Medical Screening

in a systems review you are looking for what?

signs or symptoms possibly indicative of systemic condition

a systems review includes a brief examination of the systems and what else?

includes cognition, affect and communication, learning style, and barriers to learning

what are the different systems that are apart of the systems review?

• cardiac, pulmonary, and peripheral vascular systems

• GI system

• genitourinary

• nervous

• integumentary

• endocrine

• neuromuscular/MSK

what are red flags?

indicators that raise suspicion of potentially serious pathologies where the patient needs either immediate emergent care, referral to MD, or they can proceed with treatment but need close observation w/ great suspicion

are red flags diagnostic or predictors of diagnosis?

NO

is there a lot of evidence to support red flags?

no but they are the best we have

what are generic red flags?

• history of cancer

• recent infection

• persistent illness

• recent trauma

• unrelenting/pulsating pain

• immunosuppression

• injection drug use

• loss of appetite

• difficulty swallowing

• altered speech

• fever, chills, sweats

• unexplained weight loss

• nausea and vomiting

• weakness

• changes in mentation or emotional status

• unusual fatigue

• dizziness

• menstrual irregularities

• pregnancy

• failure to respond to conservative care

• non-mechanical pain

• disproportionate symptoms

• inordinate symptom persistence

• bilateral neurological symptoms

• visual disturbances

• balance/coordination deficits

• fainting or drop attacks

• chest pain

• palpitations

• generalized or sudden weakness

• altered muscle tone

• poorly localized pain

• symptoms worse with exertion

• shortness of breath

• headache not of cervical origin

• signs and sx consistent with viscera

• inexplicable swelling or redness in an area

• severe depression/threat of suicide

• any suggestion of CNS involvement

• cranial nerve signs

• tremors

• seizures

• suggestion of reaction to medication

• persistent cough

• lack of logical pattern of signs

what are inordinate symptom persistence?

where the patient has symptoms that have a normal MSK condition to explain it but the symptoms are persisting longer than what you would expect for that condition

what are disproportionate symptoms?

when what the patient describes does not match up to what your physical exam findings are

what is a drop attack

a sudden collapse without loss of consciousness

what are acute headache red flags?

• over 50 years

• seizure/collapse/loss of consciousness

• thunderclap HA

• worst HA

• drowsy/confused/agitated

• visual/neurological symptoms

• pupil asymmetry

• nausea/vomiting

• paralysis/weakness

• UMN signs

• sensory loss

• meningeal irritation

• systemic illness

• ataxia/incoordination

what is a thunderclap HA?

a headache that has a sudden onset and great severity

what is the SNOOP tool? what is it based on?

a screening tool used to identify secondary HA associated with potentially serious pathology ; based on a well-taken history and targeted physical exam

what does SNOOP stand for?

• Systemic symptoms suggestive of infectious or other underlying systemic disorder

• Neoplasm of brain

• Neurological signs or symptoms

• Onset is sudden and consistent with vascular disorder

• Older than age 50

• P = multiple P items

what are the 12 P items in SNOOP?

• significant pattern change

• positional headaches

• HA precipitated by sneezing, coughing, exercise

• papilloedema

• progressive HA

• pregnancy or puerperium (period of adaptation after birth)

• painful eye

• post-traumatic (acute)

• pathology of immune system

• painkiller usage

• post COVID

• post vaccination

what are SNOOP green flags that suggest lesser severity of risk factors?

• HA present since childhood

• temporal relationship with menstrual cycle

• HA-free days

• close family members with same HA phenotype

• stopped or occurred more than 1 week ago

what is the give me 5 for stroke signs?

• Walk: is balance off ?

• Talk: is their speech slurred or face droopy?

• Reach: is one side weak or numb?

• See: is vision partially or fully lost?

• Feel: is their HA severe?

what is the AMA BEFAST symptoms for stroke?

• Balance loss

• Eyes: loss of vision in one or both eyes

• Facial weakness

• Arm weakness

• Speech problems

• Time to act for quicker tPA administration

what is the classic cluster for CVA?

