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Screening for referral is based on what three items?

~Clinical presentation
~Associated S/S


What is PMH-

What they told you


What is Clinical Presentation?

What you saw


What is associated signs and symptoms

What you asked about


The idea behind screening is..

to know what to look for so that when it appears in the clinical presentation (or when the patient reports certain red flag histories, risk factors, or symptoms) you will recognize it immediately and respond appropriately


What are some questions to keep in mind during the screening?

~What questions would be appropriate for your first physical therapy interview with a patient/client?
~What test procedures should you carry out?
~If you suggest that the patient/client see a physician, how would you make that recommendation?
~How would you communicate your findings to the physician?


What is the first thing to do when screening/ examining the pt?

take vitals!


What are other important ideas to keep in mind during the screening/ examination?

~Review the pain body chart
~Review medications and their potential side effects against current signs and symptoms
~Watch for red flag histories, risk factors, and associated signs and symptoms
~Always ask a broad, open-ended question


What are normal variations for systolic when comparing sides?



What are normal variations for diastolic when comparing sides?

they should be the same/ no variations


What are some red flags (some s/s to look for) to keep in mind when taking vitals?

If you see unusual vital signs, you need to see if any of these s/s are also present


What vital signs should be documented?

~Pulse oximetry (O2 saturation)
~Skin temperature
~Core body temperature (oral or ear)
~Blood pressure


What should your response to "constant" pain be?

Do it ever come and go? Do you ever get any relief?


Constant pain: is it worrisome??

It can be. It depends on the type of pain.

~Musculoskeletal pain can be constant but it can also be moderated (made better or worse)

~Pain that is always present and intense (7 or higher on a scale from 0 to 10) requires further evaluation (worrisome)


If a person says that they are in constant pain, what can you give them to see how the pain is throughout the day?

~The McGill Home Recording Card can be used to further evaluate constant pain

~The patient/client can track pain for 24 to 48 hours (rather than every day for a week) to help give a more accurate picture of the pain pattern


Why do we look at the medication list? (I know that there are lots of reasons, but think when we are screening)

~Many unusual signs and symptoms are adverse effects of medications and/or drug combinations
~When appropriate, compile a list of medications currently being taken by the patient and consult with a pharmacist regarding possible side effects
~Compare current symptoms with side effects
~Report any suspicious clinical presentation to the physician


What are some ref flags for a systemic illness?

~Gradual onset with no known cause (progressive weakness)
~Gradual, progressive, cyclical onset (endometriosis)
~Symptoms unrelieved by rest or change in position
~Bilateral (spinal cord impingement)
~Constitutional symptoms (organ dysfunction or systemic illness/infection)


What type of bilateral symptoms are we looking for?

~Pigmentation changes
~Clubbing/nail bed changes


What are other s/s that we need to watch out for (constitutional symptoms)?

~Night sweats
~Weight loss


What are some other s/s that we need to keep an eye out for?

~Visual changes
~Unusual vital signs
~Warning signs of cancer
~Orthostatic hypotension


What should you do if you see a cluster of red flags/ s/s that shouldn't be there?

~ask some additional questions

~if it looks like there is an identifiable system (e.g., endocrine, renal, pulmonary system) or body part (e.g., shoulder, back) involved, look in the text at the most appropriate Special Questions to Ask sections of our book


What are some good examples of questions to ask at the end of the subjective/ to make sure that you have a complete picture?

~Are there any other symptoms anywhere else in your body that we haven’t talked about yet?

~Is there anything else you would like to tell me?

~Is there anything else you think I should know?

~Is there anything else you think is important about your condition that we haven’t discussed yet?


Case 1: 33 y.o. male c/o L shoulder pain, initially reports “constant pain at night.” Made worse by lying down, day or night; deep ache; moves from bed to couch to chair in search of comfortable position. Arm was injured 6 months ago in a basketball game when he fell and landed on shoulder. Symptoms gradually increasing, although a small amount of relief by putting a rolled towel in armpit.
Takes no medications; family history of CAD, father died of MI at 67 y.o. No personal or family history of cancer except breast cancer in maternal aunt.

Relevant PMH, Clinical presentation, s/s?

~Mechanism of injury
~Positional pain
~pain gradually increasing

*father died of MI old enough for us not to worry
*FH of cancer is only an aunt with breast cancer


Case 2: 56 year old male referred to PT with c/o R sided paraspinal T 4 pain. Symptoms began following a chiropractor’s intervention to relieve lumbosacral pain with a rotational manipulation of the lumbar spine. A sharp shooting pain was felt at T4, radiating under the R axilla and into the anterior chest. He also reported tension and tightness along the same thoracic level and moderate discomfort during inspiration. There was no previous history of thoracic pain. Patient now unable to complete a full day at work without discomfort.
Pt. has a 40 pack-year history of smoking. He has a chronic cough and mild dyspnea after walking 1 flight of stairs to your office.

Relevant PMH, Clinical presentation, s/s?

~ age
~cough/ dyspnea

~not constant P

*Flags- constistant with he takes breath, worsening

*gallbladder, liver, heart, lungs can refer
Ask do you drink and how much;
Ask about eating- if you eat fatty food- gallbladder
Ask about the consistency of the pain
Ask about PMH of any cancer
*Could have a primary in the lungs that go to the spine
He is high risk so you need to be thinking about cancer- don’t manip without an xray- need to refer so that an xray can be done


Case 3: 73 y.o woman referred to PT by oncologist with dx of cervical radiculopathy. Hx includes uterine cancer 20 years ago and breast cancer 10 years ago. She has had hysterectomy, L radical mastectomy, radiation therapy, and chemotherapy. While she has been cancer free for almost 10 years, you palpate suspicious L cervical and axillary lymph nodes.

relevant PMH?

~Cancer 2 different types

*lymphoma can appear (enlarged lymph nodes) within 24 hours