Week 1 Guiding Q's (Exam 1)

Question 1

What regions of the body may systemic disease refer to? Of these regions, which two are the most common paths of referred systemic disease?

Answer 1

• Back (thoracic and lumbar spine) – most common
• Shoulder – most common
• Neck
• Chest/ribs
• Hip/groin
• Sacrum/pelvis

Question 2

What are the 3 options that Physical Therapists have after each patient encounter?

Answer 2

• Treat the patient – appropriate for PT
• Refer the patient -refer due to yellow or red flags
• Treat and refer the patient -safe to treat, but still needs referral for a separate condition ex: elevated BP but there for a back issue)

Question 3

What are the 5 steps of the Goodman Screening Model?

Answer 3

Carried out through the patient interview and verified during the physical exam

Includes

• Client history
• Risk factors
• Clinical presentation
• Pain types/pain patterns
• Associated signs and symptoms of systemic disease
• Review of systems

Steps:

1. Identify chief and secondary problems
2. Identify information inconsistent with the presenting complaint
3. Identify noncontributory information
4. Generate a differential diagnosis/working hypothesis regarding possible causes of complaints
5. Determine whether referral or consultation is indicated
6. Identify the presence of red/yellow flags

Question 4

What are constitutional symptoms and why is it important to identify them? What are examples of these symptoms?

Answer 4

Nonspecific symptoms that could be related to many different systems of the body. If they have these symptoms and they aren’t explainable that’s a red flag. You will either need to screen further or refer them out.

Symptoms:

1. Fever
2. Diaphoresis (unexplained perspiration during day or night)
3. Chills
4. Sweats (night or day)
5. Appetite loss
6. Nausea
7. Vomiting
8. Diarrhea
9. Pallor (loss of color)
10. Dizziness/syncope (fainting)
11. Fatigue/malaise/weakness (figure out what type of fatigue is)
12. Weight loss

Question 5

Name a few examples of red flags and the medical condition(s) associated with the red flag. Name a few examples of yellow flags.

Answer 5

Red Flag: requires immediate attention that will either require pursuing further screening or make the appropriate referral

• GI symptoms affect back pain, high/elevated BP over the course of several visits, etc.

Yellow flag: Psychosocial barrier to recovery. Potential to increase risk of long term disability and work loss. Ex: depression, anxiety, pain catastrophizing

• Presence of any one symptom not usually cause for extreme concern
• Review Red and Yellow flags in the context of the whole patient
• Looking for pattern to suggest viscerogenic or systemic origin

Question 6

How do you determine if a patient presenting with 1 or more red flags needs to be referred to a physician?

Question 7

Describe the difference between the systems review and the review of systems? What is included in your systems review (hint: review content from CP1)?

Answer 7

Systems Review:

◦ Defined by Guide as “a brief or limited exam of the anatomic and physiologic status of the cardiovascular/pulmonary, integumentary, musculoskeletal and neuromuscular systems”

◦ Also includes assessment of patient’s communication ability, affect, cognition, language and learning style

◦ Looks beyond patient’s primary complaint

◦ “Whole person”

◦ Helps answer “What should I do next?”, “ What do I need to examine in depth?” and “What don’t I need to do?”

◦ Review of Systems:

◦ Defined by Guide as “a series of questions or checklists to identify symptoms potentially associated with occult disease, medical conditions, and/or adverse medication events that may mimic conditions that are amenable to physical therapist intervention”

◦ Identified clusters of associated signs and symptoms are reviewed to search for potential patterns identifying underling system involvement and possible need for medical referral

◦ If the signs and symptoms fall primarily within the pulmonary system, then PT will want to go over the related review of systems questions

Categorize all complaints and associated signs and symptoms and determine if they pertain to a specific system

◦ie Are the signs and symptoms GI related?

If symptoms do fall into one specific system, follow-up questions related specifically to that system are indicated (see Appendix D5)

Ask all patients General, Integumentary & Musculoskeletal/Neurologic question sets

Question 8

Differentiate a sign verses a symptom.

Answer 8

• Signs- observable findings detected by the PT in an objective exam (ie unusual skin color, clubbing of fingers, hematoma, etc)
• Symptoms- reported indications of disease that are perceived by the patient but cannot be observed by someone else (ie pain, discomfort, numbness, etc)
• Each system has typical set of core signs and symptoms
• Awareness of signs and symptoms associated with individual system assist the PT in making an early connection
• The presence of constitutional symptoms is always a red flag

Question 9

What are the 4 red flag factors found to be informative for vertebral fracture?

Answer 9

Red flags for fracture considered to be informative

• Prolonged steroid use
• Age >70
• Significant Trauma
• Female

having 2 or 3 features is highly predictive of a fracture