• numbness

• weakness

• difficulty speaking

• change in vision

• difficulty walking

• HA

• clumsiness or difficulty understanding

what are the most common symptoms of CVA?

weakness and difficulty speaking

what are CVA prodromal symptoms? are they more common in males or females?

self-reported symptoms prior to the 24 hours of hospital admission; more common in women

women have a greater frequency of experiencing what symptoms of CVA?

• general weakness

• disorientation, confusion, memory problems

• fatigue, nausea, vomiting

what are the non-modifiable risk factors for CVA?

• age

• men more common than women

• low birth weight

• blacks > whites > asian and hispanic

• family history (especially paternal)

what are potentially modifiable risk factors for CVA?

• smoking

• hypertension

• DM

• high total cholesterol (low HDL)

• atrial fibrillation

• asymptomatic carotid stenosis

• sickle cell disease management

• postmenopausal hormone therapy

• oral contraceptives

• diet/nutrition

• physical inactivity

• obesity

• CVD / CHD

• heart failure

what is the battery of testing that screens for cognitive impairment? if there is even 1 positive result, what does that tell you?

• 5 word test

• clock test

• verbal fluency test

• mini-geriatric depression scale in mini-mental state exam

this battery has a high sensitivity and specificity so it is not diagnostic but gives good reason for suspicion and referral for cognitive impairment

research has been favorable for which 2 tests to screen for cognitive impairment?

MOCA and Qmci (quick mild cognitive impairment screen)

what is the memory and executive screening tool (MES)? what is it efficacious in identifying?

a relatively new screening tool to help screen for reason for referral for cognitive impairment; subtle cognitive decline

what is the stick design test? how do you do it?

a screening tool of cognitive impairment that correlates to ADLs and is an assessment of visuospatial abilities in older adults w/ low formal education ; the subject is shown 4 models to be made w/ 4 wooden matches and is asked to align the matches to make a square, triangle with a leg, chevron, and rake

when should clinicians undertake cognitive assessment? what are signs that you should maybe undergo a cognitive assessment?

when prompted by clinical indicators associated with risk for cognitive impairment rather than screening community-dwelling adults;

• memory loss

• functional, behavioral, or personality change

• family history

what are 3 questions related to memory that you should ask to screen for cognitive impairment?

• does the patient forget appts or have difficulty keeping track of the day or time?

• does the patient repeat questions or comments?

• does the patient forget recent events or conversations?

what are 2 questions related to attention that you should ask to screen for cognitive impairment?

• does the patient have periods of decreased alertness?

• is the patient easily distracted?

what are 2 questions related to language that you should ask to screen for cognitive impairment?

• does the patient have word-finding difficulties or struggle to find common words?

• does the patient have trouble communicating thoughts or understanding what is being said to them?

what are 2 questions related to visuospatial processing that you should ask to screen for cognitive impairment?

• does the patient tend to get lost or turned around?

• does the patient ever fail to see something that is right in front of them?

what are 2 questions related to executive function that you should ask to screen for cognitive impairment?

• can the patient successfully complete tasks that require multiple steps, for example planning a trip or throwing a dinner party?

• can the patient use appliances and devices as well as they used to?

what are 2 questions related to social comportment that you should ask to screen for cognitive impairment?

• does the patient behave appropriately in social situations?

• has the patient become impulsive, careless, or unguarded?

what are the basics of bedside screening for cognitive impairment?

• orientation (state name, month, date, year, day of week, season, and current location)

• attention

  • spell “world” forward and backward

  • state months of the year in reverse

  • count backward from 100 by 7s

• memory

  • repeat 3 words and remember them for 5 minutes

  • describe what has been going on in the news lately

• language

  • name 3 common items

  • repeat a phrase

  • provide a speech sample like describing a picture

• visuospatial processing

  • draw a clock

  • bisect a line

• executive function

  • name as many words that begin with the letter F as you can think of in 1 minute

  • state letters of alphabet alternating with sequential numbers

what are signs you should look for when assessing cardiovascular, peripheral vascular, and pulmonary systems?

