Ch. 1 & 2

Risk factors and red flags for domestic violence

- women w/disabilities - cognitively impaired adult - chronically ill and dependent adult - chronic pain clients - daily headache - pelvic floor problems - recurrent unwanted pregnancies - history of alcohol abuse in male partner

Final questions

- Are there any other symptoms of any kind anywhere else in your body that we have not discussed yet? - Is there anything else you think is important about your condition that we have not discussed yet? - Is there anything else you think I should know?

Follow-up questions for signs and symptoms

- Are there any symptoms of any kind anywhere else in your body that we have not yet talked about? - Are there any symptoms of any kind anywhere else in your body that may not be related to your current problem?

Asking the patient about signs and symptoms

- Are you better, the same, or worse today? - What can you do today that you could not do yesterday/last week/last month/etc?

Follow-up questions about sleep/eating

- Are you satisfied with your eating patterns? - Do you force yourself to exercise, even when you do not feel well? - Do you exercise more when you eat more? - Do you think you will gain weight if you stop exercising for a day or two? - Do you exercise more than once a day? - Are there days when you do not eat anything? - Do you ever make yourself throw up after eating as a way to control your weight?

Screening for assault or domestic violence

- Are you threatened or hurt at home or in a relationship with anyone? - We are required to ask everyone we see about domestic violence. Many of the people I treat tell me they are in difficult, hurtful, sometimes even violent relationships. Is this your situation? - I see you have a bruise here. It looks like it is healing well. How did it happen? - You seem concerned about your partner. Can you tell me more about that? - Does your partner keep you from coming to therapy or seeing family and friends?

What follow-up questions should you ask a patient with a signed referral?

- Did you actually see the physician? - Did the doctor (dentist) examine you?

Screening for risk of falls

- Do you have any episodes of dizziness? - Do you have trouble getting in/out of bed without losing your balance? - Do you avoid walking on uneven surfaces outside, such as grass or curbs, to avoid falling? - Has there been any change in the dosage of your regular medications?

Closed-ended questions

- Do you have any pain after lying in bed all night? - Are you under any stress? - Is the pain relieved by food? - Did you sleep well last night?

Follow-up question about medications

- Do you notice any increase in symptoms, or perhaps the start of symptoms, after taking your medications? - Why are you taking these medications? - Have you taken these drugs today? - Do the medications relieve your pain or symptoms? - How long have you been taking these medications? - When did your physician last review these medications? - Are you taking any medications that were not prescribed for you

Questions related to work/living environment

- Do you think your health problems are related to your work? - Do you wear a mask at work? - Are your symptoms better or worse when you are at home or at work? - Do others at work have similar problems? - Have you done any remodeling at home in the last 6 months? - Have you ever been exposed to chemical agents or irritants? - Have you ever served in any branch of the military?

How to communicate with a physician if the patient comes to physical therapy without a referral and you find yellow/red flags

- Do you want Mr. X/Mrs. Y to check with his/her family doctor... or do you prefer to see him/her yourself? - How do you want to handle this? or How do you want me to handle this? - What do you think? or Please advise

How to communicate with the patient if the physician refuses to see them or finds nothing wrong

- Have you ever thought about getting a second opinion? - What do you think your options are? or What are your options? - provide a list of names where the client can get a second opinion

Follow-up questions to substance abuse screening

- Have you had any fractures of dislocations to your bones/joints? - Have you been injured in a road traffic accident? - Have you injured your head? - Have you been in a fight or assaulted?

Follow up questions for alcohol abuse

- How often do you have six or more drinks on one occasion? - How many drinks containing alcohol do you have each week? (>14/week for men and >7/week for women constitutes a problem) - I can smell alcohol on your breath right now. How many drinks have you had today? - Are there any other drugs or substances you take that you have not mentioned?

Follow-up questions about sleep

- If you wake up because of pain, is it because you rolled onto that side? - Can you get back to sleep? If yes, what do you have to do to get back to sleep?

Follow-up questions about level of fitness

- Since the onset of symptoms, are there any activities that you can no longer accomplish? - Do you ever experience shortness of breath or lack of air during any activities? - Are you ever awakened at night breathless? If yes, how often and when does this occur?

Follow-up questions screening for stress

- What major life changes or stresses have you encountered that you would associate with your injury/illness? - On a scale of 0 to 10, with 0 being no stress and 10 being the most extreme stress you have ever experienced, what number rating would you give your stress in general at this time in your life? - What number would you give your stress level today? - Do you ever get short of breath or dizzy or lose coordination when you are fatigued?

