Outpatient Cases (10/9a) [Examination/Intervention] Flashcards
Goals of Interview
Establish rapport
Past medical history (PMH), history of present illness (HPI), chief complaint (CC)
Functional limitations and baseline status
Are they appropriate for PT? Any red flags?
Develop hypothesis
Plan physical examination
Establish Rapport
Hearing vs active listening
Nonverbal cues
Patient centered interview
Patient’s goals
Types of questions: open vs closed ended
Barriers to communication
Obtaining PMH
Interview
Self report measures
- PT Guide version (open ended, limited OTC)
- Patient self administered questionnaire in an orthopedic outpatient setting
Questionnaire with targeted follow up
Questionnaire - Demographics
AGE
- Some diseases are more common in certain age groups
- EX: breast and prostate cancer are most common in those 60 and older, while RA and MS are more common in younger adults
RACE
- Sickle cell anemia is more common in African American individuals
- skin cancer is more common in Caucasians
EDUCATIONAL LEVEL
- Helps you know how to interact and educate people
- Someone who has not graduated from HS will have different baseline knowledge than a physician
Questionnaire - Social History
Occupation
Hobbies or recreational activities
Habits
- Caffeine, > 2-3 cups/day, can cause tachycardia, insomnia, cardiac arrhythmia
- Alcohol, >7 females, > 14 males per week, can cause HTN, hepatitis
- Tobacco
Family medical history
Support systems and others dependent upon the patient
PMH/Comorbidities/Precautions
Cancer — over 50 yo, think recurrence if prior history
Infection — pneumonia, UTI
Cardiac — myocardial infarction> shoulder pain, HTN, CVA, angina
Depression
Pulmonary — asthma, COPD
Osteoporosis — compression fractures
Diabetes
Seizures
Pregnancy
Surgeries, especially recently — DVT, deconditioning, atrophy
Medications — Prescribed or OTC
Cardiac* — orthostatic hypotension, nitroglycerine
Steroids — long term effects on bone
NSAIDS (Aspirin, Motrin, Aleve) — GI bleeds
Asthma medication*
Insulin*
Seizure medications*
Other Questions for Screening
Feelings of depression, feeling down or hopeless
Feel unsafe at home, has anyone tried to injure you in any way
Any recent: weight loss/gain, nausea/vomiting, dizziness, fatigue, weakness, fever, chills, sweats, numbness or tingling
What is the Chief Complaint?
Pain Stiffness Weakness Numbness Joints Locking/Giving Way Referred Pain
Describing Pain
Behavior and quality — constant or intermittent, better/worse
Location — body diagram
Severity/Intensity (VAS, VRS 0-10)
Irritability
Stability
Types of Pain
Nerve - dermatomal or peripheral nerve distribution
Bone - pressure on the outside can produce deep/local pain
Vascular - throbbing, aching pain
Muscle - resistance and stretching
Referred Pain
somatic pain and visceral pain fibers enter dorsal horn and synapse on the same second order neuron
Physician’s Assistant - OPQRST
PAs use OPQRST for interview about pain
Onset Provocation/palliation Quality Region and radiation Severity Time (history)
When to refer pt to another healthcare practitioner, can’t be managed by PT at this time?
Red flags for:
- Cancer
- Cardiovascular
- GI/Urinary
- Neurological
- Others
Red Flags - General
Severe unremitting pain
Pain not affected by medication or position
Severe pain at night
Severe pain with no history of injury (not cumulative trauma)
Severe spasm
Unexplained fever/night sweats
Unexplained joint swelling/redness
Recent severe emotional disturbances
Symptoms not unaffected by movement or position
Red Flags - Cancer
Persistent night pain
Constant, unremitting pain
Unexplained weight loss
Unusual lumps or growths
Unwarranted fatigue
History of cancer
Age >50
Red Flags - Cardiovascular
Shortness of breath (SOB)
Dizziness
Chest pain / heaviness
Constant & severe calf pain or swelling/redness, esp with history of decreased activity
Pulsating pain
Discolored or painful feet
Unexplained swelling
Red Flags - GI/Urinary
Frequent or severe abdominal pain
Frequent heartburn/indigestion
Frequent nausea/vomiting
Altered bladder function
Unusual menstrual irregularities
CL example — balance worse
Red Flags - Neurological
Altered hearing
Frequent/severe headaches w/o history of injury
Problems swallowing or with speech
Vision problems
Balance/coordination problems/falling
Fainting spells (drop attacks)
Sudden weakness
When PT can manage with consultation from another practitioner?
Psychological issues (depression, fear, nonorganic signs)
Exchange of information
- Test results
- Guidelines for intervention in a medically complicated patient
Alert physician or health care practitioner
- Social worker: suspected abuse
- MD: exam findings
3 Components of Irritability
Amount of activity needed to trigger symptoms
Severity of symptoms provoked
What activity/amount of time for symptoms to subside
High Tissue Irritability
SYMPTOMS
- Resting pain
- Pain before resistance or end-range
- Recent trauma
- Symptoms easily increased
TREATMENT
- Pain control
- Inflammation
- No significant stretch or resistive exercise
Low Tissue Irritability
SYMPTOMS
- No significant resting pain
- Pain w/ overpressure, resistance before pain
- Symptoms mild and stable
TREATMENT
- Restore impairments
- Strength
- Flexibility
Plan Examination
Medical screening (EX: CVA tenderness)
Upper/lower quarter screening examinations
Specific joint examination and special tests
