10-9a Outpatient Interview Cases Flashcards
What portions of the SOAP tie into the Examination portion of PT practice?
Subjective and Objective
What portions of the SOAP tie into the Diagnosis portion of PT practice?
Assessment
What portions of the SOAP tie into the Prognosis portion of PT practice?
Plan
What portions of the SOAP tie into the Intervention portion of PT practice?
Observation
What are the goals of the patient interview?
Establish rapport
PMH (past medical history)
HPI(history of
present illness)
CC (chief complaint)
Functional limitations/
Baseline status
What conclusions can be made after the patient interview?
Are they appropriate for PT? /red flags
Develop hypothesis
Plan physical examination
How do you build rapport with the patient?
What does the patient want to get out of PT?
active listening
patient-centered
closed questions = efficiency
What parts of the pt’s Health History/screen are considered?
demographics social history health history (comorbidities) Medications and other questions
What about the patient’s demographics are you interested in?
Age (likelihood for certain cancers)
Race (same)
educational level (word choice)
What about the patient’s PMH/comorbidities are you interested in?
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
What medications should one be cognizant of?
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
What to ask about different types of pain?
intermittent: movements/positions
constant: mechanical or chemical/inflammation
what makes it better or worse
What are signs of nerve pain?
shooting pain at dermatome distribution or peripheral nerve site
What are signs of bone pain?
□ Exquisite tenderness to palpation at a specific point if it’s fracture
Oftentimes deep, boring, and localized
What are signs/causes of vascular pain?
venous insufficiency (old, postpartum) widespread and throbbing
What are signs of muscular/tendinous pain?
motion, stretching
What is the pain rating scale?
0-10
What are signs pain is getting better?
proximalizing
What are signs pain is getting worse?
peripheralizing
What are examples of a c/c?
Pain Stiffness Weakness Numbness: Paresthesia vs Anesthesia Other (ex. joint locking or knee giving way) Consider Associated Areas referred pain
What is an atypical pain pattern?
Painful during the morning, gets better throughout the day, worse at night
What does OPQRST stand for?
Onset of event Provocation Quality of pain Region and Radiation Severity Time
What are signs that the patient requires referral and cannot be treated at this time?
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
What are cancer red flags?
Persistent Night Pain Constant, unremitting pain Unexplained wt loss Unusual lumps or growths Unwarranted fatigue History of cancer Age >50
What are cardiovascular red flags?
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
What are GI/urinary red flags?
Frequent or severe abdominal pain Frequent heartburn / indigestion Frequent nausea / vomiting Altered bladder function Unusual menstrual irregularities CL example-balance worse
What are some neurological red flags?
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
What are miscellaneous red flags?
Unexplained fever / night sweats
Unexplained joint swelling / redness
Recent severe emotional disturbances
Symptoms not unaffected by movement or position
What are some ways to handle yellow flags by PT or consultation?
Test results
Guidelines for intervention in a medically complicated patient
Alert physician or health care practitioner (Social worker: suspected abuse
MD: exam findings)
What is considered when forming a hypothesis post pt interview?
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
What are signs of high tissue irritability? How do you treat?
resting pain
pain before resistance or end-range
recent trauma
sx’s easily increased
treatment:
pain control
inflammation
NO significant stretch or resistive ex
What are signs of low tissue irritability? How do you treat?
no sig resting pain
pain w/ overpressure, resistance before pain
sx’s mild and stable
treatment:
restore impairments
strength
flexibility
What do you do in the examination?
Medical screening:
Ex: CVA tenderness
Upper/lower quarter screening examinations
Specific joint examination and special tests
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.
Call doctor and suggest compression fracture
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.
Send back to doctor for MRI/X Rays
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
order imaging
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.
treat
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.
refer
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.
treat
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.
treat
55 year old male s/p total knee replacement has redness, warmth, and swelling of his left calf.
DVT
refer
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
treat
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. `
911
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
clot
refer
48 year old female s/p MVA referred with dx CS sprain/strain
bilat UE numbness
c/o decreased vision
impaired memory`
bilat symptoms are a concert
fracture
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.
infection of bone
call doc