• dyspnea/SOB

• cough

• palpitations

• syncope

• dizziness

• sweats

• edema

• cold distal extremities

• skin discoloration

• open wounds/ulcers

• clubbing of nails

• wheezing/stridor

what can yellow nail syndrome be a sign of?

can be from fungal infection but over 50% is related to respiratory tract disease and suspected to be due to poor lymphatic drainage in gravity dependent areas, especially when accompanied by lymphedema

what are the classic symptoms of MI?

chest discomfort, discomfort in other areas of the upper body, and SOB

MIs do not always present w/ typical chest pain and pressure in which populations?

women and older persons

what signs are a possible MSK mimicker of MI that you should be aware of?

interscapular/upper back and L arm pain as well as jaw pain, nausea and vomiting

men are more likely to attribute MI symptoms to ___ whereas women are more likely to report ___ symptoms

muscle pain or indigestion; epigastric symptoms and jaw, neck, arm, or shoulder pain

most women have ___ symptoms prior to MI such as:

prodromal symptoms;

• unusual fatigue most common

• SOB

• anxiety

• sleep disturbances

• indigestion

• chest discomfort, neck, and shoulder pain

many cases of MI are non-Hollywood and may begin with vague symptoms such as ___. Most cases with diffuse symptoms have higher or lower survival rates?

cold sweats, nausea, or light-headedness; lower survival rates

what are acute heart failure signs and symptoms?

• dyspnea most common

• peripheral edema

• cough

• orthopnea

• chest pain/discomfort

what are individual key history factors for sudden cardiac death?

• exertional chest pain

• exertional dizziness

• unheralded syncope

• excessive breathlessness

• palpitations

• epilepsy

• prior cardiac disease

• drug history

what are family key history factors for sudden cardiac death?

• known heritable disorder

• premature CAD under 50 years old

• SCD

• epilepsy

• unexplained drowning

• MVAs

a venous thromboembolism (VTE) can be exhibited in what 2 ways?

• DVT (either proximal to the trifurcation of the popliteal vein or distal to it)

• PE

is a proximal DVT or distal DVT more immediate threat?

proximal but a distal DVT can become proximal

what are symptoms of type 1 DM?

• frequent urination most common

• unusual thirst most common

• extreme hunger

• unusual weight loss

• extreme fatigue and irritability

what are signs and symptoms of hyperglycemia?

• extreme thirst

• hunger

• frequent urination

• dry skin

• nausea

• drowsiness

• blurred vision

• HA

• nervousness and shakiness

• sleepiness

• feeling anxious or weak

• confusion

• difficulty speaking

• perspiration

• dizziness/lightheadedness

• hunger

• neuromuscular incoordination

what are you looking for in a GI systems assessment?

• swallowing difficulties

• indigestion/heartburn

• food intolerance

• bowel dysfunction (color, consistency, frequency, urgency, control)

what are the 3 questions in cluster 1 of the abdominal pain of MSK origin question clusters?

• does coughing, sneezing, or taking a deep breath make your pain feel worse?

• do activities such as bending, sitting, lifting, twisting, or turning over in bed make your pain feel worse?

• has there been any change in your bowel habit since the start of your symptoms?

what are the 2 questions in cluster 2 of the abdominal pain of MSK origin question clusters?

• does eating certain foods make your pain feel worse?

• has your weight changed since your symptoms started?

if you answered ___ to either of the first 2 questions and ___ to the third question in cluster 1 of the abdominal pain of MSK origin clusters, you have a moderate probability that the patient’s abdominal complaints are of MSK origin. The probability increases to strong if what?

yes; no; if both questions in cluster 2 are answered with a no

how do you do abdominal palpation? what is considered normal?

• begin with gentle circular light pressure palpation in each of 4 quadrants

• follow with deep palpation with greater pressure, also with small circles of hands in the 4 quadrants

• observe for guarding or pain response

• test for rebound tenderness with quick release of pressure from each quadrant

softness and absence of tenderness are normal

what are the different signs you are looking for when doing abdominal palpation?

• Rovsing’s sign

• Blumberg’s sign

• Kehr’s sign

• Murphy’s sign

if a patient has tenderness over the R iliac fossa, especially at McBurney’s point, during abdominal palpation, what sign is that called? what does it indicate?