Questions to encourage the patients to engage during the interview process

- What questions do you have? - What would you like me to go over?

behavioral red flags indicating need to screen for substance abuse

- consistently missed appointments - noncompliance w/the home program - poor attention to self-care - shifting mood patterns - excessive daytime sleepiness or unusually excessive energy - deterioration of physical appearance and personal hygiene

OTC symptoms (Four D's)

- dizziness - drowsiness - depression - disturbance in vision

Clinical signs and symptoms of menopause

- fatigue and malaise - depression , mood swings - difficulty concentrating; "brain fog" - headache - altered sleep pattern - hot flashes - irregular menses - vaginal dryness, pain during intercourse - atrophy of breasts and vaginal tissue - urge incontinence

Sleep-related history

- fevers and sweats are characteristic signs of systemic disease - anyone reporting sweats must be asked if the same phenomenon occurs during the waking hours - certain neurologic lesions may produce local changes in sweating associated with nerve distribution - if a change in position can increase/decrease level of pain, it is likely a musculoskeletal problem - *if the client is awakened by pain in any location unrelated to physical trauma and is unaffected by change in position, this may be a serious systemic disease, particularly cancer

Special screening for women

- gynecologic disorders can refer to pain to the low back, hip, pelvis, groin, or SI joint - any woman having pain or symptoms in any one or more of these areas should be screened for possible systemic diseases - any woman with a positive family/personal history of cancer should be screened for medical disease

Screening for risk factors and effects of NSAIDs

- look for presence of GI distress (indigestion, nausea, heartburn, chronic fatigue) - blood pressure - ask about muscle weakness, unusual fatigue, restless legs syndrome, nocturia

essential components of the nursing assessment for PT's

- medical status - pain - physical status - patient orientation - discharge plans

Warning signs of elder abuse

- multiple trips to ER - depression - falls/fractures - bruising/suspicious sores - malnutrition/weight loss - pressure ulcers - *changing physicians/therapists often - confusion attributed to dementia

specific indications for physician referral

- spontaneous postmenopausal bleeding - a growing mass, whether painful or painless - persistent rise or fall in BP - hip, SI, groin, pelvic, or low back pain - marked loss of hip motion and referred pain to the groin in a client taking long-term systemic corticosteroids - a positive family/personal history of breast cancer in a woman with chest, back, or shoulder pain of unknown cause - elevated BP in any woman taking birth control pills

Population groups at risk for substance abuse

- teens and adults w/ADD or ADHD - history of PTSD - baby boomers w/a history of substance abuse - individuals w/sleep disorders - individuals w/depression and/or anxiety disorders

Kleinman's 8 questions to facilitate cultural competence

1. What do you think has caused your problem? 2. Why do you think it started when it did? 3. What do you think your sickness does to you? How does it work? How severe is your sickness? 4. Will it have a short or long course? 5. What kind of treatment do you think you should receive? 6. What are the most important results you hope to receive from this treatment? 7. What are the chief problems your sickness has caused for you? 8. What do you fear most about your sickness?

Paraphrasing technnique

A useful skill that can assist in synthesizing and integrating the information obtained - What makes you feel better? -> You've told me that the pain is relieved by such and such, is that right? What other activities or treatments offer relief from your pain or symptoms?

CAGE Questionnaire for excessive alcohol

C: Have you ever thought you should cut down on your drinking? A: Have you ever been annoyed by criticism of your drinking? G: Have you ever felt guilty about your drinking? E: Do you ever have an eye-opener (a drink or two) in the morning?

Guildelines for immediate medical attention

Client has - anginal pain not relieved in 20 mins - nausea, vomiting, profuse sweating w/angina - bowel/bladder incontinence and/or saddle anesthesia - anaphylactic shock - symptoms of inadequate ventilation or CO2 retention - confusion or lethargy associated with diabetes - positive McBurney's point or rebound tenderness - throbbing chest, back, or abdominal pain - changes in size, shape, tenderness, and consistency of lymph nodes

Interview DON'Ts

DON'T - jump to premature conclusions based on answers to one or two questions - interrupt or take over the conversation when the client is speaking - destroy helpful open-ended questions with closed-ended follow-up questions; ex: How do you feel this morning? Has your pain gone? - use professional or medical jargon - overreact to information presented; ex: reactions including raised eyebrows, puzzled facial expressions, gasps, "Oh, really?", "Wow!" - use leading questions because pain is difficult to describe

Interviewing DOs

Do - extend small courtesies - use a sequence of questions that begins with open-ended questions - leave closed-ended questions for the end as clarifying questions - select a private location where confidentiality can be maintained - give your undivided attention - listen attentively and make appropriate eye contact - ask one question at a time and allow the client to answer the question completely before continuing - encourage the client to ask questions - listen with the intention of assessing the client's current level of understanding and knowledge of his/her current medical condition - eliminate unnecessary information and speak to their level of understanding - correlate signs and symptoms with a medical history and objective findings to rule out systemic disease - provide several choices/selections to questions that require a descriptive response

T/F: Direct access is the only reason PT's must screen for systemic disease.

