ultimate screening

services

• comprehensive list of service for free

WCMC

• 24 hour hotline

• assistance filing Protection from Abuse Orders onsite at courthouse

• court accompaniment to PFA, district court, preliminary hearings

• legal advocacy and options counseling

• assistance w/ Crime Victim Compensation and restitution filings

• assistance w/ SAVIN registration

• court orientation and instruction for victims on legal procedures

• individualized and Support group counseling

• assistance locating emergency, affordable and/or temporary housing

• info and referral for crisis callers

• advocates to intervene on a victim’s behalf w/ employer or creditor

• professional trainings and technical support for Law enforcement and criminal justice personnel

• professional trainings and technical support for healthcare providers

• prevention education in schools, workplaces and community settings

• systems advocacy at local and state level for the rights of domestic violence victims

• assistance to victims w/ immigration issues due to victimizations

• bilingual and language line support

teen support lines

• private not confidential

abuse

domestic violence doesn’t discriminate. People of any race, age, gender, sexuality, religion, education level, or economic status can be a victim — or perptretotor — of domestic violence

• multiple forms of abuse are usually present at the same time in abusive situations and its essential to understand how these behaviors interact so you know what to look for

signs of abuse

• using intimidation

• using emotional abuse

• using isolation

• denying, minimizing, and blaming

• using children

• using privilege

• using economic abuse

• using coercion and threats

why do people stay

• low self-esteem

• fear

• the belief the partner will change

• fear of financial stability

• love

• abuse is normal

• for the children

• but growing up in a violent home may be terrifying and traumatic experience that can affect every aspect of a child’s life, growth and development

low self esteem

people w/ low self esteem might not want to feel the rejection could come w/ speaking up. they may feel theabuse is deserved or that others won’t beleive them

fear

often people impacted by abuse are afraid of being physically harmed, being lonely, being outed or afraid of the unknwon

children who witness their parent abusing each other

• physically

• behaviorally

• emotionally

physically

suffer symptoms of PTSD, such as bed-wetting or nightmares, and are at greater risk than their peers of having allergies, asthma, GI problems, headaches and flu. they might have more ailments as adults as well

behavioralay

are at an increased risk of exhibiting aggressive, anxious, depressed or hyperactive behvior

emotionally

ae more likely to be abused as teens and adults

trauma informed stance

• transparency

• predictability

• client control

• reliability

when it comes to documentation

less is more

high risk groups

• history of cancer

• any adult over 65

• Any cardiac procedure/medical history

• Unknown cause/etiology, insidious onset

• Bilateral clinical presentation

Why is it important for PT’s to screen patients for non-musculoskeletal or neuromuscular issues?

• Systemic disease can mimic neuromuscular or musculoskeletal dysfunction
• PT’s responsibility is to triage patients appropriately
• Need to refer to another health care provider?
• Recommendations for additional services

when might someone need to be referred

• Medical conditions yet to be diagnosed
  • Responsible for symptoms
  • Not responsible for symptoms

• Existing medical conditions
  • Clinically stable or unstable

• Outside scope of PT practice

What Is Medical Screening?

• Medical screening is the process of evaluating patient examination data for the purpose of deciding whether a patient referral is warranted
• Screening for referral is the expanded definition to include referral for other health care services/consultation
• APTA’s Vision 2020
• Direct access

What are the typical subjective reports and signs/symptoms of a musculoskeletal issue?

• Pain
• Stiffness
• Weakness
• Mechanical behavior
• Relieved with rest
• Signs of inflammation
• Impaired function
• Traumatic or atraumatic
• Others

history of cancer

• ver 40

• risk increases over 50

adult over 65

• age-related changes across multiple systems

• multiple comorbidites

common comorbidities

• Hypertension: 21%
• OA: 18%
• Depression: 15%
• Asthma: 10%
• Anemia: 10%
• Stomach ulcer: 7%
• Heart disease: 7%
• Hypothyroidism: 7%
• Urinary incontinence: 5%
• Diabetes: 5%
• RA: 4%
• Hepatitis: 3%
• DVT: 3%
• Heart attack: 3%
• Chemical dependence: 2%
• Hyperthyroidism: 1%

hypertension

• • U.S. adults: approximately 30%
  • Similar percentage for males and females

• Prevalence increases with age
  • 18–39: 7.5%
  • 40–59: 33.2%
  • 60 and older: 63.1%

• 51% controlled

• 82% aware of their hypertension

ischemic heart disease

• Higher incidence in males; incidence increases in females after menopause
• Angina most common indicator of CAD
• Associated with smoking, hypertension, diabetes

clinical relevance of ischemic heart disease

• Looking for change in baseline of symptoms

• Recognize symptoms suggesting unstable angina
  • Stable: regular with consistent pattern
  • Unstable: abrupt change in usual pattern

