Exam: Review of systems and medical screening Flashcards

1
Q

Past Medical History

A
  • Review of Systems– Medical Screening
  • Checking for constitutional signs…general signs/symptoms that are present with illness involving any of the systems:
  • Assess patient’s overall physical (weight changes, fatigue/lethargy) and emotional (anxiety, hopelessness) well‐being
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2
Q

Nausea/ Vomiting screening

A
  • low level nausea
    > often goes unreported
  • inquire
    > is there a reason for nausea? constant, intermittent, describe?
    > any other new/unusual signs and symptoms?
    > vomiting w or w/out nausea?
    > are they taking OTC Meds? may mask nausea
  • referral
    > persistent vomiting usually reported to physician
    > nausea w increased need meds, other constitutional signs
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3
Q

Nausea/vomiting may be caused by

A
  • GI disorders
  • Infection (hepatitis, influenza)
  • MI
  • Cancer
  • Vestibular disorders
  • Migraines
  • Pregnancy
  • Adverse drug reactions
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4
Q

Fever/sweats/chills screening

A
  • systemic response to a systemic illness
    > have you been feverish or unusually hot, noted excessive sweating, or felt chilly and cold?
    > have you been taking your temp?
  • Temp: significant if 99.5 or higher for >2 weeks
    > accounts for self limiting virus
    > absence of fever doesn’t rule out infection
    > higher fever (ie. 102) = urgent referral
    > complete full pt picture (fatigue, malaise, decreased thermoregulation in elderly)
    > caution in post-op pts with signs of op-site infection
  • night sweats
    > concerns: regular, interrupt sleep, have other sxs, fever, wt loss
    > can also occur w menopause, some meds, room too warm, many other causes
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5
Q

fever/sweats/chills caused by

A
  • infections
  • metastatic cancers
  • rheumatic disorders
  • menopause

be cautious of negative responses in these cases

  • elderly - reduced thermoregulatory responses
  • post-surgical
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6
Q

weight changes screening

A
  • are you experienceing any unexplained wt changes?
  • 5 to 10% increase or decrease of BW over a 4-6 month period (time period definition varies)
    > unexplained
    > red flag response

-exceptions requiring referral
> pregnancy: >5lb wt gain in 1 week or >5 lb loss in first trimester
> CHF: > 2-3 lbs in a day

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7
Q

Weight changes caused by

A
  • metastatic cancers (unexplained, > 10 lbs over 6 mo)
  • depression
  • GI disorders
  • infections
  • anorexia nervosa
  • chronic pulmonary, cardiac, or renal failure
  • rheumatic disorders
  • endocrine disorders, thyroid dysfunction, DM
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8
Q

Parasthesia, weakness or balance problems screening

A
  • are you experiencing any numbness or tingling in your…
  • pins and needles
  • are you experiencing any weakness in your arms or legs
  • are you experiencing any dizziness or lightheadedness when you…
  • have you had any difficulty maintaining your balance when you walk?
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9
Q

parasthesia

A
  • concern if bilateral, atypical pattern, or UE/LE together, other neuro sxs present (vision, taste, smell, hearing)
  • saddle anesthesia
  • possible disorders contributing
    > neurologic disorders
    > endocrine disorders
    > renal disease
    > adverse dug reactions
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10
Q

Weakness

A
  • concern if non-myotomal
  • concern if any other neuro sx present
  • urinary retention, increased frequency, overflow incontinence
  • possible disorders contributing
    > neurologic disorders
    > endocrine disorders
    > muscular injury/disease
    > rheumatic disorders
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11
Q

balance problems

A
- dizziness or lightheadedness?
> vestibular issues
> vascular insufficiency
- possible disorders contributing
> neurologic disorders
> adverse drug reactions
> msk injury/disease
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12
Q

night pain

A
  • difficulty sleeping or falling asleep due to sxs
  • wakes at night due to sxs and unable to easily fall back asleep
  • pain not relieved by lying down
  • pain unchanged w/ position change or food
  • frequency ( per week, per night)
  • due to possible:
    > infection
    > neoplasm
    > other… inflammation, OA
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13
Q

Fatigue

A
  • accounts for more than 20% PC visits/year in US
  • normal fatigue- life, stresses, work, grief
  • concern if interfering with function for more than 2 to 4 weeks
    > especially if not related to above factors
    > presentation may be subtle
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14
Q

fatigue may be caused by

A
  • psychosocial
  • endocrine/ metabolic
  • infections
  • neoplasms
  • cardiopulmonary
  • connective tissue disease
  • sleep disturbances
  • medication use
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15
Q

malaise

A
  • sense of uneasiness or general discomfort
  • out of sorts feeling
  • something just isn’t right
  • i feel like i’m coming down with something
  • often associated with fever
  • PT needs to inquire about this question since patients do not usually reveal this and is not on medical screening form. It is usually derived from pt comments.
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16
Q

Mentation or cognition

A
  • based on observation
    > alert, oriented
    > attention and thought processes
    > good historian - memory and judgment
  • may be difficult to assess
    > may need to determine over time or discuss with family member or caregiver
    > broad range of impact
- possible disorders contributing
> infection
> adverse drug reaction
> neurologic disorders
> drug/alcohol abuse
  • yellow flag
    > physician aware/monitor
  • get sufficient detail for discussion w physician
17
Q

medications

A
  • name, dosage, frequency
    > check point: for every medication listed, there should be a corresponding current or past medical history that can be related
  • type of medication currently taking
    > should correlate with medical conditions in chart
    > statin drugs- control of high cholesterol
    > opioid narcotics - excessive pain correlating to diagnosis, condition
  • inquiry into
    > any recent change in meds/dosage
    > are they taking the meds regularly
    > over the counter medications/supplements
    > do they feel the meds are causing any adverse symptoms
  • consult physician
    > may need to consult with physician about meds
    > encourage patient o discuss with physician
18
Q

medications side effects

A
  • NSAIDS
    > GI bleeds, fatigue, death
  • statin drugs
    > complaints of fatigue, weakness, myalgias
  • steriods
    > can cause fatty infiltrates into bone marrow leading to bone death
    > osteoporosis
  • anticoagulants
    > aggressive exercise or mobilization or manipulation should warrant precaution/contraindication- may cause bleeding
19
Q

psychosocial

A
  • screen for depression fear, anxiety, signs of abuse

> depression questions

20
Q

Social History

A
  • Occupation/former occupation
  • Home environment
    > City or rural location
    >Single or multiple level
    >How many steps or stairs, location, handrails
    >Tub/shower design, grab bars
    > Other specifics PRN
  • Religious beliefs
21
Q

Current health behaviors

A
  • ETOH: drinks per day or week
  • smoking history: packs per day or week
  • nutrition/diet: fruits, veggies, cardiac, diabetic, etc
  • sleep: hours per night
  • physical activity: exercise, general activity level
  • stress level
22
Q

Activities and participation

A
  • prior level of function
  • patient goals - what patient would like to be able to do
  • key information:
    > justification for skilled PT intervention and POC
    > reimbursement for services
23
Q

Red flags

A
  • unexplained weight loss
  • symptoms that awaken the patient at night
  • severe pain is unchanged by position or movement
  • alterations in bowel/bladder function
  • recent history of fever, chills, night sweats, nausea, vomiting