EEI 10/9a Outpatient Interview Cases

Question 1

The guide to PT practice

Answer 1

Diagnosis
Prognosis
Intervention
Outcomes
Examination
Evaluation

Question 2

Goals of PT interview

Answer 2

• Establish Rapport
• PMH
• History of Present Illness (HPI)/CC
• Functional limitations/baseline status
• Ask yourself about red flags, referrals, etc
• Develop a hypothesis

Question 3

importance of establishing rapport with your patient

Answer 3

• Hearing vs active listening (clarify, ask questions, practice eye contact)
• nonverbal cues
• **Patient’s goal
• Patient centered interview (what brings you here, goals for today)
• Open vs Close ended questions
• barriers of communication (language and hearing imparirment)

Question 4

Breakdown of PMH Interview

Answer 4

1. Interview
2. Self-report measures
3. questionnaire with targeted follow up
4. social history
5. comorbidities
6. medications
7. psycho-social (depression, safety at home, recent drastic changes in body)

Question 5

good questions to include in the self-administered questionnaire in an outpatient ortho setting (self report measures)

Answer 5

latex sensitivity? heart problems? occupation? List out comorbidities? diabetes? diabetes before age 18?

Question 6

If yes on questionnaire, what do you do?

Answer 6

follow up!

Question 7

health history should include

Answer 7

demographics - age, race, education level

• can explain some diseases/disabilities
• age (breast and prostate cancer = older adults, vs MS and RA = younger diagnosis)
• race (sickle cell = black, skin cancer = white)
• education (communication targets)

Question 8

what should the social history interview include?

Answer 8

part of PMH

• occupation with follow up about requirements on job
• hobbies/rec
• habits (caffeine > 2-3x per day side effects are insomnia, tachycardia; for alcohol > 14 male and >7 female side effects are HTN, Hepatitis, Serosis; tobacco)
• family medical history
• support systems

Question 9

comorbidities during interview

Answer 9

• PMH
• cancer if >50y/o think recurrence if prior hx
• infection (pneumonia, UTI) think redness, heat, swelling
• cardiac think shoulder pain, HTN, CVA, angina and avoid aerobic activity
• depression effects outcome, poor recovery in back, knee, hip
• pulmonary think asthma, COPD decreased endurance and make sure they have inhaler
• osteoperosis post menopausal or long term steroids, compression fractures, no bending
• diabetes
• seizures
• pregnancy (no stim and manips because ligamentous laxity)
• surgeries (DVTs)

Question 10

Medication side effects

Answer 10

• cardiac (orthostatis hypo, nitroglyc)
• steroids (long term effects on bone)
• NSAIDS (GI bleeds)
• asthma (inhaler!)
• insulin (fatigue and hypoglycemia)
• seizure meds

Question 11

HPI/CC

Answer 11

History of Present Illness/Chief Complaint

• Pain
• Stiffness
• Weakness
• Numbness
• ligament tears
• OPQRST (onset, provocation, quality of pain, region/radiation, severity, time - history)

Question 12

interviewing about pain

Answer 12

1. behavior and quality: constant (mechanical or chemical) vs intermittent (mechanical)
   - better or worse?
   - nerve distro (dermaatome or periph nerve)
   - bone (tenderness to palpation, deep and localized)
   - vascular (widespread and throbbing)
   - muscle (resist motion and stretching cause pain)
2. location
3. numeric rating scale
   - severity/intensity (1-10 scale)
   - irritability
   - stability
4. periph or central?

Question 13

parasthesia vs anesthesia

Answer 13

parasthesia = numbness/tingling from damage to a nerve
anesthesis = no feeling because nerve has been cut

Question 14

functional limitations aspect of the interview?

Answer 14

• what do your symptoms prevent you from doing?

- different outcome measures

Question 15

what do you ask yourself as a PT during the patient interview?

Answer 15

manage case by:

1. referral to another healthcare practitioner and cannot be managed by PT
2. by PT with a consult from another practitioner
3. independently by PT

Question 16

Red flags for referral to another healthcare provider and not managed by PT

Answer 16

• severe unremitting pain
• pain not affected by medication or position
• severe pain at night
• severe pain with no history of injury
• severe spasm

Question 17

red flags for patients who may have cancer

Answer 17

• persistent night pain
• constant, unremitting pain
• unexplained weight loss
• unusual lumps or growths
• unwarranted fatigue
• history of cancer
• > 50 y/o

Question 18

red flags for patients who may have a CV disease?

