10-9a Outpatient Interview Cases

Question 1

What portions of the SOAP tie into the Examination portion of PT practice?

Answer 1

Subjective and Objective

Question 2

What portions of the SOAP tie into the Diagnosis portion of PT practice?

Answer 2

Assessment

Question 3

What portions of the SOAP tie into the Prognosis portion of PT practice?

Answer 3

Plan

Question 4

What portions of the SOAP tie into the Intervention portion of PT practice?

Answer 4

Observation

Question 5

What are the goals of the patient interview?

Answer 5

Establish rapport

PMH (past medical history)

HPI(history of
present illness)

CC (chief complaint)

Functional limitations/
Baseline status

Question 6

What conclusions can be made after the patient interview?

Answer 6

Are they appropriate for PT? /red flags
Develop hypothesis
Plan physical examination

Question 7

How do you build rapport with the patient?

Answer 7

What does the patient want to get out of PT?
active listening
patient-centered
closed questions = efficiency

Question 8

What parts of the pt’s Health History/screen are considered?

Answer 8

demographics
social history
health history (comorbidities)
Medications
and other questions

Question 9

What about the patient’s demographics are you interested in?

Answer 9

Age (likelihood for certain cancers)
Race (same)
educational level (word choice)

Question 10

What about the patient’s PMH/comorbidities are you interested in?

Answer 10

Cancer (>50)
Infection
Cardiac (heart attack signs/take BP)
Depression (effects outcomes)
Pulmonary issues (asthma, COPD): decreased endurance
OA (older women)
Diabetes
Surgeries
Pregnancy
Rec. Surgeries

Question 11

What medications should one be cognizant of?

Answer 11

Cardiac meds for BP; can cause orthostatic hypotension
Steroids (side effects on bone)
Aspirin, Motrin, Aleve: GI bleeds
Asthma Meds (inhaler)
Insulin (monitor/check for hypoglycemic signs)
Seizure meds

Question 12

What to ask about different types of pain?

Answer 12

intermittent: movements/positions
constant: mechanical or chemical/inflammation
what makes it better or worse

Question 13

What are signs of nerve pain?

Answer 13

shooting pain at dermatome distribution or peripheral nerve site

Question 14

What are signs of bone pain?

Answer 14

□ Exquisite tenderness to palpation at a specific point if it’s fracture
Oftentimes deep, boring, and localized

Question 15

What are signs/causes of vascular pain?

Answer 15

venous insufficiency (old, postpartum)
widespread and throbbing

Question 16

What are signs of muscular/tendinous pain?

Answer 16

motion, stretching

Question 17

What is the pain rating scale?

Answer 17

0-10

Question 18

What are signs pain is getting better?

Answer 18

proximalizing

Question 19

What are signs pain is getting worse?

Answer 19

peripheralizing

Question 20

What are examples of a c/c?

Answer 20

Pain
Stiffness
Weakness
Numbness: Paresthesia vs Anesthesia
Other (ex. joint locking or knee giving way)
Consider Associated Areas
referred pain

Question 21

What is an atypical pain pattern?

Answer 21

Painful during the morning, gets better throughout the day, worse at night

Question 22

What does OPQRST stand for?

Answer 22

Onset of event
 Provocation
Quality of pain
 Region and Radiation
Severity
Time

Question 23

What are signs that the patient requires referral and cannot be treated at this time?

Answer 23

Severe unremitting pain
Pain not affected by medication or position
Severe pain at night
Severe pain with no history of injury (not cumulative trauma)
Severe spasm

Question 24

What are cancer red flags?

Answer 24

Persistent Night Pain
Constant, unremitting pain
Unexplained wt loss
Unusual lumps or growths
Unwarranted fatigue
History of cancer
Age >50

Question 25

What are cardiovascular red flags?

Answer 25

``` Shortness of breath (SOB) Dizziness Chest pain / heaviness Constant & severe calf pain or swelling/redness, esp with history of decreased activity Pulsating pain Discolored or painful feet Unexplained swelling ```

Question 26

What are GI/urinary red flags?

Answer 26

``` Frequent or severe abdominal pain Frequent heartburn / indigestion Frequent nausea / vomiting Altered bladder function Unusual menstrual irregularities CL example-balance worse ```

Question 27

What are some neurological red flags?

