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Subjective Review or Systems (Step 3)

 
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Subjective Review or Systems (Step 3) - March 22, 2006 2:07:00 AM   
Andrew M. Ball PT PhD

 

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Okay, so you've completed your general health screening. Knowing the organ systems sometimes associated with specific tyes of pain, we proceed with a pain-specific review of systems:

For LBP, for example, we're going to want to ask questions related to the functioning of the following systems:
Gastrointestinal
Urogenital
Peripheral Vascular

For example:

GI (Upper):
Dysphagia?
Nausea?
Vomiting?
Heartburn/Indigestion?
Specific food intolerance?

GI (Lower):
Constipation?
Change in Caliber?
Diarrhea?
Difficulty initiating defecation?
Change in Color?
Incontinence?

Urogenital (Unisex questions):
Frequency (Nocturia)?
Urgency?
Color?
Dysuria?
Reduced caliber of stream?
Reduced force?
Incontinence?

Urogenital (Male Questions):
Discharge?
Impotence?
Dyspareunia?
(pain during or after intercourse)

Urogenital (Female Questions):
Menstruation?
Frequency?
Length?
Date of last?
Dysmenorrhea?
# of pregnancies including complications?
# of deliveries including complications?
Menopause?
Post Menopausal bleeding?

Peripheral Vascular:
Dyspenea?
Orthopnea?
Palpitations?
Pain/Sweats?
Syncope?
Peripheral Edema?
Cough?

The point is to collect information in a systematic way so as to determine if a specific organ system might be involved. From there, the determination to treat, to treat and refer, or not to treat but refer, is made. If either of the latter --- a systematic approach to differential diagnosis provides the PT/DPT with the information to efficiently and effectively communicate to the MD the RELEVANT information necessary for them to continue with the diagnostic process.

_____________________________

Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation
Post #: 1
Re: Subjective Review or Systems (Step 3) - March 22, 2006 2:11:00 AM   
Andrew M. Ball PT PhD

 

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Similalry, for shoulder pain, especially left to right shoulder pain, we'd want to review the following organ systems:

Cardiovascular
Pulmonary
Gastrointestinal (Note - R scapular pain could be gallbladder)

For example:

Cardiovascular:
Dyspenea?
Orthopnea?
Palpitations?
Pain/Sweats?
Syncope?
Peripheral Edema?
Cough?

Pulmonary:
Dyspnea?
Tachypnea?
Cough?
Hemoptysis?
Sputum?
Stridor?
Wheezing?
Clubbing?

GI
See above, but if right shoulder pain, we'd also want to ask about greasy food intake and it's association with intermittent shoulder pain.

Drew

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Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

(in reply to Andrew M. Ball PT PhD)
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Re: Subjective Review or Systems (Step 3) - March 22, 2006 10:27:00 AM   
Dr.Wagner


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The ONLY issue that I have, is that this can get sooooo complex, that it takes the right training to be able to filter out some "red herrings" otherwise everyone is going to fit into a pathological category at some point.

In other words, an overly complex model doesn't do ANYONE any good IF it is too complex to use.

ie the job of the PT SHOULDN'T be to find the exact problem, but rather weed out the problems that do not seem to fit into the paradigm.

If one suspects something is not "right", refer back to the physician or send them to the ER if it is acute. You don't need to pinpoint the pathology, that isn't necessary.

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Moderator of Medical Complexity Forum

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Re: Subjective Review or Systems (Step 3) - March 22, 2006 10:36:00 AM   
Shill

 

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Another issue, albeit minor, with this is the time. It is not always necessary to take the screen to such an extremely detailed level, as by the time you get done, you have no time to actually treat and provide something helpful, should you find that it is completely negative. Where this is a bigger factor is with students and residents who feel that they need to do all of this with each and every patient. These do help to weed out the surprises, but I would like to see some stats on the frequency of these rarities too.

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Steve Hill PT

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Re: Subjective Review or Systems (Step 3) - March 22, 2006 6:57:00 PM   
Andrew M. Ball PT PhD

 

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Dr. Wagner,

I agree that the job of the PT SHOULDN'T be to find the exact problem, but rather weed out the problems that do not seem to fit into the paradigm. The point is to contact an MD when appropriate, not to "cry wolf" when inappropriate, and to communicate effectively.

Until now, however, PT's genererally have not pre-emptively used 5 minutes during the eval to complete a subjective medical scan, but rather waited until something "didn't look right". One of the many goals of all of this is to be a better early warning system for the MD.

_____________________________

Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

(in reply to Andrew M. Ball PT PhD)
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Re: Subjective Review or Systems (Step 3) - March 22, 2006 7:04:00 PM   
jma

 

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No arguements here!!

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Re: Subjective Review or Systems (Step 3) - March 23, 2006 6:56:00 AM   
Dr.Wagner


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All I am saying is the more complex the tool, the less of a tool it becomes.
Also, "cast out a big net"...that is ok, I would RATHER you be proactive than make a bad decision on a faulty exam. NOT EVERY PATHOLOGY follows the chart, I have had pediatric pneumonia presenting with RLQ pain, appendicitis with RUQ pain, AMI with simple epigastric pain.