False

Funnel sequence/technique

Moving from open-ended line of questions to the closed-ended questions; can establish an effective forum for trust between the client and the therapist - Are your symptoms aggravated or relieve by any activities? If yes, what? - How has this problem affected your daily life at work or at home? - How has it affected your ability to care for yourself without assistance?

What are the major decision-making tools used in the screening process?

Past medical history, risk factors, clinical presentation, signs and symptoms, review of systems

Open-ended questions

Questions that elicit more than a one-word response - How does bed rest affect your back pain? - Tell me how you cope with stress and what kinds of stressors you encounter on a daily basis. - What makes the pain better? or What makes the pain worse? - How did you sleep last night?

RAFFT Questionnaire for adolescent substance abuse

R: Relax - Do you drink or take drugs to relax, feel better about yourself, or fit in? A: Alone - Do you ever drink or take drugs while you are alone? F: Friends - Do any of your closest friends drink or use drugs? F: Family - Does a close family member have a problem with alcohol or drugs? T: Trouble - Have you ever gotten into trouble from drinking or taking drugs?

Name some red flags that suggest the need for further screening

Severe chest pain, elevated BP, blood in urine, persistent fever, vaginal bleeding, signs of asthma during exercise

T/F: Physical therapy evaluation and intervention may be a part of the physician's differential diagnosis.

True

T/F: Screening for alcohol use would be appropriate when the client reports a history of accidents.

True

T/F: Spontaneous uterine bleeding after 12 consecutive months without menstrual bleeding requires medical referral.

True

chief complaint

a symptomatic description given by the client for which they are seeking care/advice for

Most of the information needed to determine the cause of symptoms is contained in the a. patient interview b. family/personal history form c. physical examination d. all of the above e. a and c

a. patient interview

In the context of screening for referral, the primary purpose of a diagnosis is to: a. Obtain reimbursement b. Guide the plan of care and intervention strategies c. Practice within the scope of PT d. Meet the established standards for accreditation

b. Guide the plan of care and intervention strategies

A risk factor for NSAID-related gastropathy is the use of a. antibiotics b. antidepressants c. antihypertensives d. antihistamines

b. antidepressants

Alcohol screening tools should be a. used with every client sometime during the episode of care b. brief, easy to administer, and nonthreatening c. deferred when the client has been drinking or has the smell of alcohol on their breath d. conducted with one other family member present as a witness

b. brief, easy to administer, and nonthreatening

What is the effect of NSAIDs? a. no effect b. increases blood pressure c. decreases blood pressure

b. increases blood pressure

Screening for medical disease takes place: a. Only during the first interview b. Just before the client returns to the physician for his/her next appointment c. Throughout the episode of care d. None of the above

c. Throughout the episode of care

Instruct clients with a history of hypertension and arthritis to a. limit physical activity and exercise b. avoid OTC medications c. inform their primary care provider of both conditions d. drink plenty of fluids to avoid edema

c. inform their primary care provider of both conditions

What is the significance of sweats? a. a sign of systemic disease b. side effects of chemotherapy or other medications c. poor ventilation while sleeping d. all of the above e. none of the above

d. all of the above

You should assess clients who are receiving NSAIDs for which physiologic effect associated with increased risk of hypertension? a. decreased heart rate b. increased diuresis c. slowed peristalsis d. water retention

d. water retention

Medical referral for a problem outside the scope of the PT practice occurs when: a. No apparent movement dysfunction exists b. No causative factors can be identified c. Findings are not consistent with neuromuscular or musculoskeletal dysfunction d. Client presents with suspicious red-flag symptoms e. Any of the above f. None of the above

e. Any of the above

Which of the following are red flags to consider when screening for systemic or viscerogenic causes of neuromuscular and musculoskeletal signs and symptoms a. fever, sweats, night sweats, dizziness b. symptoms are out of proportion to the injury c. insidious onset d. no position is comfortable e. all of the above

e. all of the above

information of the symptoms you want to obtain through interview

frequency, duration, intensity, length, breadth, depth, anatomical location

present illness

including the chief complaint, gives a broad, clear account of the symptoms (how they developed and events related to them)

Special screening for men

men describing symptoms related to the groin, low back, hip, or SI joint may have prostate or urologic involvement

associated signs

observable findings detected by the therapist in an objective examination; signs can be seen, heard, smelled, measured, photographed, shown to someone else, or documented

associated symptoms

reported indications of disease that are perceived by the client but cannot be observe by someone else; ex: pain, discomfort, numbness, tingling, creeping

telescoping

when a client may forget, underreport, or combine separate health events into a single memory

What is the difference between a yellow- and a red-flag symptom?

yellow-flag = warning red-flag = requires immediate attention, further screening, and maybe referral