Exam 1-- week 1-2 Flashcards
Characteristics of Primary Care
Comprehensive Coordination Continuity -safe -effective -timely -efficient -equitable -patient-centered
Characteristics of Secondary Care
Consultative Short term disease oriented assisting PCP historically what PT was considered
List of Primary Care providers
Family physicians/general practitioners osteopathic physicians general internists nurse practitioners physician assistants physical therapists
Family/Osteopathic Physicians/GPs
Graduation from med school
minimum of 3 years post-grad training
at least 1 month learning MSK conditions
Shadowing orthopedist/sports medicine
General Internist
Graduate of med school
complete minimum of 3 years post-grad training
Focus of expertise in internal medicine (viscera)
Focus on chronic conditions–Cardiac disease, hypertension, diabetes, chronic pulmonary disease, etc.
(Treat mostly older population)
No requirement for training with orthopedist or SM to treat MSK conditions
knowledge of MSK conditions and treatment is limited
Physician assistants
Two years of training
- 1 yr classroom
-1 yr rotations in various IP and OP clinical settings
BS and MS degrees
PAs never practice completely independently
clinical focus depends on supervising physician’s expertise
Nurse Practitioners
Graduates of RN training program
length and focus of training is variable
Not typically a general practitioner–more focused on a specification
Generally VERY good primary care practitioners because of their background of patient-centered care and patient interaction
Physical Therapists
Postgraduate degrees–BS > MS > DPT (as of 2016)
CAPTE accreditation
content required in basic science
general practitioners upon graduation
eligible to apply for post-grad residency programs and specialty certifications
Physical therapy specialties
Cardiovascular and Pulmonary (CCS) Clinical Electrophysiology (ECS) Neurology (NCS) Orthopedics (OCS) Pediatrics (PCS) Sports (PCS) Women's Health (WCS) Geriatrics Oncology Wound management
T/F All 50 states have achieved some sort of form of direct access
True
Varying from Eval Only to unrestricted care
Potential benefits of Primary Care PT
more efficient use of health care resources
care being delivered in a more timely manner
interdisciplinary collaboration
US Army Model
Preparation for primary care practice
neuromusculoskeletal evaluation (triage model)
privileges
outcomes
US Army prerequisites and competencies
National selection through military review board
strong academic background
adapt to variable clinic environments
commitment to serve
Advanced training in differential diagnosis, diagnostic imaging, pharmacology, laboratory values common in primary care, and acute MSK injuries
Completion of ongoing CE
Kaiser Permanente Model
Largest not-for-profit HMO in US
PT services are primary care in most regions
PTs work with medical providers
Outcomes
Kaiser PT prerequisites and competencies
Strong foundation in orthopedic PT
4-6 years of OP PT
Required CE
competency in differential diagnosis, diagnostic imaging, pharmacology, laboratory values common in primary care, and acute MSK injuries
VA PT services and access
MSK, neuromuscular, integumentary, cardiovascular/pulmonary systems
PTs screen patients in the ED
primary care clinic– triage by a nurse
Direct: overweight patients or those who wish to improve their general health
Mercy Model prereqs and competencies
strong foundation in orthopedic PT
demonstrated competency in differential diagnosis, diagnostic imaging, pharmacology, laboratory values common in primary care, and chronic MSK injuries
Ability to work in collaboration with medical residents
Mercy Model educational program for medical residents
PT instructs medical residents in low back, neck, shoulder, and knee Rotations MSK examination performed by medical residents Case presentations--clinical reasoning residents observe a PT Benefits: enhanced use of resources multidisciplinary approach better utilization of resources more efficient access
Elements of the patient-centered interview
- exploring pt’s disease/diagnosis and its effect on his or her life
- understanding the whole person
- finding common ground regarding intervention or management
- advocating prevention and health promotion
- enhancing the patient-provider relationship
- providing realistic expectations
Dimensions of the illness experience
- patient profile
- patient goals
- functional limitations
- patient’s perception about the disorder
- patient’s feelings about the disorder
Goals of patient history
- establishing rapport
- identifying any barriers to communication
- identifying the patient’s preferred learning style
- establishing the patient’s goals for physical therapy in addition to our functional based goals
- SINSS
Communication strategies
- ask one question at a time
- periodic restatement or summarization
- avoid medical jargon
- use patient’s line of thought
- avoid assumptions
- self-assessment
Keys for patients with hearing deficits
- utilize a quiet area for the interview
- patient should use hearing and visual aids when available
- clinician should position themselves to facilitate lip reading
- use of interpreter (ASL) may be needed
Manifestations and cautions for angry patients
Manifestations: -obvious -use of sarcasm or cynicism -negativity -lack of compliance -non-verbal forms of communication -escalation Be cautious: -patient tensely moving toward edge of chair -patient tensely gripping arm rests -loud, forceful speech -restless agitation, pacing, and inability to be still
Signs of depressed patients
- impaired concentration
- poor compliance with home instructions
- clinician should acknowledge the situation
- explore potential reasons
- recognize potential for suicide
Important keys to a thorough exam
- differential diagnosis
- safe delivery of physical exam
- review patient’s list of medications
- assess potential impact of co-morbidities
Patient health history data
- patient demographics
- age, sex, race, marital status, level of education
- Body chart - social history
- cultural customs, religion, occupation, living environment, family/social support - current medical situation
- past medical history–illness, allergies, surgeries, injuries, medications
- social habits
- exercise frequency/intensity, use of tobacco, alcohol, caffeine - family medical history
CAGE (questions for alcoholism)
have you ever felt you should Cut down on your drinking?