Maybe that is something we can do...edit the tool you gave, so that it is more user friendly.

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Dr. Wagner DO
Moderator of Medical Complexity Forum

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Re: Subjective Review or Systems (Step 3) - March 23, 2006 2:23:00 PM   
Andrew M. Ball PT PhD

 

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I'm all for that.

Drew

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Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

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Re: Subjective Review or Systems (Step 3) - March 23, 2006 7:43:00 PM   
steve

 

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Dr. Wagner,

I think your statement about complexity being inversly correlated with usefullness is a great quote, very similar to what we see in the field of orthopaedic treatment. Asking a multitude of questions without being aware of their properties just creates "Noise" that can lead us astray of clinical diagnosis and cause excessive referrals and medicalization for patients.
This certainly isnt my area of expertise but I'm guessing that there are components of the subjective history that have determined sensitivity and specificity that would help guide us in determining if there is substantial basis upon which to base further investigation/referal.

Steve

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Re: Subjective Review or Systems (Step 3) - March 23, 2006 8:14:00 PM   
Andrew M. Ball PT PhD

 

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I suppose I'm a bit confused as to what anyone is thinking is "noisy" or complex here. Please elaborate.

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Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

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Re: Subjective Review or Systems (Step 3) - March 23, 2006 8:41:00 PM   
steve

 

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Andrew,

By noise, I mean the collection of data without knowledge of its significance. We ask all these questions (Which I am all for our screening for serious pathology) and will invariably get some positive replies to our questions. When do these reach a level of significance that will cause us to refer back to the physician? Which questions carry more clinical weight?

By this I am not suggesting that we not perform a screening exam but rather we refine it and place value to the questions we ask.

Steve

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Re: Subjective Review or Systems (Step 3) - March 24, 2006 5:47:00 AM   
Andrew M. Ball PT PhD

 

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I suppose I disagree then, that when taken into context, a systematic process, that the aforementioned review of systems, AFTER a general health screening, and AFTER taking a subjective history, is in any way "noisy." After completion of the process I'm certainly comfortable that I can tell, with greatly increased accuracy than the "something's not right" or "red flag" methods that I learned in MSPT school, what is clinically significant and what is not.

I'd hate to think that it takes a DPT trained or portal-of-entry trained PT to understand what is clinical significane and what is not, as it's really not that tough --- although I have seen some wannabe "home-run hitting" new-grad MPT's without portal-of-entry training pull the trigger of "clinical significance" without completing a full general health screening or review of systems, pat themselves on the back, and end up, more often than not, being wrong. So maybe it does take specific DPT and/or portal-of-entry training --- but it shouldn't. Maybe I'm in err in thinking that it's not that hard, as on second thought, I have seen quite a few eager clinicians get it either all wrong, or lucky and correct in spite of their own lack of complete examination.

If done correctly, this process does not increase calls to a referring MD, or to a specialist, or to the PCP who did not refer the patient --- but REDUCES those calls, while at the same time INCREASING the true-positive rate when a call is made, while at the same time increasing the true-negative rate.

If taken out of context, however, if performed as random, unorganized, or non-systematic questions, (as some on this forum have suggested), I agree that the information gathered ends up being scattered and useless --- the latter is NOT what I am suggesting or advocating.

So again, I don't understand what you mean by "noisy." The point IS NOT to diagnose down to the pathology level, that's the MD's job, but a portal-of-entry provider should be able to ACCURATELY diagnose down to the organ system level with subjective information only.

The "does the patient response make me comfortable, or does this rise to the level of clinical significance" and "now what do we do, and who do we call" discussions are for another thread entirely --- but it really boils down to "What does your PCP know, and what have you told me that you've not told your PCP?"

Drew

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Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

(in reply to Andrew M. Ball PT PhD)
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Re: Subjective Review or Systems (Step 3) - March 24, 2006 7:24:00 AM   
SJBird55

 

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Drew, I didn't suggest an unorganized, random way of doing things. All I said was that it truly doesn't matter which order I do a review of systems or a general health screening. And I don't do my review as you do it... I just have one sheet organized by system with the symptoms listed.

We all do things differently - but at a glance, I can easily see if I need to focus on making a determination that the complaint is something I can treat or not. 9 times out of 10 it is a waste of paper because there is nothing to consider... but in that 1 time out of 10, I'm glad I used my form. And, before I even talk to the person, I preview that form first. Why do I do it that way? Because before I even speak to them, I mentally try to make a note of how much time it's going to take to do my job (kind of assist me with time management). AND, I can start thinking about how the symptom complaints may tie in to their referring Dx.

And, yes, I will admit it - I'm a lazy PT. If I have to think on my feet and have to ask open ended questions or memorize something, well, my interview ability has always been lacking where I do get easily sidetracked and can't always refocus because of something a patient says or how they want to tell their story. So, for me, to stay on track, to stay focused and to not get into too much time listening to a story that generally doesn't have any relevance - forms are very necessary for me. And, since I know that is a weakness I have, my solution was additional forms. It works for me.