Answer 27

``` Altered hearing Frequent / severe headaches w/o hx of injury Problems swallowing or with speech Vision problems Balance / coordination problems/falling Fainting spells (drop attacks) Sudden weakness ```

Question 28

What are miscellaneous red flags?

Answer 28

Unexplained fever / night sweats Unexplained joint swelling / redness Recent severe emotional disturbances Symptoms not unaffected by movement or position

Question 29

What are some ways to handle yellow flags by PT or consultation?

Answer 29

Test results Guidelines for intervention in a medically complicated patient Alert physician or health care practitioner (Social worker: suspected abuse MD: exam findings)

Question 30

What is considered when forming a hypothesis post pt interview?

Answer 30

What is going on? What am I trying to rule in/rule out? Contraindications/precautions Irritability determines vigor of exam 3 components: (22yo fridge delivery) amount of activity needed to trigger symptoms severity of symptoms provoked what activity/ amn’t of time for sx to subside

Question 31

What are signs of high tissue irritability? How do you treat?

Answer 31

resting pain pain before resistance or end-range recent trauma sx’s easily increased treatment: pain control inflammation NO significant stretch or resistive ex

Question 32

What are signs of low tissue irritability? How do you treat?

Answer 32

no sig resting pain pain w/ overpressure, resistance before pain sx’s mild and stable treatment: restore impairments strength flexibility

Question 33

What do you do in the examination?

Answer 33

Medical screening: Ex: CVA tenderness Upper/lower quarter screening examinations Specific joint examination and special tests

Question 34

What do you do with: A 75 year old Caucasian female is sitting in the waiting room on a chair with her daughter, who has brought her. The woman complains of constant pain in her midback and she has severe twinges with any trunk movement. The patient does not remember injuring her back.

Answer 34

Call doctor and suggest compression fracture

Question 35

What do you do with: 53 year old active female status post knee arthroscopy for torn meniscus has persistent medial knee joint pain, swelling and tenderness to palpation 3 months post op with no change in symptoms after 5 weeks of PT.

Answer 35

Send back to doctor for MRI/X Rays

Question 36

26 year old male working as an insurance agent, avid golfer, with insidious onset of back pain and intermittent bilateral leg pain who does not obtain relief from movements or positions with pain at night

Answer 36

order imaging

Question 37

37 year old patient with 1.5 year history of back and leg pain which began after running a marathon. Has no significant PMH. MRI 1 year ago positive for HNP L5.

Answer 37

treat

Question 38

65 year old sedentary female referred for back pain which is worse at the end of the day when she works. PMH is significant only for osteopenia. You take her baseline BP and HR at rest and after you put her on the treadmill for 5 minutes. She is asymptomatic, but you note that her pulse is irregular post exercise.

Answer 38

refer

Question 39

70 year old male with a history of liver cancer s/p surgery and chemotherapy, COPD, and left total knee replacement that is now cancer free. He is referred for reconditioning. Six weeks into therapy, he is unable to tolerate his usual amount of exercise and his narcotic pain medications are not controlling his pain.

Answer 39

treat

Question 40

45 year old female referred with neck pain. During the examination, she has blurred vision with movement of the neck and upon questioning relates an episode of perioral numbness earlier this week.

Answer 40

treat

Question 41

55 year old male s/p total knee replacement has redness, warmth, and swelling of his left calf.

Answer 41

DVT | refer

Question 42

Person with back pain that you have treated 1 year ago who experiences an exacerbation of pain after a 60 hr work week sitting at a computer

Answer 42

treat

Question 43

87 year old make WWII vet you are seeing for a frozen shoulder complains of feeling lightheaded and needs to sit down. You have him sit down and he becomes pale and nonresponsive for about 10 seconds then becomes nauseous. `

Answer 43

911

Question 44

46 year old female status post knee arthroscopy 2 months ago complains of persistent LE swelling and onset of calf discomfort yesterday after flying home from California

Answer 44

clot | refer

Question 45

48 year old female s/p MVA referred with dx CS sprain/strain bilat UE numbness c/o decreased vision impaired memory`

Answer 45

bilat symptoms are a concert | fracture

Question 46

11 year old with perthes disease had her hip external fixator removed 1 week ago and returns to PT for ROM and strength. She complains of tenderness and pain in her medial distal tibia.

Answer 46

infection of bone | call doc