Introduction to the screening process Flashcards
Three factors that create a need for screening
- Side-effects of medications
- Comorbidities
- Visceral pain mechanisms
If medical diagnosis is delayed, correct diagnosis is made when…
- The patient does not get better with PT interventions
- Patient gets better, THEN worse
- Other signs and symptoms eventually develop
Quickly, what are the reasons for screening??
DQSMDSSP
(Do question “sound medical doctor” S&S predictors)
- Direct access
- Quicker and sicker patient/client base
- Signed prescription without direct MD contact
- Medical specializations
- Disease Progression
- Patient disclosure
- Symptoms not previously reported because of forgetfulness, fear, or embarrassment
- Presence of one or more yellow or red flags
What is meant by “quicker and sicker?”
QUICKER–healthcare system we live in is trying to move patients in and out of hospital or follow up care facilities as quickly as possible.
It is important to be vigilant as a PT and not become complacent; always be looking for yellow and red flags during this short period of time you are with the patient
SICKER–The “American lifestyle” contributes heavily to the predisposition of our patients to have more than one condition taking place at once. It is important to constantly be identifying areas of possible concern in patients who may fit the mold of a certain condition that they did not come in to see you for
What is meant by “natural history?”
Medicine has changes immensely in a short period of time. People who have been diagnosed with certain conditions or diseases are living longer lives.
There are certain symptoms that you must be aware of that could occur secondarily from the chronic disease such as chronic pain, changes or limitations in ambulation and endurance, increased fatigue, etc.
What is a yellow flag?
Cautionary or warning symptom that give the practitioner pause. Screening may need to be considered
Require further investigation (screening, inquisition)
What is a red flag?
Features of a patient’s history and clinical examination that are thought to be associated with high risk of a serious disease process such as infection, inflammation, fracture, or cancer
Require immediate action (referral)
What are red flags associated with PAST MEDICAL HISTORY (Personal or family)?
CIRRHH
Personal/family history of CANCER
INFECTION within the last 6 weeks followed by:
- Neurologic symptoms 1-3 weeks after
- Joint pain
- Back pain
RECURRENT COLD/FLU
RECENT TRAUMA
HISTORY OF IMMUNOSUPPRESSION
HISTORY OF INJECTION DRUG USE
What are red flags associated with RISK FACTORS?
STAGE BASE DOO
SUBSTANCE ABUSE TOBACCO USE AGE GENDER EXPOSURE TO RADIATION
BMI
ALCOHOL USE/ABUSE
SEDENTARY LIFESTYLE
ETHNICITY/RACE
DOMESTIC VIOLENCE
OOPHERECTOMY/HYSTERECTOMY
OCCUPATION
What are red flags associated with CLINICAL PRESENTATION?
Unknown cause
Sxs unrelieved after PT intervention
Sxs get worse after PT intervention
Sxs get better, then worse
Significant weight loss (10% BW in 10-21 days)
Gradual, progressive, or cyclical sx presentation
Sxs unrelieved by rest or a change in position
Change of position, heat application, or rest no longer relieve sxs
Sxs out of proportion with what is typically seen in a condition
Sxs last longer that what is typically seen in a condition
Unable to alter sxs during examination
Sxs do not fit expected mechanical or NMS pattern
No pattern of sxs
A growing mass
Post-menopaual vaginal bleeding
Bilateral sxs:
- Edema
- Numbness
- Skin pigment changes
- Clubbing
- Nail bed changes
- Skin rash
Changes in muscle tone/ROM for individuals with neurologic conditions
What are red flags associated with PAIN PATTERN?
BFINCWTPCF
(Before finding immense negative changes within true pain, care fully)
Back/shoulder pain
Full and painless ROM accompanied with pain at rest
Inconsistent pain when compared with emotional/psychological overlay
Screening tests for emotional overlay negative
Night pain
Constant and intense pain (ARE YOU HAVING PAIN RIGHT NOW?)
Worsening pain with activity relieved by rest (area of interest being inactive)
Throbbing (vascular), knife-like, boring, or deep aching
Poorly localized pain
“Comes and goes”
Food intake or medications change MSK pain sxs
What are red flags associated with ASSOCIATED SIGNS AND SYMPTOMS?
