Medical Screening

Why is it important for PTs to screen patients for non MSK issues?

systemic disease can mimic neuromuscular or MSK dysfunction, responsibility to triage pts appropriately, recommendations for additional services

when do you as a PT need to refer to another healthcare provider?

outside scope of PT practice, medical conditions yet to be diagnosed

what is medical sceening?

the process of evaluation patient examination data for the purpose of deciding whether a patient referral is warranted

what are high risk groups

history of cancer, any adult over 65, cardiac procedure/medical history, unknown cause/etiology w/ insidious onset, bilateral clinical presentation

incidence rates of cancer _______ with age

increase

most common comorbidities seen in outpatient PT

hypertension, OA, depression, asthma, anemia

why are adults over 65 a high risk group?

age-related changes across multiple systems, multiple comorbidities

clinical relevance of ischemic heart disease

look for change in baseline of symptoms, recognize symptoms suggesting unstable angina

goal of medical screening/screening for referral

identify symptoms that are unusual for impairment related conditions, identify symptoms unrelated to the patient’s chief complaint (existing comorbid conditions, occult disease, adverse drug rxns)

conditions that require an immediate referral to another healthcare provider

red flags

what strategies can be used during medical screening?

medical record review, self-report screening tools, patient interview and examination

what makes up the review of systems top 9?

fatigue, malaise, fever/chills/sweats, unexplained weight change, nausea/vomiting, dizziness, paresthesia/numbness, weakness, change in mental or cognitive status

when is fatigue a red flag?

when it interferes with ADLs/work/school, when it has lasted 2-4 weeks or longer

what is malaise and how is it typically identified?

sense of uneasiness or general discomfort that something isn’t right, identified by patient comments

what is fatigue associated with?

serious illness, psychological disorders, infections, cancers, endocrine disorders medications

what is malaise associated with?

systemic conditions that generate a fever

what is fever/chills/sweats associated with?

infections, cancers, CT disorders (ex: RA)

what is the general guidance for unexplained weight change?

5-10% of body weight

what is unexplained weight gain associated with?

fluid retention, depression, hypothyroidism, cushing’s syndrome

causes of nausea/vomiting

organ system disease, systemic illness, adverse drug reaction

when is paresthesia/numbness/weakness a red flag

progressive neurologic loss, saddle anesthesia, urinary retention, increased urinary retention, overflow incontinence

potential causes of dizziness and lightheadedness

neurologic, cardiac and vascular, DM, cervical pathology, anxiety/psychosis, hypoxia

what can cause change in mentation?

delirium, dementia, head injury, adverse drug reaction, infection

what systems are involved in the systems level screening?

CV, pulmonary, nervous, GI, psychological, endocrine, urogenital, integumentary

characteristics of visceral pain patterns

vague and not well localized, considerable overlap with MSK disorders, knowledge can guide systems screen

where can the ovaries/testes refer pain to?

lower abdomen, sacral

where can the uterus refer pain to?

L/S junction, sacral, T/L spine

where can the kidney refer pain to?

T/L junction, middle lumbar of ipsilateral side, upper/lower abdominal

where can the stomach refer pain to?

upper abdominal, middle and lower T spine

where can the small intestine refer pain to?

middle thoracic spine

where can the pancreas refer pain to?

upper abdominal, lower thoracic spine, upper lumbar spine

where can the gallbladder refer pain to?

right upper abdominal, central and right sided middle/lower T spine, right scapula

where can the liver refer pain to?

right middle and lower T spine, right scapula

where can the large intestine refer pain to?

lower abdominal, middle lumbar spine, buttock

where can the heart refer pain to?

cervical anterior jaw, teeth, upper thorax, epigastric, left UE

where can the lungs and bronchi refer pain to?

ipsilateral T spine, chest wall, shoulder

what are the mechanisms of referred visceral pain?

referred pain is perceived at a remote location from site of the lesion due to multi segmental innervation or direct pressure and shared pathways

what systems should be screened if a patient has thoracic spine pain?

CV, pulmonary, GI, urogenital

what systems should be screened if a patient has L/R shoulder pain?

CV, pulmonary, GI

what systems should be screened if a patient has lumbo-pelvic pain?

GI, urogenital, peripheral vascular

what systems should be screened if a patient has an inconsistent symptomatic pattern?

psycological, endocrine, neurological

signs/symptoms of acute appendicitis

RLQ pain, periumbilical pain, pain before vomiting, psoas sign, fever, rebound tenderness

what increases the risk for colorectal cancer?

age over 50, male, african american, inflammatory bowel disease/polyps

2 key psychological screening 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

other areas to questions in regards to psycological involvement

sleep, stress, fatigue, agitation, confusion, anxiety, irritability, mood changes

what is cellulitus?

bacterial skin infection that causes redness/swelling/warmth/pain in the infected area

when is medical attention needed for cellulitis? how is it treated?

if the red area of the skin spreads quickly or with fever/chills, treatment is antibiotics

potential complications of cellulitis

bacteremia, osteomyelitis, endocarditis, vein swelling necrotizing fasciitis

what are the 2 main types of skin cancer?

nonmelanoma skin cancer and melanoma

examples of non-melanoma skin cancer

basal cell carcinoma and squamous cell carcinoma

less common more aggressive form of skin cancer that can arise from either pre-existing moles or from normal skin

melanoma

risk factors for skin cancer

UV radiation exposure, genetic predisposition, immune system, organ-transplant recipients on immunosuppressive drugs, arsenic exposure

skin cancer that appears most often on sun-exposed areas of the body and evolves very slowly, growing bump that may have rough/scaly surface and flat reddish patches

squamous cell carcinoma

in what race is skin cancer (melanoma) the most common?

non-hispanic white

in what age group is skin cancer (melanoma) the most common?

65-74

what is the prognosis for black and hispanic patients with melanoma compared to white patients? why?

2-3 times the risk of death- perception they are not at risk, different anatomic location of lesions, less screening emphasis, less access

adults aged 35-75 with one or more of these risk factors should be screened at least annually for melanoma

history/family history of skin cancer, immunocompromised, UV radiation overexposure, severe sun damage, light skin, blonde/red hair, >40 nevi, history of indoor tanning

ABCDEs of melanoma

asymmetrical, border (irregular), color (uneven), diameter (>6mm), evolving

what does screening for chemical dependence include?

smoking, alcohol, medications, opioids

hoe can you follow up on alcohol dependency?

CAGE or AUDIT

signs of chemical dependency

agitation/restlessness, undue evasiveness/defensiveness, fidgeting or shakiness, frequent missed or late appointments, inappropriate behaviors or outbursts

basic screening for abuse in a PT setting

asking “do you feel safe at home”, resources in the waiting room

what is an appropriate response from you as a PT is someone discloses abuse to you?

Acknowledge that you understand and show support, then provide resources to a domestic violence organization (don’t make therapy session about that), call 911 if you think they are in immense danger (very rare)

how do you screen someone if their abuser is with them?

try to have a safe space where you can talk to the patient alone (can say its because of medical reasons/HIPPA)

how would you doccument domestic abuse/violence concerns?

less is more/very factual, in case someone else takes the case and it changes opinion of client (ex: disclosed abuse, gave number to women’s center)