Ch. 1 Introduction to Screening for Referral in PT

What is primary care?

Coordinated, comprehensive, personal card provided at first contact on a continuous basis.
Includes primary/secondary prevention and whole-person care.

Primary care PT is best described as what?

A philosophy of care, not a setting

What is meant by “whole-person care” in primary care PT?

Treating the patient as a person, not just the body part. Considers all factors affecting clinical decision-making

What does “screening” mean in PT practice?

A methodical exam used to separate patients into diagnostic groups and determine appropriateness for PT

Differential diagnosis includes what 2 major ideas?

- Differentiating between similar conditions
- Ruling out medical diseases that masquerade as MSK problems

What is the PT’s main responsibility in primary care?

To determine if the patient is an appropriate candidate for PT

What should a PT do if the presentation is beyond scope or expertise?

Refer or consult with an appropriate medical provider

Are PTs medical diagnosticians?

No. PT perform medical screenings, not diagnosis

What is the purpose of screening for medical diseases?

Identify clusters of concerning signs/symptoms and refer appropriately

What is a key foundation of evidence-based screening?

A well-developed history guiding appropriate questions and tests

What is a yellow vs red flag?

Yellow - a cautionary sign signaling “slow down” often related to psychological distress
Red - a warning sign suggesting risk of serious pathology

Do red flags always mean referral?

No- referral decisions depend on context and clusters

What is the general guideline for red flag concern?

3 or more red flags or risk factors + red flags together increases concern

Why is a single red flag not always an emergency?

Because context matters, and many red flags can occur for benign reasons

What is the best approach to identifying red flags?

Identify patterns and clusters, then follow up with screening questions

What is an example of a “false alarm” red flag presentation?

Shoulder pain relieved by position
Weight loss due to intentional dieting
Intermittent night pain due to sleeping positions

What are the key areas PTs identify red flags?

PMH
Risk factors
Clinical presentation
Pain patterns
Associated signs/symptoms

What are some common clinical presentations of red flags?

- Symptoms are out of proportion to the injury
- Symptoms persist beyond the expected time for that condition
- Unable to alter symptoms during exam
- Does not fit the expected pattern
- No discernable pattern
- Growing mass
- Bilateral symptoms

What are some common pain patterns for red flags?

- Back or shoulder pain
- Full and painless ROM
- Night pain
- Symptoms are truly constant and intense
- Pain poorly localized

What are some PMH indications of potential red flags?

- Personal or family history of cancer
- Recent infections (last 6 weeks)
- Recurrent cold/flu symptoms
- Inadequate relief with rest/positioning

What are some immunosuppression red flag examples?

Steroid use, organ transplant history, HIV

What is a major behavioral red flag?

IV drug use

What are some examples of major systemic disease risk factors?

- Smoking
- Alcohol abuse
- Sedentary lifestyle
- Obesity/BMI
- Radiation Exposure
- Age
- Occupation

What does “pain out of proportion” suggest?

Possible serious pathology or non-MSK origin

What does “symptoms persist beyond expect healing time” suggest?

Potential misdiagnosis or underlying systemic cause

What does “unable to alter symptoms during exam” suggest?

Symptoms may not be MSK in nature

What is a key red flag or females post-menopause?

Vaginal bleeding 1+ year after last period

Why are bilateral symptoms concerning?

Can indicate systemic or central involvement rather than local MSK dysfunction

What pain regions are most common for systemic referral patterns?

Back and shoulder pain

Why is confusion a red flag?

Suggests systemic illness or neurological involvement

What is an example of unusual vital signs suggesting systemic pathology?

Temperature > 100 F

Proximal muscle weakness and Deep Tendon Reflex changes may suggest what?

Neurological/Systemic Disease

What are constitutional symptoms?

Systemic symptoms suggesting serious illness

List a few key constitutional symptoms

- Fever
- Night sweats
- Night pain
- Vomiting
- Diarrhea
- Pallor

Why are constitutional symptoms considered “true red flags”?

They strongly suggest systemic pathology and often warrant referral

Why must PTs screen in modern healthcare?

Patients are “quicker and sicker”

What does “quicker and sicker” mean in healthcare?

Shorter medical visits and more comorbidities. Patients have faster discharge and less time with physicians to reduce healthcare costs. Patients often have multiple comorbidities aka “sicker”

What does “natural history” of disease progression mean?

People are living longer with serious disease, but they develop secondary impairments over time

Even given a signed prescription, why is performing a thorough evaluation still important?

Physicians may not have done a full screening or evaluated thoroughly prior to PT referral

Why can medical specialization sometime increase patient risk?

Specialists may assume someone else ruled out systemic causes

What is “screening for referral” in PT?

Determining whether communication with a physician is warranted and if PT is appropriate

What major questions should PTs ask during screening?

“Is this patient appropriate for PT intervention”

What are the 4 categories in the Guide to PT Practice?

- MSK
- Neuromusculoskeletal
- Cardiopulmonary
- Integumentary

What is the purpose of differential diagnosis in PT?

Rule in/out possible causes and identify movement dysfunction while recognizing need for referral

What improves confidence in differential diagnosis?

The more conditions you can rule out, the more confident you are in what remains

What is Phase 1 of Patient Managament?

Refer/consult (if needed) and evaluation/examination

What is Phase 2 of Patient Managament?

Diagnosis > Prognosis > Intervention > Outcomes

What is the difference between examination and evaluation?

Examination - collecting data
Evaluation - synthesizing/interpreting it

What is Step 1 of the Diagnostic process in PT?

Screening for non-MSK sources of symptoms

What is Step 2 of the Diagnostic process in PT?

PT differential diagnosis (movement systems + treatment planning)

What are some core components of the screening process?

- Intake forms/chart review
- Vitals
- History
- Chief Complaint
- PMH review
- Systems review
- Physical exam
- Correlate signs/symptoms

What is the difference between systems review vs review of systems?

Systems Review - limited exam of the 4 main PT systems
Review of Systems - broader assessment across body systems

What is a sign vs symptom?

Sign - observable finding
Symptom - patient-reported experience

Why is “expert thinking” the best for clinical reasoning?

Patient’s do not present neatly in one category, so its important to interconnect patterns across systems

What is a critical legal/professional step when referring patients?

Document everything and communicate effectively with the physician (paint the picture)

When deciding on whether a patient needs a referral, we base it off of “Emergent” or “Non-Emergent”. What is the difference?

Emergent - need immediate sending to ER or call to the physician office for guidance on patient care
Non-Emergent - can email or fax the physician on the findings and have them decide the next steps

Even if red flags exist, can the patient still have MSK dsyfunction?

Yes - systemic pathology and MSK impairment can coexist