• Immediate communication with MD if recent increase in:
  • Pain intensity, pain frequency, pain duration
  • Symptoms more easily provoked
  • More frequent use of medication
  • Predictable and consistent to unpredictable and inconsistent

diabetes

• 10.5% of the U.S. population
• Age 65 and older: prevalence is 26.8%
• 7.3 million adults aged 18 years or older who met laboratory criteria for diabetes were not aware of, or did not report, having diabetes, representing 2.8% of all U.S. adults

goals of medical screening

• Identify symptoms unusual for impairment related conditions

• Identify symptoms unrelated to the patient’s chief complaint
  • Existing comorbid conditions
  • Occult disease
  • Adverse drug reactions

strategies for medical screening

• medical record overview

• self-report screening tools

• patient interview/exam

review of systems

• Fatigue
• Malaise
• Fever, chills, sweats
• Unexplained weight change
• Nausea, vomiting
• Dizziness, lightheadedness
• Paresthesia, numbness
• Weakness
• Change in mental status, cognitive status

fatigue

• ~20% of primary care visits

• Associated with:
  • Serious illnesses
  • Psychological disorders
  • Infections
  • Cancers
  • Endocrine disorders
  • Medications

follow-up questions for fatigue

look at slide 33

red flags for fatigue

• Fatigue interferes with ADL’s, work, school
• Lasted 2 to 4 weeks or longer

malaise

• Sense of uneasiness or general discomfort
  • “Something isn’t right.”

• Associated with:
  • Systemic conditions which generate a fever

• Often identified by patient comments

fever, chills, sweats

• • Fever the result of the release of pyrogens into the bloodstream from toxic bacteria

• Associated with:
  • Infections
  • Cancers
  • Connective tissue disorders (ex. RA)

• Reduced thermoregulatory response in older
  adults

red flag for fever, chills, sweats

Fever for 2-3 weeks or longer and patient has not seen a physician
• Higher than 98.9°

unexplained weight change

General guideline of 5-10% of body weight
• During pregnancy, a loss of more than 5% during the first trimester should be reported

Gain of 5 lbs or more over 1-week during pregnancy may be associated with preeclampsia

weight gain is associated with

• Fluid retention
• CHF, liver or renal disease, preeclampsia
• Depression
• Hypothyroidism
• Cushing’s syndrome

nausea

• Organ system disease
• Systemic illness
• Adverse drug reaction

red flags of paraesthesia, numbness or weakness

• Progressive neurologic loss (motor or sensory)
• Saddle anesthesia
• Urinary retention
• Increased urinary frequency
• Overflow incontinence

Paresthesia, Numbness or Weakness

• Glove and stocking distribution of altered sensation
• Bilateral neurologic extremity deficits
• Combination of upper and lower extremity neurologic deficits

potential causes of dixxiness and lightheadedness

• Neurologic

• Cardiac and vascular

• Other
  • DM
  • Cervical pathology related (794)
  • Anxiety
  • Psychosis
  • Hypoxia

changes in mentation

Onset or worsening of confusion or disorientation
• Delirium
• Dementia
• Head injury
• Adverse drug reaction

Need to collect specific details for communication with the physician

Systems Level Screening

• Cardiovascular
• Pulmonary
• Nervous
• Gastrointestinal
• Psychological
• Endocrine
• Urogenital
• Integumentary

Visceral Pain Patterns

• Often vague and not well localized
• Considerable overlap between pain location patterns associated with visceral disorders and common musculoskeletal issues
• Knowledge of pain patterns associated with the viscera can guide which systems to screen
• Knowledge of pain patterns associated with various diseases can guide which disorders/diseases should be screened

look at visceral patterns

Mechanisms of Referred Visceral Pain

• Referred pain is perceived at a remote location to the site of the lesion
  • Pain that is diffuse and difficult to describe or pinpoint

• Pathways for visceral sensation are diffusely organized both peripherally and centrally

potential mechanisms for visceral pain

• multi-segmental innervation

  • direct pressure and shared pathways

Multi-segmental innervation

• Multiple levels of innervation to organs
• Sensory fibers for the viscera and somatic structures enter the spinal cord at the same levels converging on the same neurons

Thoracic Spine Pain

• Cardiovascular
• Pulmonary
• Gastrointestinal
• Urogenital

L/R Shoulder Pain

• Cardiovascular
• Pulmonary
• Gastrointestinal

Lumbo-Pelvic Pain

• Gastrointestinal
• Urogenital
• Peripheral vascular

Inconsistent Symptomatic Pattern

• Psychological

• Endocrine

• Neurological

• Consider
  • Rheumatic conditions
  • Adverse drug reaction
  • Neoplastic
  • Congenital
  • Autoimmune

Cardiovascular Checklist

• Dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Palpitations
• Pain with sweating
• Syncope
• Peripheral edema
• Cough
• Peripheral vascular
• Cold Hands/feet
• Skin discoloration
• Open wounds
• Absence of hair
• Limb pain with activity
• ASSESS VITALS!