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Re: Subjective Review or Systems (Step 3) - March 24, 2006 6:51:00 PM   
Andrew M. Ball PT PhD

 

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Quit being so defensive. I wasn't talking about you in the first place. SHEESH! And for the record, I use TONS of forms. Who has the time to memorize different outcome measures and screening tools?

Drew

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Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

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Re: Subjective Review or Systems (Step 3) - April 6, 2006 10:27:00 AM   
truthseeker

 

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Drew,

I have been reading this thread with renewed interest. I had a patient recently who works at a machining plant. He sits all day and twists his back to the right and left. He was seen by is primary family practice doc for complaints of the gradual onset of LBP. He was referred to PT and was in fairly severe pain so we did little in the way of objective evaluation during our first visit.
His symptoms seemed to calm down a bit with some unloading and mechanical traction. Unfortunately, the traction became less effective after the first 2-3 trials. No neuro signs, just symptoms in the posterior thigh stopping above the knee.

Horrible flexibility, MRI showed small focal protrusion of L4-L5 disk with a small annular tear at L5-S1.

Severity of symptoms were somewhat out of proportion to the findings on the MRI, but his complaints were explainable by the objective findings or poor hip flexibility, horrible lifting technique, and the type of work he does.

After several visits 5-6 over a 4 week period, his symptoms are not really changing in spite of compliance with his HEP. He was getting more flexible, his trunk control was improving, his lifting technique was much better, but his pain was unchanged or perhaps worse. He was referred back to his doc who referred him to a neurosurgeon, thinking that maybe the annular tear was the pain generator. Neurosurgeon didn't think so and sent him back to PT.

The patient was admitted a total of 4 times for intractable back pain. Sweating, doubled over etc . . .

Complicating factor: Pt has a fairly recent conviction for marijuana posession and is on probabation. Seems he gets morphine or demerol when he comes in to the hospital so there is concern about drug seeking behavior.

This week he was admitted with unrelenting back pain that was not controlled with narcotics. His new primary care doc (the first one moved away) and I went into his hospital room together. The patient then said he wanted to show us something and dropped his pajama bottoms to show us his tennis ball sized L testicle.

Neither the doc or I was aware of it before.

This was a work comp case and so the notes pertaining to this particular type of complaint (the back pain) was in a separate portion of his clinic chart so it was not automatically reviewed but after doing a more thorough review, we found a note from one year ago where he discussed the testicle with the original doc who refered him to a urologist. The patient did not make an appointment with urology because he had just gotten new insurance or something, then the original doc left and the patient never brought it up again.

What I am trying to illustrate here, is this guy has testicular cancer. What could I have done differently? What questions could I have asked? Should the patient have taken more responsibility?

I am in the process of developing a more thorough screening/questionnaire for my initial evaluations.

Usually, during my history gathering, I ask if they have any other medical problems "cancer, heart problems, diabetes or anything else like that?" I plan to be more specific in the future and would like the patient to fill out a yes/no questionnaire to help find stuff like the above story.

I have been looking for such a questionnaire online but have not run across one that is to my liking.
Does anyone have a form such as this that they use and are satisfied with? I would love to have or see a copy to use as a template for my own.

Thanks.

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Re: Subjective Review or Systems (Step 3) - April 7, 2006 6:25:00 AM   
Andrew M. Ball PT PhD

 

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Tough one! I'm not sure that any question serries we create is going to catch everything with 100% sensitivity. I would refer you back, however, to the General Health Screening. Asking the essential 7 questions may have helped raise an eyebrow a little earlier, but clinically, I'm not sure it would have made much difference:

Fatigue?

Malaise?

Weakness?

Chills/Sweats/Fever?
(Low-grade fever of 100 degrees or higher for 2 or more weeks are significant)

Unexplained Weight Loss/Gain (5% increase or decrease over a period of 4 weeks are significant)

Nausea?

Paresthesia/Numbness?

Again, these questions alone won't tell us much, but cross-referenced with additional subjective information and objective findings, serve to raise and eye-brow regarding CONSIDERATION for possible need for referral such as (in order of likelihood in the PT department):

For CA, we would have expected to hear something about intractable and constant non-positional dependent pain, fever/chills, unexplained/unexpected weight gain/loss --- but if none were symptoms, as PT we're unlikely to catch the appropriate set of objective findings to pass along to the MD.

The goal isn't to be perfect. The goal is to be better!

Drew

_____________________________

Andrew M. Ball, PT, DPT, Ph.D.
Orthopedic Physical Therapy Resident
Carolinas Rehabilitation

(in reply to Andrew M. Ball PT PhD)
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Re: Subjective Review or Systems (Step 3) - April 7, 2006 7:38:00 AM   
Tom Reeves DPT ATC

 

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Thanks Drew,

He didn't have fever or chills, no weight changes, pain was positional intially, became global after I sent him back.

It just sucks.

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He who is wise in the ways of science
The Omniscient One

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Re: Subjective Review or Systems (Step 3) - May 2, 2006 8:51:00 PM   
JLS_PT_OCS

 

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Moderator please?
It's time to take out the trash...

J

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Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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