have people Annoyed you by criticizing your drinking?
have you ever felt bad or Guilty about your drinking?
have you ever had a drink first thing in the morning to steady your nerved or get rid of a hangover? (Eye-opener)
presentation of caffeine withdrawal
headache lethargy fatigue dysphoric mood muscle pain/stiffness
Pertinent documents for health history information
medical records
patient self-reports
screening questionnaires
Do not want to miss list
major depression suicide risk femoral head/neck fracture cauda equina syndrome cervical myelopathy AAA DVT PE atypical myocardial infarction
Clinical manifestations of major depression
Yes to one/both of the following: 1) felt down, depressed or hopeless and/or 2) little interest or pleasure in doing things
Noting 3-4 of the following:
1) significant weight change, 2) insomnia or hypersomnia, 3) psychomotor agitation, retardation, 4) fatigue, 5) feelings of worthlessness and/or guilt, 6) difficulty concentrating, thinking ot 7) recurrent thoughts of suicide
risk factors associated with major depressive disorder
- current or previous history of major depressive episodes
- women, especially during pregnancy or postpartum
- significant medical history such as DM, MI, cancer, CVA, chemical dependency
- suffering from significant loss
- positive family history from immediate relative
common risk factors associated with suicide
- gender (males higher completion rate, females higher attempt rate)
- widowed, divorced, living alone
- history of psychiatric illness
- previous suicide attempts
- history of chronic progressive illness
- recent significant loss
- unemployment
- sense of hopelessness
- family history of suicide completion or attempt
risk factors for femoral fractures
- female
- hormonal menstruation irregularities
- involvement in running, jumping, marching activities
- change in training program or routine
- nutritional deficiencies
- leg length discrepancy
- diminished muscle strength
- loss of general function and mobility
clinical manifestations of femoral neck/head fractures
- pain and local tenderness
- deformity
- edema
- ecchymosis
- loss of general function and mobility
what % of those suffering a hip fx die within a year?
30%
disorders that may compromise bone density
chronic renal failure GI malabsorption rheumatoid arthritis ankylosing spondylitis hyperparathyroidism hypogonadism T2 DM MS chronic alcohol dependency Cushing's syndrome
medication/substance use or abuse that may compromise bone density
aluminum anticonvulsants corticosteroids cytotoxic drugs excessive thyroxine heparin, warfarin (coumadin) methotrexate caffeine (> 3 cups daily) tobacco soft drinks
risk factors for cauda equina syndrome
low back injury, central disk herniation congenital or acquired spinal stenosis spinal fx ankylosing spondylitis tuberculosis, Pott's disease
clinical manifestations of cauda equina syndrome
urinary dysfunction bowel dysfunction sexual dysfunction sensory deficits (perineum, "saddle" region, LE paresthesia) motor deficits (LE--multiple spinal levels)
risk factors for cervical myelopathy
spondylotic changes in cervical spine
Age mid 50-60s and older
previous neck trauma (MVA, sports injury)
rheumatoid arthritis
clinical manifestations of cervical myelopathy
History: -impaired hand dexterity -gait, balance difficulties -numbness/paresthesia in UE/LE -neck stiffness -urinary dysfunction physical exam: -hand--intrinsic atrophy -muscle weakness, often triceps; hand intrinsic -muscle weakness of LE -UMN signs (hyperreflexia, clonus,, Babinski's, Hoffman's)
Risk factors of Abdominal Aortic Aneurysm (AAA)
Age male hx of smoking hypercholesterol hx of coronary heart disease family hx of AAA
clinical manifestations of AAA
usually asymptomatic, but may produce pain in lumbar region, back, hip and buttock, groin, abdominal region
satiety, weight loss, and nausea
palpable abdominal mass
Signs of AAA vessel dissection
LBP described as: sudden, severe intense, persistent hot, searing ripping or tearing sensation *medical emergency*
risk factors for DVT
previous hx of DVT hx of cancer or chemotherapy hx of CHF hx of SLE major surgery or other trauma immobility hormone changes in women age > 60 yrs
clinical manifestations of DVT
ache, tightness, tenderness
general pitting edema
prominent superficial venous plexus
increased local skin temperature
Modified Wells criteria for detecting probability of DVT
active cancer
paralysis, paresis, recent immobilization of LE
recently bedridden for 3 days or major surgery in last 12 weeks
localized tenderness along deep venous system
entire leg swollen
calf swelling > or = 3 cm larger than asymptomatic side
pitting edema confined to symptomatic leg
collateral superficial veins
previously documented DVT
alternative diagnosis at least as likely as DVT
Risk factors of Pulmonary Embolism
previous hx of PE or DVT immobility hx of abdominal, pelvic surgery total hip or knee replacement late-stage pregnancy LE fx malignancy in pelvis or abdomen
clinical manifestations of PE
dyspnea tachypnea pleuritic chest pain pain with respiration, cough persistent cough apprehension, anxiety tachycardia palpitations
risk factors for atypical myocardial infarction
Modifiable: -smoking -high cholesterol -HTN -DM -obesity -sedentary -excessive alcohol non-modifiable: -age: >55 yr for women, >45 yr for men -family hx -ethnicity: highest in African Americans
clinical manifestations of atypical MI
50% experience chest pain with out without left UE pain shortness of breath fatigue sleep disturbance nausea with or without vomiting palpitations dizziness diaphoresis anxiety
Descriptive words for vascular disorders
throbbing
pounding
pulsating
descriptive words for neurologic disorders
sharp
lancinating
shocking
burning
descriptive words for visceral disorders
aching squeezing gnawing burning cramping