Answer 18

• SOB
• dizziness
• chest pain/heaviness
• constant and severe calf pain or welling redness especially with decreased activity
• pulsating pain
• discolored or painful feet
• unexplained swelling

Question 19

red flags for patients with possible GI/urinary issues

Answer 19

• frequent or severe abdominal pain
• frequent heartburn/indigestion
• frequent nausea/vomiting
• altered bladder function
• unusual menstrual
• worsened balance

Question 20

red flags for neuro issues

Answer 20

• altered hearing
• altered vision
• problems with swallowing or speech
• vision problems
• balance/coordination/falling
• fainting spells
• sudden weakness

Question 21

red flags overall for possible issues

Answer 21

• unexplained fever/night sweats
• unexplained joint swelling
• recent/severe emotional disturbances
• symptoms not changed by movement/position

Question 22

what do you do with red flags?

Answer 22

• psych issues (depression, fear, nonorganic signs) = call doctor
• exchange information
  1. test results
  2. guidelines for intervention in a medically complicated patient
  3. alert physician or health care practitioner (social worker if abuse, MD if exam findings)

Question 23

develop a hypothesis at the end of the interview. ask yourself the following

Answer 23

1. what is going on? what am I trying to rule in/out?
2. contraindications/precautions
3. irritability determines vigor of exam
   - activity needed to trigger symptoms
   - severity of symptoms provoked
   - activity/amount of time for sx to subside
4. tissue irritability
5. plan physical exam (medical screen, upper/lower quad screens, specific joint exams, special tests)

Question 24

high vs low tissue irritability

Answer 24

1. high: resting pain, pain before resistance or end range, recent trauma, sx easily increased. TREATMENT: pain control, inflammation, no significant stretch or resistive exercise
2. low: no sig resting pain, pain with overpressure, resistance before pain, sx mild and stable. TREATMENT: restore impairments, strength, flexibility

Question 25

○ A 75 year old Caucasian female is sitting in the waiting room on a chair with her daughter, who has brought her. The woman complains of constant pain in her midback and she has severe twinges with any trunk movement. The patient does not remember injuring her back.

Answer 25

don't treat, call doctor and discuss disability

Question 26

○ 53 year old active female status post knee arthroscopy for torn meniscus has persistent medial knee joint pain, swelling and tenderness to palpation 3 months post op with no change in symptoms after 5 weeks of PT.

Answer 26

send patient back to surgeon, patient had arthroscope piece in knee causing pain

Question 27

26 year old male working as an insurance agent, avid golfer, with insidious onset of back pain and intermittent bilateral leg pain who does not obtain relief from movements or positions with pain at night

Answer 27

ptnt had leukemia and died 2 months later

Question 28

○ 37 year old patient with 1.5 year history of back and leg pain which began after running a marathon. Has no significant PMH. MRI 1 year ago positive for HNP L5.

Answer 28

treat patient

Question 29

○ Patient arrived for initial evaluation after left TKA The patient was unable to get into the clinic on his own, so I went to the patient’s car to assist. The patient required moderate assistance in transferring out of the car, and used a walker with minimal assistance from me The patient had difficulty with following commands and concentrating, and had difficulty with answering questions from me or his wife. During the subjective/objective portion of the evaluation, the following findings were noted:

Answer 29

patient had bilateral DVTs and a PE, was sent straight to ER

Question 30

65 year old sedentary female referred for back pain which is worse at the end of the day when she works. PMH is significant only for osteopenia. You take her baseline BP and HR at rest and after you put her on the treadmill for 5 minutes. She is asymptomatic, but you note that her pulse is irregular post exercise.

Answer 30

bundle branch block, don't treat

Question 31

70 year old male with a history of liver cancer s/p surgery and chemotherapy, COPD, and left total knee replacement that is now cancer free. He is referred for reconditioning. Six weeks into therapy, he is unable to tolerate his usual amount of exercise and his narcotic pain medications are not controlling his pain.

Answer 31

refer, may be reocurrance of cancer

Question 32

55 year old male s/p total knee replacement has redness, warmth, and swelling of his left calf.

Answer 32

DVT, refer out

Question 33

87 year old male WWII vet you are seeing for a frozen shoulder complains of feeling lightheaded and needs to sit down. You have him sit down and he becomes pale and nonresponsive for about 10 seconds then becomes nauseous.

Answer 33

call 911 with anyone who passes out

Question 34

Person with back pain that you have treated 1 year ago who experiences an exacerbation of pain after a 60 hr work week sitting at a computer

Answer 34

treat

Question 35

46 year old female status post knee arthroscopy 2 months ago complains of persistent LE swelling and onset of calf discomfort yesterday after flying home from California

Answer 35

refer out, blood clot