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PT Diagnosis

 
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PT Diagnosis - October 31, 2008 1:05:49 AM   
blast7

 

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What of my gripes with the current PT profession is our lack of uniformity in PT diagnosis. 

I was taught to use the NAGI model in school linking impairments with functional limitations and then state whether that patient was classified as disabled or not. 

An example would be:
John Doe presents with decreased shoulder ROM in capsular pattern, decrease rotator cuff strength, anterior shoulder pain and provocative tests for supraspinatus dysfunction leading to functional limits in dressing and driving.

On the flip side I've seen :
Patient has signs and symptoms consistent with rotator cuff tendinitis.

In saying this I'm curious what others do.
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RE: PT Diagnosis - October 31, 2008 1:52:52 AM   
proud

 

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"suggestive" of rotator cuff tendonitis

(in reply to blast7)
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RE: PT Diagnosis - October 31, 2008 5:42:23 AM   
jlharris


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Who are you writing it for? The MD? Another PT? We can invent our own dialect, but if we are to effectively communicate w/ other health care professionals (eg MD's) we need to do it in their language. Most often, unless it's an orthopod, the MD wants our opinion of what is going on, and for us to give it in a form they are familiar with. In my opinion, the s/s consistent w/ rotator cuff tendonitis is more applicable.

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RE: PT Diagnosis - October 31, 2008 2:48:25 PM   
Tom Reeves DPT ATC

 

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I agree with Jason on that one.  A diagnosis is a diagnosis.  do we have the training to do a good clinical evaluation? Yes.  Is our clinical ortho eval as good or better than most, if not all other specialties? I say yes.  Granted there are some PTs who don't evaluate well, and there are some FPs who do it very well.  As a group, PT's ortho eval is better than, IMO many orthopedists' evals solely because we take the time and we don't get hung up on MRI results and CT rather than listening to the patient and putting our hands on them.  When was the last time an ortho took 30 min for the hands on evaluation?  If we have the skills and the training then speak up and sound confident (iff you are, that is) and say what you think.  The wording of the first assessment sounds like you are afraid to make the call.  Sometimes you don't have enough information or the tests are inconclusive, thats OK, say that but i think we need to quit walking on verbal eggshells.

I say use the common language to describe what you really think is going on.

I am probably older than you but I think the way you were taught is frankly gobbledy-gook.  Say what you think  it is.  If the patient comes in and says that their back hurts and your assessment says "pt has signs of low back pain consistent . . . " what have they actually learned and paid for.  Go to the MD with back pain, say "doc,my back hurts" and get a diagnosis of Low Back Pain.  well DUH.  How much is that worth.

another rant

< Message edited by Tom Reeves DPT ATC -- October 31, 2008 2:54:10 PM >

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RE: PT Diagnosis - October 31, 2008 3:50:39 PM   
torques

 

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Hi Blast,  I agree that there is lack of uniformity in ways PTs  write their diagnosis. This does not mean that the profession has no guidelines on properly writing the standardized diagnosis. PT's should be refreshed with the APTA GUIDE to PT PRACTICE to aide them to consistently follow the diagnostic process. The guidelines have major headings  (eg. connective tissue dysfunction, localized inflammation et al). Under this PT diagnosis headings are probable pathologies (ICD)which are usually supplied by physicians. Impairment lists (ICF) are relative however depending on PT skills and knowledge of evidence base practice. PT's who are not relying on quality examination tools may not produce  quality diagnosis and hence poor outcome. There is a good article on hypothesis oriented algorithm (HOAC) for clinicians which emphasis a standardized evaluation process. I hope more and more PT's utilize this method to standardize their evaluation. Only then our profession can see consistency in diagnosis formulation.

