Exam Principles - Class 2 Flashcards
history includes
general info
general info from history
age
sex
race
marital status
leisure activities
occupation
how can gender be important
certain dzs are more common in one sex than the other
how can race be important
race can predispose certain groups to a higher incidence of specific dzs
ex: sickle cell is more common in african americans
how can age be important
certain dzs are more common w/in specific age groups
how can occupation be important
exposure to extremes of temp, to industrial toxins to extreme levels of mental or emotional pressures
location and description of sxs includes
location of the sxs
how the pt describes the sxs
once the chief complaint has been described
must screen the remainder of the body for the presence of other sxs
investigating the chief complaint also includes
interpreting the terms the pt uses when describing their sxs
CV system is described as
throbbing
cramping
pressure
tightness or heaviness in the thoracic, cervical facial or UE
nervous system is described as
weakness
poor balance
numbness
pins and needles
visceral is described as
ranges from sharp, severe, localized pain to poorly localized dull and vague sensations
sxs location
only occasionally helps differential dzs from impairments
but does play an important role in the medical screening process
when should sxs location prompt you to refer back
chest pain that extends to the left UE or jaw, etc.
as a PT we must know
pain patterns associated w/ various dzs
sxs behavior
change in the location, intensity +/or quality of the pt’s complaints as related to activity, cessation of activity and specific body positions
sxs from MS dsyfxn can be associated w/
change in posture or physical activity
if the pt’s complaints of MS dysfxn do not get not vary with movement or rest
must be suspicious of a pathologic disorder as the cause of sxs
what do we want to know –> sxs behavior
how the sxs behave over a 24-hr period
this includes the presence of night pain
night pain
pain waking the pt
associated w/ the presence of serious dz
who else may experience night pain
pts w/ joint dysfxn and degeneration
when should we be concerned –> night pain
pt cannot fall back to sleep
considerable effort is needed to fall back asleep
when should we be less concerned –> night pain
if pain awaken the pt and they change positions
easily fall back asleep
pt state that the pain they experience at night is the most intense pain that they experience in a 24 hr period
should be concerned
we cannot rule out the possibility of dz…
just b/c sxs vary with movement or change in posture
ex: fx that occurs w/o trauma
ex: fx that occurs w/o trauma
bone has been weakened by another dz
sxs history
onset of sxs may also be an important factor in differentiating b/w dz and dysfxn
when is the onset of sxs is truly insidious
new sxs occur insidiously during the course of tx
if resolves sxs return for no apparent mechanical reason
onset is truly insidious should
be concerned about an underlying cause
was there a specific incident prior to the oxet of sxs?
pt may have difficulty identifying a specific cuase
careful questioning by the therapist may pinpoint the problem
medical history
current and past illness
subsequent txs
family medical history
diet
tobacco use
alc and drug use
subsequent tx
medications and surgery
systems review
questions that investigate the presence of sxs in each of the major body sxs
checklist that review the pts general health
fever/chills/sweats
unexplained weight change
malaise
nausea/vomiting
bowel dysfxn
numbness and weakness
syncope
dizziness/light headiness
night pain
fever/chills/sweats are often associated with
flu
fever/chills/sweats may also be associated with the presence of
occult infections or cancer
unexplained weight change measurement
5% of BW of 4-week period
unexplained weight change is a potential sxs for
gastrointestinal disorders (ulcers and cancer)
diabetes
hyperthyroidism
adrenal insufficiency
common infections
malignancies
depression
malaise will
complain of fatigue or loss of energy
unexplained weight loss is when
the pt is not trying to lose weight
malaise can be the result of
depression
infections
hypothyroidism
diabetes
anemia
cancer
nutritional deficits
RA
certain meds may produce
malaise as a side effect
nausea/vomiting is most directly associated with
gastrointestinal system
nausea/vomiting may also denote
pregnancy
cancer
from meds
bowel dysfxn is related tot he
GI system
when else can bowel dysfxn be
spinal cord syndrome
cauda equina
numbness and weakness will lead us to investigate the
nervous system
syncope is associated with
inadequate blood flow to the brain
dizziness and lightheadedness may be from
meds
hypoglycemia (in a diabetic pt)
lightheadedness can be
vascular
night pain –> systems review
dyspnea
dysuria, urinary frequency changes and sexual dysfxns
dyspnea could indicate
CV or pulmonary system dz
dysuria, urinary frequency changes and sexual dysfxns may indicate
urogenital system
investigating pts sxs is often
the first step that first alerts you to the possible need for referral
your questioning should reveal
a pattern of sxs
usual for impairment driven conditions
if sxs dont align with impairment driven conditions
consider an underlying dz
suspicious may be based on
atypical description of sxs provided by the pt
description that does not make sense
description that does not make sense
based on your understanding of basic clinical sciences and your clinical expertise