Pulmonary Checklist

• Dyspnea
• Onset of cough
• > 3 wks?
• Change in cough
• Sputum
• Color?
• Hemoptysis
• Stridor
• Wheezing
• Position dependent?

Nervous System Checklist

• Impaired balance
• Impaired gross motor movement patterns
• Impaired mentation
• Tremors
• Muscle atrophy
• Asymmetrical facial contours (794)
• Facial contour
• Ptosis
• Pupil abnormalities
• Strabismus
• How else can you assess the nervous system?

Gastrointestinal Checklist

• Difficulty swallowing
• Heartburn, indigestion
• Specific food intolerance
• Symptoms change with food intake
• Weight change
• Bowel dysfunction
• Color-blood
• Frequency
• Shape/caliber
• Constipation/diarrhea
• Incontinence
• Rectal pain

Abdominal pain

• Abdominal viscera sensitive to stretching, distension, contractions
• Gradual distension may be painless
• Inflammation and ischemia-increase tissue metabolites
• Special tests

abdominal special tests

• Iliopsoas test/Psoas sign

• Rebound tenderness

Rebound tenderness

Positive with acute abdominal pain

Iliopsoas test/Psoas sign

• Positive if abdominal pain reproduced with resisted SLR
• Also described as passive hip extension of the right thigh which reproduces abdominal pain

Colorectal Cancer

• Approximately 4.1 percent of men and women will be diagnosed with colorectal cancer at some point during their lifetime, based on 2017–2019 data
• Risk increases dramatically after age 50 years

risk factors of colorectal cancer

Risk increases dramatically after age 50 years
• 90% of all CRCs are diagnosed after this age
• Men > women
• African American > Caucasian
• High risk include those with inflammatory bowel disease (such as ulcerative colitis or Crohn disease), polyps, heredity

Psychological Checklis

• Mental Health First Aid

• 2 key questions to ask patients...
  • “Over the past 2 weeks, have you ever felt down, depressed, or hopeless?”
  • “Over the past 2 weeks, have you had little interest or pleasure in doing things?”
  • A positive response to either question carries a 96% sensitivity and 57% specificity for a major depressive disorder

• Other areas to question
  • Sleep, stress, fatigue, agitation, confusion, anxiety, irritability, mood changes

Endocrine Checklist

• Arthralgias
• Myalgias
• Neuropathies
• Cold/heat intolerance
• Skin/hair/nail changes
• Fatigue
• Weight loss/gain
• Sleep disturbances
• Polyuria
• Polydipsia

Urogenital Checklist

• urinary

• reproductive

urinary checklist

• Frequency
• Urgency
• Incontinence
• Reduced force of stream
• Difficulty initiating
• Dysuria
• Color/ odor /clarity
• Altered mental status
• Special test: costovertebral angle tenderness (percussion

Integumentary Checklist

• Surgical sites
• Rashes
• Color
• Pruritus (itching)
• Changes in hair or nails
• Moles/spots
• History of skin cancer
• Quality

Cellulitis

• Bacterial skin infection
  • Most common is Group A Strep
  • Via openings in the skin from injury or surgery

• Redness, swelling, warmth, and pain in the infected area
  • Advancing, irregular margins of erythema/reddish streaks

• Medical attention needed if...
  • Red area of the skin spreads quickly
  • Fever or chills

• Treated with antibiotics
  • IV antibiotics in serious cases

Potential complications of cellulitis

• Bacteremia
• Osteomyelitis
• Endocarditis
• Vein swelling if blood clots form close to
the skin (thrombophlebitis)
• Necrotizing fasciitis needs immediate medical care

types of Skin Cancer

• Nonmelanoma skin cancer

• Nonmelanoma skin cancer

Nonmelanoma skin cancer

• Basal cell carcinoma
• Squamous cell carcinoma

melanoma

• Less common
• More aggressive
• Can arise from either pre-existing moles or normal skin
• Reportable on US Cancer Registrie

Basal Cell Carcinoma

• Begin as small shiny nodules which grow slowly
• Most common form of skin cancer
• Appears as a raised soft lump or a red patch on

