PT 611 - Clinical Reasoning - History and Systems Review (Day 3)

What is the definition of clinical reasoning?

A complex problem-framing, problem-solving, and decision-making process is necessary for effective health care practice.

What two things are central to clinical reasoning?

Hypothesis formation and evaluation

During a systems review, what 6 things should you look at (this is a minimal list, could be more)?

• Complete “screen” of all body systems

• Mental status (Communication / Learning ability, A & O x 3-4)

• Integumentary

• Cardiovascular Pulmonary (Vital Signs (HR, RR, BP, Temperature))

• Neuromuscular (Sensation, Reflexes)

• Musculoskeletal

Systems Review: During communication, what should be explained to the patient?

Purpose, procedure, expectations, and notification of adverse effects

When is informed consent needed?

With every patient, it is required before proceeding with hands-on techniques.

Systems Review: Describe how to ensure safety

Standard Precautions (Infection prevention), Body Mechanics (Minimize patient/client fatigue and ensure safety).

Who does safety protect during an appointment?

Both the patient/client and clinician (PT)

Mental Status - brief screen - Describe communications

Patients have the ability to understand questions and have a dialogue in their native language. (Consider whether the person is a talker or not, and use both open-ended questions and closed-ended questions).

Mental Status - brief screen - Describe A & O x 4

• Alert – is the person awake and attentive?

• Oriented to:

• Person – What is your full name?

• Place / time - What is today’s date, month, and year? or "What day of the week is it? Do you know where we are right now?

• Context – Do you know why you are here?

Integumentary System - What should you observe and palpate?

Observation

• Intact

• Skin color

• Skin condition

• Nails

• Hair

• Presence of any skin lesions

Palpation

• Skin temperature

Integumentary System - What term means pale, white with hematologic, poor circulation?

Pallor

Integumentary System - What term means blue, grey due to hypoxemia?

Cyanosis

Integumentary System - What term means yellow due to hepatobiliary systems?

Jaundice

Integumentary System - What term indicates endocrine disorders?

Gray/Brown

Integumentary System - What term indicates increased blood flow or inflammation?

Rubor

Integumentary System - What aspects would you look for when testing the skin condition?

• Appearance: shiny, dry, thin, glossy

o Decreased turgor may indicate dehydration

• Bruises, lacerations, scars

• Moles, lesions, freckles

• Rashes

Integumentary System - How do you measure temperature?

Use the back of the hand, or the ulnar border, when testing skin temperature.

Integumentary System - What are two deviations from reference seen in nails and nailbeds?

Clubbing and Beau’s lines

Integumentary System - Describe the capillary refill test.

• Quick screen of nailbed color and distal perfusion

• Pinch nailbed, should blanch and then return to baseline color

Integumentary System - What do rapid hair loss and brittle hair typically indicate?

• Rapid hair loss

• cancer or cancer management

• Brittle hair

• metabolic or endocrine or chemical

Integumentary System - When viewing a mole, what four areas indicate a sign of melanoma?

Asymmetry, poorly defined borders, more than one color, and more than a ¼ inch (pencil eraser)

Cardiovascular Pulmonary System - What tests can you run?

Vital Signs (Heart Rate HR, Blood Pressure BP, Respiratory Rate RR, temperature of core body and skin)

What is the purpose of a sensation examination?

To screen integrity of neurological system

• Central nervous system

• Peripheral nervous system

Determine an individual’s ability to detect and discern sensory input

• Detect light touch

• Discern between 2 types of stimuli

• Sharp

• Dull

What is the technique to examine sensation - touch?

1. Explain purpose: to examine ability to detect sensation on skin

2. Show patient equipment to be used

3. Establish baseline reference

• Light Touch

• Cotton ball or swab

• Sharp / Dull

• Paper clip

• Parts of reflex hammer

4. Ask patient to close eyes

5. Begin examination for light touch

• Move proximal to distal

• Compare side to side

6. Then move onto sharp/dull discrimination

• Move proximal to distal

• Compare side to side

7. Document findings

Example:

• intact light touch & sharp /dull throughout all UE dermatomes

• Impaired light touch in C5, C6 dermatome distribution on RUE

What term describes an area of skin associated with a nerve root/spinal level?