Rovsing’s sign; appendicitis

if you are palpating the patients R iliac fossa over McBurney’s point and they have tenderness that increases as you release pressure, what is that called and what sign is that?

rebound tenderness, Blumberg’s sign

what is Kehr’s sign and what does it indicate?

when you place a person in supine with their legs raised into a trendelenberg position and you palpate the left upper quadrant of the abdomen and that elicits L shoulder pain; a spleen rupture

how do you test for Murphy’s sign? what is a positive and what does it indicate?

firmly palpate the RUQ subcostal region, pushing under the ribs and ask the patient to take a deep breath; when significant pain is elicited that usually stops them mid-breath; indicates potential cholecystitis or inflammation of the gallbladder

what things are you assessing in a urinary system assessment?

• color

• flow

• reduced stream

• initiating

• incontinence

• recent invasive procedures

what things are you assessing in a reproductive system assessment?

• urethral discharge

• sexual dysfunction

• pain during intercourse

• menstrual irregularities

what are different instruments used to screen for depression?

• patient health questionnaire

• beck depression inventory

• hospital anxiety and depression scale

• geriatric depression scale

• Edinburgh postnatal depression scale

what are the 2 types of patient health questionnaires? which is common to use?

PHQ-9 (9 questions) and PHQ-2 (2 questions); usually start with PHQ-2 and then do a PHQ-9

what is the SAFE-T?

Suicide Assessment 5-Step Evaluation and Triage for Clinicians, a screening tool for depression designed for the outpatient setting

what are the pros and cons of the PHQ-9 for depression screening?

Pros:

• early detection and intervention for depression (suicide prevention data not as strong)

Cons:

• false positives can lead to unnecessary referrals, labeling, stigma

what are common signs of opioid abuse?

• the inability to control opioid use

• uncontrollable cravings

• drowsiness

• changes in sleep habits

• weight loss

• frequent flu-like symptoms

• decreased libido

• lack of hygiene

• changes in exercise habits

• isolation from family or friends

• stealing from family, friends, or businesses

• new financial difficulties

what are risk factors for opioid abuse?

• not easily identified and atypically singular

• no screening instrument widely validated

• usually complex of psychosocial, drug related, and genetic factors

• more common in younger population

• highest risk factor is personal / family hx of substance abuse and psychosocial comorbidity (especially other illegal drug, cannabis, or alcohol use)

why is opioid abuse also common in the older population?

because of procedures such as TKA

what are patient risk factors for opioid abuse?

• younger age

• anxiety/depression

• smoking

• daily pain fluctuations

• mood

• prior use/abuse

what are risk factors for negative effects of opioid therapy?

• sleep-disordered breathing (like sleep apnea)

• pregnancy

• renal or hepatic insufficiency

• age 65 or over

• mental health conditions

• history of alcohol or substance abuse disorder

• history of non-fatal overdose

a opioid risk tool score of 2 or less means ___ whereas a score of 3 or more means___

low risk for future opioid use disorder; high risk for opioid use disorder

what are obvious signs of injection abuse?

• track marks

• skin-popping scars

• poor dentition

• abscess or cellulitis

• stigmata of hepatitis (jaundice, scleral icterus, spider angiomas, pruritus, and palmar erythema)

what are tools to screen for alcohol abuse?

Audit or Audit C

what are some considerations for skin cancer screening?

total body skin exams have been used historically but many MDs and dermatologists believe these are not a good use of time and PCPs do not use these anymore so the patient’s skin likely has not been very exposed to the MD during screenings

melanoma is 20x more common in what race? what also increases risk?

white people; risk increases with age

what are risk factors for melanoma?

• pale caucasian skin

• blonde/red hair

• blue/green eyes and freckles

• inability to tan

• blistering sunburn history

• 1st degree family history

• increasing # nevi

• age over 50 years

• no regular TBSEs

• male

• basal/squamous cell cancer

• tanning bed use

• immunosuppression diseases or medications

people with lighter skin colors are more likely to have melanoma start on the ___. men are more likely to have it on the ___ whereas women are more likely to have it on ___

trunk; chest and back; legs

people who have melanoma start on the axial portion of the body rather than the extremities have a better or worse prognosis?

worse prognosis

___ is a common cancer in younger people especially young women. the major risk factors are ___ and ___

melanoma; sun exposure and tanning beds

what is the average age of diagnosis for melanoma?