Squamous Cell Carcinoma

• Appears most often on sun-exposed areas of the body
• Evolves very slowly
• Growing bump that may have a rough, scaly surface and flat reddish patches.
• Early form appears as a scaly, crusted, and large reddish patch (often larger than 1 inch).
• A sore that does not heal can be a sign of squamous cell cancer.

risk factors of skin cancer

• Exposure to UV radiation
• Genetic predisposition
• Immune system
• Organ-transplant recipients receiving immunosuppressive drugs
• Arsenic exposure

who has a higher mortality rate of melanoma

black patients and hispanic

Theories of proginis melanoma

• Perception that patients with darker skin are not at risk
• Anatomic location of lesions different for the two populations
• Trunk and lower extremities versus sun-exposed body regions
• Less screening emphasis in minority populations
• Less access to timely quality health care

Integumentary Screening

• More than 90% of melanomas that arise in the skin can be recognized with
the naked eye.
• No recommendation for or against routine total body skin examination for
people who do not have a history of skin cancer and who do not have any
suspicious moles or other spots
• https://www.cdc.gov/cancer/skin/basic_info/screening.htm
• Proposed recommendations

Adults aged 35–75 years with one or more of the following risk factors should be screened at least annually

• History of skin cancer

• Light skin

• Family history of skin cancer

• Blonde or red hair

• Immunocompromised

• Many freckles

• UV radiation overexposure

• >40 total nevi

• Severely sun-damaged skin

• History of indoor tanning

Benign

• <6 mm

• uniform color

• distict/smooth borders

• symmetrical shape

• soft to firm consistency

• no friability

• seldum ulceration

• mobile

• slow rate of change

malignment

• > 6mm

• varied color/black

• irregular/indistinct border

• asymmetricl shape

• firm to hard consistency

• often friable

• often ulceration

• mobile/non-mobile

• slow or rapid rate of change

ABCDEs of Melanoma

• asymmetrical

• border

• color

• diameter

• evolving

Screening for Chemical Dependence

• Smoking
• Alcohol
• Medications
• Prescribed
• OTC
• Opioids

Smoking history

• 2–4 times more likely to develop coronary heart disease
• 10 times as likely to develop peripheral vascular disease
• 20% of all adults smoke cigarettes

e-cigarttes

• Most e-cigarettes contain nicotine
• Can contain other harmful substances besides nicotine

Alcohol dependency

• NIH: 2-10% those over 65 are alcoholics
• NIAAA definition of at-risk drinking
• Men: more than 14 drinks per week or more than four drinks per occasion
• Women: more than seven drinks per week or more than three drinks per occasion
• Screens: “CAGE” and “AUDIT”
• “Because alcohol can affect many areas of health ...”
• How many drinks containing alcohol do you have each week?
• How often do you have X or more drinks on an occasion?

CAGE

• Ever felt you should Cut down?
• Ever been Annoyed by people criticizing your drinking?
• Ever felt Guilty or bad about your drinking?
• Ever had an Eye opener?

• Single yes response suggests chemical dependency evaluation (referral)
• 2–3 yes responses strongly suggests follow-up

AUDIT

• Identify “at-risk” hazardous/harmful
• 10 items on self-report
• Questions on amount, frequency, dependence, and problems
• A score of 8 or higher on the AUDIT generally indicates harmful or hazardous drinking

For each medication

• Taking medications for what
• How long taking medications
• Dosage level
• Dosing schedule
• Helping/not helping
• Side effects noted
• For OTCs: Is MD aware?

Signs of Chemical Dependency

• Agitation, restlessness
• Undue anger evasiveness, defensiveness when asked about drug/alcohol use
• Fidgeting or shakiness on repeated clinic visits
• Frequent late or missed appointments
• Inappropriate behaviors, outbursts
• Multiple mood-altering prescription medications from different MDs

Symptom-Based Diagnosis

Chief complaint and pain/symptom diagram
• Current treatment?
• Current limitations?
• Location/description/ intensity scale?
• History of symptoms?
• 24-hour report?
• Who else are you seeing?

Atypical Symptoms

24-hour report “red flags”

• Pain that never changes

• Night pain
  • Not acute
  • Not if it can be relieved by changing position

• Pain with no pattern
  • Endocrine system?
  • Psychological?
  • Neurological system?

Decision-making process

• Begins at first patient contact
• Ongoing and iterative process
• Progresses through a defined episode of care
• May involve other practitioners

Is This Patient Appropriate for PT?

• Decision-making process

• Immediate need to communicate with other health care providers?

• Proceed with musculoskeletal or neuromuscular exam?