Dermatome

What is the purpose of reflex testing?

To examine integrity of sensorimotor component (reflex arc) of a nerve root/spinal level.

What is the technique of reflex testing?

• Use reflex hammer

• Strike tendon briskly to elicit response

• Can put thumb on tendon and strike tendon or strike tendon directly

Reflex Testing - What are five deep tendon reflexes and just briefly describe the grading scale.

Biceps (C5-C6), Brachioradialis (C5-C6), Triceps (C7-C8), Patella (L3-L4), Achilles (S1-S2)

Grading:

0 = No response, absent

+1 = Low normal, decreased; slight muscle contraction

+2 = Normal, visible muscle twitch producing movement of arm/leg

+3 = More brisk than normal, increased or exaggerated; may not indicate disease

+4 = Hyperactive; very brisk; spinal cord disorder suspected

Reflex Testing: What refers to axons (nerve fibers) that project onto and modulate lower motor neurons? Cell bodies are either in the brainstem or cortex

Upper motor neurons (UMNs)

Reflex Testing: What is present with upper motor neuron lesion? Positive would indicate an involuntary flexion of the thumb and/or index finger when an examiner flicks the fingernail of the middle finger downwards.

Hoffmann Sign or Reflex

Reflex Testing: What is present with an upper motor neuron lesion? Positive would indicate dorsiflexion of the great toe with fanning of the other toes upon stimulation of the lateral sole of the foot.

Babinski Sign or Reflex

Motor Examination: What is the normal extent of movement in a joint? (The amount of motion allowed between two bony levers).

Range of motion

Motor Examination: What is a movement of a joint or body segment produced by active, voluntary muscle contractions by the patient, within their available range of motion?

Active range of motion (AROM)

Motor Examination: What is a movement of a joint or body segment produced by a force external to the body, without active, voluntary muscle contractions by the patient, within their available range of motion?

Passive range of motion (PROM)

Systems Review - AROM and Myotome screening - What is the purpose / what does it help determine? (6 things)

• Ability to follow directions

• Willingness to move

• Provocation of any symptoms

• Ability to maintain trunk stability to allow extremities to move through space

• Position dependent

• Integrity of neuromuscular components

• Ability to move through a range of motion

• Helps to screen joint function as well

What term means ‘a muscle or group of muscles innervated by a spinal nerve’?

Myotome

What is the action of the C3 myotome?

Cervical lateral flexion

What is the action of the C4 myotome?

Shoulder shrug (scapular elevation)

What is the action of the C5 myotome?

Elbow flexion (shoulder abduction)

What is the action of the C6 myotome?

Wrist extension (elbow flexion)

What is the action of the C7 myotome?

Elbow extension (wrist flexion)

What is the action of the C8 myotome?

Finger flexors (thumb extension)

What is the action of the T1 myotome?

Finger abduction (finger adduction)

What is the action of the L2 myotome?

Hip flexion

What is the action of the L3 myotome?

Knee extension

What is the action of the L4 myotome?

Dorsiflexion

What is the action of the L5 myotome?

Great toe extension

What is the action of the S1 myotome?

Plantar flexion (eversion)

What is the action of the S2 myotome?

Knee flexion

What is the myotome testing procedure?

• Explanation & Informed Consent

• Patient positioned

• Sitting or supine or prone depending on the myotome being tested

• Ask patient to go through desired AROM.

• Tell them and show them

• Ex: elbow flexion

If patient is able to go through full ROM, then position

limb so the myotome to be tested is at mid- range.

• Stabilize proximal to the joint that is involved

• Ask patient to hold that position and then resist your countermotion.

• Make sure they don’t hold their breath