66

what are the ABCDEs of melanoma?

• asymmetry

• border: irregular, scalloped, or poorly defined border

• color varied from one area to another (tan, brown, black, white, red or blue)

• diameter: melanomas are usually over 6 mm when diagnosed but can be smaller

• evolving/elevation/enlargement: skin lesion that looks different from the rest or is changing in size, shape, or color

90% of melanoma cases in the US are related to what? patients at high risk of melanoma should do what?

UV exposure; have regular TBSE

what are the 3 phases of many serious disorders?

• subclinical

• prodromal

• clinical

in the ___ phase of a serious disorder, there are no signs or symptoms but the pathology is underway. Recognition is not possible unless what?

subclinical; the patient has an incidental finding

in the ___ phase of a serious disorder, there are vague, nonspecific symptoms and few signs if any. There are some indications but what is present could be attributed to other benign conditions.

prodromal

in the ___ phase of a serious disorder, there are well-developed signs and symptoms and red flags are present. What do you do as a clinician?

clinical; refer for immediate medical care

which phase of a serious disorder is critical for primary contact clinicians to have the appropriate level of suspicion and inquiry?

prodromal

discrimination in the prodromal phase is dependent on what?

obtaining enough meaningful information via:

• questions and answers

• pattern recognition

• vigilance in observation

what are the 3 A’s that are critical for primary contact clinicians in discriminating a serious disorder in the prodromal phase?

• appropriate index of suspicion

• avoidance of misattribution

• avoidance of unnecessary alarm

what is the OSPRO?

Optimal Screening for Prediction of Referral and Outcome, a 23-item screening tool for red and yellow flags that is highly sensitive

what questions are on the OSPRO 10-item abridged version?

1. have you recently experienced abnormal sensations such as numbness, pins and needles?

2. have you recently experienced headaches?

3. have you recently experienced night pain?

4. have you recently experienced sustained morning stiffness?

5. have you recently experienced light-headedness?

6. have you recently experienced trauma (MVA, a fall)

7. have you recently experienced night sweats?

8. have you recently experienced constipation?

9. have you recently experienced easy bruising?

10. have you recently experienced changes in vision?

what questions are on the OSPRO 23-item version?

1. have you recently experienced abnormal sensations such as numbness, pins and needles?

2. have you recently experienced headaches?

3. have you recently experienced night pain?

4. have you recently experienced sustained morning stiffness?

5. have you recently experienced light-headedness?

6. have you recently experienced trauma (MVA, a fall)

7. have you recently experienced night sweats?

8. have you recently experienced constipation?

9. have you recently experienced easy bruising?

10. have you recently experienced changes in vision?

11. have you recently experienced changes in menstruation patterns?

12. have you recently experienced gait or balance disturbances?

13. have you recently experienced chest pain with rest?

14. have you recently experienced shortness of breath?

15. have you recently experienced muscle weakness?

16. have you recently experienced a failure of conservative intervention (failure to improve within 30 days?)

17. have you recently experienced excessive sweating?

18. have you recently experienced edema or weight gain?

19. have you recently experienced a heartbeat in your abdomen when you lie down?

20. have you recently experienced cramps in your legs when you walk for several blocks?

21. have you recently experienced abdominal pain?

22. have you recently experienced changes in the integrity of your nails?

23. have you recently experienced prolonged use of corticosteroids?

what are the main differences between the OSPRO red and yellow flag tools?

the yellow flag tool is 17 items and targets assessment of pain-associated psychological distress including positive affect/coping and may help identify those at greater risk for poor outcomes

you use the OSPRO yellow flag screening tool to do what 2 things?

• help inform treatment selections

• enhance interprofessional communications

what is the SBAR model of communication?

• Situation:

  • who are you?

  • who is the patient?

  • why are you seeing the patient?

• Background:

  • the patient’s clinical background or context

• Assessment:

  • your hypothesis of the patient’s problem

• Recommendation/request:

  • your suggestion of what should occur next and why/what info is needed to improve the situation