Recent report of confusion (often reported by family)
Presence of constitutional symptoms, unusual vitals
Proximal muscle weakness associated with change in DTRs
Joint pain with skin rashes and/or nodules
Cluster of S&S observed during review of systems that characterizes a particular organ system
Unusual menstrual cycle/sxs
ASK! ANY OTHER SXS OR PROBLEMS THAT MAY NOT SEEM RELATED TO CURRENT PROBLEM?
What is primary prevention?
Stopping the process that leads to the development of some disease in the first place
FOCUS IS ON TRUE PREVENTION OF DISEASE
What is secondary prevention?
Regular screening for early detection of diseases or conditions
FOCUS IS ON IMPROVING OUTCOMES OF DISEASES
What is tertiary prevention?
Provides ways to limit the extent of disability while improving function in patients with chronic or terminal diagnoses
FOCUS IS ON MANAGING DISEASE PROGRESSION
What are constitutional symptoms?
Fever
Diaphoresis (unexplained sweating)
Sweats (occurring at any time, night or day)
Nausea
Vomiting
Diarrhea
Pallor
Dizziness/Syncope (fainting)
Fatigue
Weight-loss
What does the Goodman screening referral method entail?
Past medical history
Personal and family history
Risk factor assessment
Clinical presentation
Associated signs and symptoms of systemic diseases
Review of systems
What is a sign?
Observable findings detected by the therapist upon objective examination
Signs can be seen, heard, smelled, measured, photographed, shown to someone else, or documented in some way
What is a symptom?
Reported indications of disease which are perceived by the patient but cannot be observed by someone else
“Numbness, tingling, or creeping,” sensations are examples
What should you ask your patients instead of: “How are you today?”
“Are you better, the same, or worse today?”
“What can you do today that you could not do yesterday/last week/last month?”
What questions can the therapist ask to identify the presence of associated signs and symptoms?
“Are there any symptoms of any kind anywhere else in your body that we have not talked about yet?”
ALTERNATIVELY:
“Are there any symptoms or problems anywhere else in your body that may not be related to your current problem?”
What is the difference between a SYSTEMS REVIEW and a REVIEW OF SYSTEMS?
SYSTEMS REVIEW–brief and limited view of the anatomic and physiologic status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems as well as the patient’s ability to communicate
REVIEW OF SYSTEMS–Therapist is actively searching for any characteristics of systemic disease; it is a useful tool recognizing clusters of associated signs and symptoms and the possible need for medical referral
What are scenarios in which immediate medical referral are advised?
Anginal pain not relieved in 20 minutes with reduced activity/administration of nitroglycerin; angina at rest
Angina pain accompanied by nausea, vomiting, profuse sweating
Bowel/bladder incontinence and/or saddle anesthesia (cauda equina syndrome); cervical spine pain with incontinence
Anaphylactic shock
Inadequate ventillation/CO2 retention
Diabetic patient is confused or lethargic/changes in mental function
Positive McBurney’s point (Appendicitis); rebound tenderness (inflamed peritoneum)
Sudden worsening of claudication (thromboembolism)
Throbbing chest, back, or abdominal pain that increases with exertion accompanied by sensation of heartbeat when lying down which is palpable (aneurism)
Changes in size, shape, tenderness, or consistency of lymph nodes; detection of palpable, fixed, irregular mass in the breast, axilla, or elsewhere especially in cases of previous cancer history
In the context of screening for referral, what is the primary purpose of a diagnosis?
To guide the plan of care and intervention strategies
True or false? Direct access is the only reason PTs must screen for systemic disease
FALSE
A patient gives you a written prescription from a MD, chiropractor, or dentist. What is the first screening question to ask?
“Did the MD (chiropractor, dentist) examine you?”
When does screening for medical diseases take place?
Throughout the episode of care
PTs are qualified to make human movement system diagnosis regarding primary neuromusculoskeletal conditions, but, we must do so in accordance with…
State practice acts
When does medical referrral for a problem outside the scope of PT practice take place?
No apparent movement dysfunction exists
No causative factors can be identified
Findings are not consistent with neuromuscular or musculoskeletal dysfunction
Patient presents with suspicious red flag-type symptoms
True or False? PT evaluation and intervention may be a part of the MD’s differential diagnosis
TRUE
What is the major difference between a yellow- and a red-flag symptom?
Yellow–requires further investigation (screening)
Red–requires practitioner to seriously consider referral within the context of the patient’s complete examination
What are the major decision-making tools used in the screening process?
Past medical history
Risk factor assessment
Clinical presentation
Associated signs and symptoms of systemic diseases
Systems review vs Review of systems
