confusion Irritability Misc. Atypical symptom pattern Temperature intolerance Visual changes Increased bruising Orthostatic hypotension |
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Common Features of Non-Mechanical Musculoskeletal Conditions
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Red Flags on the General Health Screen
Insidious onset of symptoms Atypical pain pattern or physical findings Night pain Inadequate relief with rest or rehabilitation Lack of impairments that match the patient’s functional limitations Inability to alter symptoms during examination |
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Serious Medical Conditions of the Head, Face, and TMJ
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Meningitis
Brain Tumor Subarachnoid Hemorrhage |
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Serious Medical Conditions of the Cervical Spine and Shoulder
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Miocardial Infarction
Cervical Instability Peripheral Neuropathy Spinal Accessory N. Axillary N. Long Thoracic N. Suprascapular N. Pancoast Tumor |
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Serious Medical Conditions of the Elbow, Wrist, and Hand
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Fractures
Flexor Tendon Rupture Infection Raynaud’s CRPS |
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Serious Medical Conditions of the Thoracic Spine and Rib Cage
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Miocardial Infection
Unstable Angina Stable Angina Pericarditis Pulmonary Embolus Pleurisy Pneumothorax Pneumonia Cholecystitis Peptic Ulcer Pylelonephritis Kidney Stones |
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Serious Medical Conditions of the Lumbar Spine
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Fractures
Cauda Equina Infection Tumor Abdominal Aneurysm |
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Serious Medical Conditions of the Pelvis, Hip and Thigh
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Colon Cancer
Hip Fracture Avascular Necrosis (AVN) Legg-Calve-Perthes Slipped Capital Femoral Epiphysis |
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Serious Medical Conditions of the Knee, Leg, Ankle, or Foot
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Peripheral Arterial Occlusion
Deep Vein Thrombosis (DVT) Compartment Syndrome Septic Arthritis Cellulitis |
