Comprehensive Medical Screening Notes

Medical Screening Introduction

  • The instructor has been teaching medical screening for 19 years, twice a year, totaling about 38 opportunities.
  • They've taught in Puerto Rico, Con Ed courses, and Loma Linda homecoming weekends.

Hypertensive Crisis

  • Pre-quiz question: What are three symptoms of a hypertensive crisis?

Low Back Pain and Cancer

  • How to be virtually 100% certain that a patient with low back pain does not have cancer.

Malignant Melanoma & Skin Inspection

  • Learn the ABC's, E's, F's of malignant melanoma in the skin inspection class.

Acute Anterior Compartment Syndrome

  • What are the three common symptoms associated with acute anterior compartment syndrome?

Cancer Metastasis to the Spine

  • Which type of cancer metastasizes to the spine? This is a concern during rib, thoracic, and lumbar manipulations.

Promises and Support

  • The instructor promises full support on the journey towards proficiency in medical screening.
  • Providing necessary tools, resources, videos, skills, and confidence.

Weekly Topics

  • Difference between differential diagnosis and medical screening.
  • The 12 body systems that PTs need to screen.
  • General health questionnaires: four important questions to ask patients.
  • Pain mapping: musculoskeletal and visceral systems.
  • Direct access.

Orthopedic Physical Therapy

  • Focuses on movement systems, impairments, and limitations.
  • Aims to identify the top three musculoskeletal reasons for a patient's pain.

Comorbidity

  • Consider if there's a comorbidity affecting the patient's outcome.
  • Determine if the patient's pain is coming from something other than muscle, nerve, or bone.

Medical Screening Process

  • Patient questionnaires and body chart.
  • History and subjective interview with 21 and 14 special questions to assess patient health.
  • Special tests to rule out non-musculoskeletal conditions in the 12 body systems.

12 Body Systems

  • Cardiovascular, pulmonary, GI, urogenital, nervous, skeletal, muscular, etc.
  • Three systems (nervous, skeletal, muscular) are already familiar.
  • The course will focus on the remaining nine systems.
  • A single disease can affect multiple body systems (e.g., diabetes mellitus).

Diabetes Mellitus Example

  • Can affect vision, balance, sensation, skin, and cardiovascular system.

Vertical and Horizontal Learning

  • Course uses spacing and interleaving for high-level learning.
  • Content is revisited at the right time to look at it in a different way.

Endocrine System

  • Responsible for hormones that regulate metabolism.
  • Checking for diabetes, thyroid disorders, adrenal issues, and cortisone treatment.

Thyroid Issues and Adhesive Capsulitis

  • Thyroid issues increase the risk of adhesive capsulitis (7x for females, 2x for males).
  • Thyroid problems can also cause carpal tunnel syndrome and contractures.

Diabetes Mellitus and Adhesive Capsulitis

  • Diabetes mellitus increases the likelihood of frozen shoulder (5x for females, 6x for males).

Instructor's Story (1994)

  • Patient with right lumbosacral pain and the "parking lot experience" (pain returns by the time they reach their car).
  • Features did not fit a musculoskeletal condition.
  • The instructor recommended advanced testing and no further PT.
  • Physician prescribed PT three times a week for six weeks.
  • The instructor refused to treat due to ethical concerns.

Second Encounter

  • The patient returned wanting to learn home exercise programs.
  • Showed the wife how to do muscle energy technique.
  • As the patient was getting up, he screamed in pain, became diaphoretic, and collapsed.
  • Paramedics were called, and the patient was taken to the hospital.

Diagnosis

  • The patient had Hodgkin's lymphoma, which was previously undiagnosed.
  • He suffered a burst fracture of L4, leading to paraplegia.

Court Case

  • The family settled the court case without subpoenaing the instructor.

Lessons Learned

  • The importance of courage and transparency with patients.
  • The need to know how to percuss and determine if a patient has cancer.

Clinical Reasoning Referral Decision Model

  • Patient history and physical examination followed by screening.
  • Assess level of concern (low, medium, high).
  • Referral decision based on the level of concern (green, yellow, orange, red).

Do Not Miss List

  • Cervical myelopathy.
  • Cauda equina syndrome.
  • Femoral fractures.
  • Psychological depression and suicide.
  • Cardiovascular issues (myocardial infarction, abdominal aneurysm, DVT, pulmonary embolism).

Patient Input Form (21 Items)

  • List of conditions to check, such as thyroid disorder.
  • Example: Thyroid disorder with shoulder pain in a diabetic male may indicate adhesive capsulitis.

