EEI 10/9a Outpatient Interview Cases Flashcards
The guide to PT practice
Diagnosis Prognosis Intervention Outcomes Examination Evaluation
Goals of PT interview
- Establish Rapport
- PMH
- History of Present Illness (HPI)/CC
- Functional limitations/baseline status
- Ask yourself about red flags, referrals, etc
- Develop a hypothesis
importance of establishing rapport with your patient
- Hearing vs active listening (clarify, ask questions, practice eye contact)
- nonverbal cues
- **Patient’s goal
- Patient centered interview (what brings you here, goals for today)
- Open vs Close ended questions
- barriers of communication (language and hearing imparirment)
Breakdown of PMH Interview
- Interview
- Self-report measures
- questionnaire with targeted follow up
- social history
- comorbidities
- medications
- psycho-social (depression, safety at home, recent drastic changes in body)
good questions to include in the self-administered questionnaire in an outpatient ortho setting (self report measures)
latex sensitivity? heart problems? occupation? List out comorbidities? diabetes? diabetes before age 18?
If yes on questionnaire, what do you do?
follow up!
health history should include
demographics - age, race, education level
- can explain some diseases/disabilities
- age (breast and prostate cancer = older adults, vs MS and RA = younger diagnosis)
- race (sickle cell = black, skin cancer = white)
- education (communication targets)
what should the social history interview include?
part of PMH
- occupation with follow up about requirements on job
- hobbies/rec
- habits (caffeine > 2-3x per day side effects are insomnia, tachycardia; for alcohol > 14 male and >7 female side effects are HTN, Hepatitis, Serosis; tobacco)
- family medical history
- support systems
comorbidities during interview
- PMH
- cancer if >50y/o think recurrence if prior hx
- infection (pneumonia, UTI) think redness, heat, swelling
- cardiac think shoulder pain, HTN, CVA, angina and avoid aerobic activity
- depression effects outcome, poor recovery in back, knee, hip
- pulmonary think asthma, COPD decreased endurance and make sure they have inhaler
- osteoperosis post menopausal or long term steroids, compression fractures, no bending
- diabetes
- seizures
- pregnancy (no stim and manips because ligamentous laxity)
- surgeries (DVTs)
Medication side effects
- cardiac (orthostatis hypo, nitroglyc)
- steroids (long term effects on bone)
- NSAIDS (GI bleeds)
- asthma (inhaler!)
- insulin (fatigue and hypoglycemia)
- seizure meds
HPI/CC
History of Present Illness/Chief Complaint
- Pain
- Stiffness
- Weakness
- Numbness
- ligament tears
- OPQRST (onset, provocation, quality of pain, region/radiation, severity, time - history)
interviewing about pain
- behavior and quality: constant (mechanical or chemical) vs intermittent (mechanical)
- better or worse?
- nerve distro (dermaatome or periph nerve)
- bone (tenderness to palpation, deep and localized)
- vascular (widespread and throbbing)
- muscle (resist motion and stretching cause pain) - location
- numeric rating scale
- severity/intensity (1-10 scale)
- irritability
- stability - periph or central?
parasthesia vs anesthesia
parasthesia = numbness/tingling from damage to a nerve anesthesis = no feeling because nerve has been cut
functional limitations aspect of the interview?
- what do your symptoms prevent you from doing?
- different outcome measures
what do you ask yourself as a PT during the patient interview?
manage case by:
- referral to another healthcare practitioner and cannot be managed by PT
- by PT with a consult from another practitioner
- independently by PT
Red flags for referral to another healthcare provider and not managed by PT
- severe unremitting pain
- pain not affected by medication or position
- severe pain at night
- severe pain with no history of injury
- severe spasm
red flags for patients who may have cancer
- persistent night pain
- constant, unremitting pain
- unexplained weight loss
- unusual lumps or growths
- unwarranted fatigue
- history of cancer
- > 50 y/o
red flags for patients who may have a CV disease?
- SOB
- dizziness
- chest pain/heaviness
- constant and severe calf pain or welling redness especially with decreased activity
- pulsating pain
- discolored or painful feet
- unexplained swelling
red flags for patients with possible GI/urinary issues
- frequent or severe abdominal pain
- frequent heartburn/indigestion
- frequent nausea/vomiting
- altered bladder function
- unusual menstrual
- worsened balance
red flags for neuro issues
- altered hearing
- altered vision
- problems with swallowing or speech
- vision problems
- balance/coordination/falling
- fainting spells
- sudden weakness
red flags overall for possible issues
- unexplained fever/night sweats
- unexplained joint swelling
- recent/severe emotional disturbances
- symptoms not changed by movement/position
what do you do with red flags?
- psych issues (depression, fear, nonorganic signs) = call doctor
- exchange information
1. test results
2. guidelines for intervention in a medically complicated patient
3. alert physician or health care practitioner (social worker if abuse, MD if exam findings)
develop a hypothesis at the end of the interview. ask yourself the following
- what is going on? what am I trying to rule in/out?
- contraindications/precautions
- irritability determines vigor of exam
- activity needed to trigger symptoms
- severity of symptoms provoked
- activity/amount of time for sx to subside - tissue irritability
- plan physical exam (medical screen, upper/lower quad screens, specific joint exams, special tests)
high vs low tissue irritability
- high: resting pain, pain before resistance or end range, recent trauma, sx easily increased. TREATMENT: pain control, inflammation, no significant stretch or resistive exercise
- low: no sig resting pain, pain with overpressure, resistance before pain, sx mild and stable. TREATMENT: restore impairments, strength, flexibility
○ 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.
don’t treat, call doctor and discuss disability
○ 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 patient back to surgeon, patient had arthroscope piece in knee causing pain
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
ptnt had leukemia and died 2 months later
○ 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 patient
○ Patient arrived for initial evaluation after left TKA The patient was unable to get into the clinic on his own, so I went to the patient’s car to assist. The patient required moderate assistance in transferring out of the car, and used a walker with minimal assistance from me The patient had difficulty with following commands and concentrating, and had difficulty with answering questions from me or his wife. During the subjective/objective portion of the evaluation, the following findings were noted:
patient had bilateral DVTs and a PE, was sent straight to ER
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.
bundle branch block, don’t treat
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.
refer, may be reocurrance of cancer
55 year old male s/p total knee replacement has redness, warmth, and swelling of his left calf.
DVT, refer out
87 year old male 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.
call 911 with anyone who passes out
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
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
refer out, blood clot