General Health Questions (14 Items)

  • Fever, chills, sweats
  • Unexplained weight change
  • Malaise (something doesn't feel right)
  • Fatigue and loss of energy
  • Nausea and vomiting
  • Bowel and bladder changes
  • Numbness
  • Weakness
  • Syncope (drop attacks)
  • Dizziness and lightheadedness
  • Night pain
  • Difficulty urinating
  • Sexual dysfunction
  • Urinary frequency

Numbness Causes

  • Endocrine system
  • Neuromuscular/Skeletal issues
  • Kidney problems
  • Vascular issues

Syncope

  • Syncope requires urgent or emergent referral. Dizziness and lightheadedness can be cervicogenic but need to rule out sinister causes.

Red Flag Categories

  • Category 1: Emergent condition (paramedics to ER).
  • Category 2: Urgent condition (family to urgent care).
  • Category 3: Medical consultation needed (phone call to physician/charge nurse).

CHEST (Syncope Mnemonic)

  • Congestive Heart Failure
  • Hematocrit below 30
  • Abnormal EKG
  • Shortness of Breath

Systolic Blood Pressure

  • Systolic blood pressure less than 90 mmHg is a concern.
  • Blood pressure should be part of an orthopedic physical exam.

Hematocrit

  • Number of red blood cells.
  • Abnormal volume may indicate bleeding, cancer, kidney/liver disease, RA, lupus, pregnancy, nutritional deficits, peptic ulcer.

Syncope Statistics

  • 3-6% of ER visits are due to syncope.
  • 50% of syncope patients spend the night in the hospital.
  • Adverse events: death, heart attack, arrhythmia, pulmonary embolism, stroke, blood transfusion.
  • High return rate within 30 days.
  • 31% diagnosed with a vagal response.

Syncope Referral

  • Drop attacks require referral.

Non-Emergent Syncope

  • Vasovagal responses from massage chairs.
  • Risk factors: skipping a meal, low blood pressure, fainting history, flu, beta blockers, dehydration.
  • Signs and symptoms: fidgeting, sweating.

Vasovagal Response

  • Usually, there's a vasovagal response. Need to prevent falls.
  • Position patient backwards in chair with legs elevated.

How to decide if it is necessary to refer a patient?

  • Clinical patterns of musculoskeletal or visceral issue.
  • Top three list including medical screening considerations.
  • Valid special tests.
  • Is this the best form of care for the patient?
  • Treat, refer, or treat and refer.

Pain Recognition

  • Orthopedic courses cover ligament and facet joint referral patterns.
  • Nerve root involvement with arm pain and scapula pain.
  • Chances are patterns will be harder to recognize sometimes.

Night Pain Indication

  • Patients who have to sleep in a recliner to manage pain often have sinister conditions involving hollow organs (viscera).

Visceral Pain

  • Organs have nerve receptors that connect to specific skin patches.
  • Examples: inner thigh pain (ureter), sacrum pain (colon).
  • Neck pain: heart, lungs, liver, gallbladder references.

Uncertain Diagnoses

  • Multiple layers of diagnostic uncertainty exist.
  • Physicians also face uncertainty, and we can refer when needed.
  • Patient might spend years trying to navigate the source of their pain.

Ameliorating or Aggravating Factors

  • Easing factors: burping, diet changes, antacids (may not be musculoskeletal).
  • Aggravating factors: menstrual cycle, urination (probably not musculoskeletal).

Head and neck pain

  • Need vascular origin.
  • Consider: Are we missing any other patterns?

Onset

  • Sudden and traumatic indicates something is damaged.
  • Gradual worsening and morphing symptoms need consideration.

Causation

  • Causation: causation matters in determining if medical screening is required.

Duration

  • Duration: Duration of pain is important, and if it falls in time with the menstruation cycle matters.

Quality of Pain

  • Visceral pain is hard to pinpoint and deep.
  • Tearing, ripping pain can be sinister.
  • Sharp pain that makes the patient catch their breath is concerning.
  • Pressure or heaviness in the chest is concerning.

McGill’s Pain Questionnaire

  • Lumping things together like sickening, fearful, exhausting, and punishing pain can indicate some psychosocial origins.

Direct Access

  • Referral required if signs/symptoms are outside the scope of practice.
  • Direct access allows 45 calendar days or 12 visits.
  • Telehealth visits with an MD were permissible.
  • Prohibited from diagnosing diseases or performing tissue penetration (hematocrit tests).
  • When referring, describe the patient's symptoms and findings without diagnosing.

California Direct Access Data

  • Only 10% of patients used direct access (older data).
  • Fewer visits and lower costs with direct access.
  • No adverse events or lawsuits reported 20 years ago.
  • Must treat patients within the scope of practice.

APTA report

  • There isn't anything in the California practice act requiring payment for direct access.
  • There were people concerned about reimbursement.
  • 7% of direct access claims are denied.
  • 50% of respondents are using some form of direct access.

Unrestricted Direct Access

  • States with unrestricted direct access have a 65% usage rate.
  • Oregon has unrestricted direct access with required education for PTs.