Jules M Rothstein and John L Echternach.Hypothesis-Oriented Algorithm for Clinicians: A Method for Evaluation and Treatment Planning. PHYS THERAPY.Vol. 66, No. 9, September 1986, pp. 1388-1394








www.ptjournal.org/cgi/content/abstract/66/9/1388

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RE: PT Diagnosis - October 31, 2008 3:58:44 PM   
Shill

 

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I agree with Jason on the idea that we need to communicate in language that most understand.  However, I also think that if an MD couldnt figure out what was meant by this:
"John Doe presents with decreased shoulder ROM in capsular pattern, decrease rotator cuff strength, anterior shoulder pain and provocative tests for supraspinatus dysfunction leading to functional limits in dressing and driving", then he or she needs to take a lesson in English language.  Descriptive explanations should not be negated or avoided because others cant figure it out.  Im sure there are times when we use terms and phrases that are completely non-objective and bordering on dumb, but this is not one of them.

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RE: PT Diagnosis - October 31, 2008 4:33:32 PM   
Myostrain

 

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I agree with Jason,
The PT guide to practice is our guide to practice but what happened to "keep it simple stupid"  or keep to the language of the entended readers.
With what we do, we do not diagnosis medical conditions and the PT diagnoses, patient presents with signs and symptoms consistent with impaired joint mobility, muscle performance, ROM associated with localized inflammation of the rotator cuff may sum up in our language the problem but not in the docs language.
A perfect world, we would have our most appropriate diagnosis, an agreeance consistence with the medical diagnosis and/or additional diagnosis along with a problem list of the primary impairments related to that patients problem.
I think it better that what we write has objective information, our assessment agrees or does not agree with the diagnosis and optimally we indicate what objective information from the evaluation is improveable by us and indicated as problems to the patients primary c/o.

(in reply to Shill)
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RE: PT Diagnosis - November 1, 2008 2:28:15 AM   
TLB

 

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quote:

ORIGINAL: jlharris

Who are you writing it for? The MD? Another PT? We can invent our own dialect, but if we are to effectively communicate w/ other health care professionals (eg MD's) we need to do it in their language. Most often, unless it's an orthopod, the MD wants our opinion of what is going on, and for us to give it in a form they are familiar with. In my opinion, the s/s consistent w/ rotator cuff tendonitis is more applicable.


Here's my favorite "piriformus syndrome" which doesn't exist. But maybe we should get in line with their language. (sarcasm intended).

(in reply to jlharris)
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RE: PT Diagnosis - November 1, 2008 2:29:13 AM   
blast7

 

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I really like the idea of stating your assessment and then listing primary impairments.  This is similar to the way physicians document and they typically take it a step further and include specific plan of care items for each impairment.

One particular question I have is that if we write exactly what we think/know and it does not agree with the MD's diagnosis then are we not medically diagnosing this patient?

(in reply to Myostrain)
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RE: PT Diagnosis - November 3, 2008 2:37:03 AM   
Tom Reeves DPT ATC

 

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Steve, if we use your example ""John Doe presents with decreased shoulder ROM in capsular pattern, decrease rotator cuff strength, anterior shoulder pain and provocative tests for supraspinatus dysfunction leading to functional limits in dressing and driving"" and the patient comes to us with a diagnosis of "shoulder" which happens a lot in my practice (and I appreciate the trust in my evaluation skills that it implies) then what ICD-9 code do you select?

I think the language that we use needs to conform with the medical diagnoses that the docs and the payors are expecting to hear.  Personally, I think that the terminology that the Guide to PT practice suggests is mostly descriptive garbage and dumbs our profession down. 

I will probably take heat for this from some but I think many of us think the same way.  I commend the Guide as a first step toward unifying the language that we use and how to use evidence and science to assess and categorize our patients, but we cannot separate ourselves from the terminology that is used all around us by everyone else that we deal with. 

The example above really appears to me that the therapist is saying " well, um, I think it might be related to this but, um, I think, it might not be and, well, it could be a supraspinatus injury of some kind but I am just a stupid therapist and I can't be expected to, you know, really come up with a likely diagnosis with any confidence."

(in reply to blast7)
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RE: PT Diagnosis - November 3, 2008 5:26:43 AM   
rwillcott

 

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I agree with you Tom.  We have the knowledge and skills to make a diagnosis.  I used to be tentative to write my diagnosis on a report to a physician.  However, I have learned that it helps demonstrate our competence as health professionals.  I will say that I proceed with caution if a physician refers a patient for a trapezius strain and it's C5/C6 discogenic symptoms.

How about when you refer a patient back to a physician if you suspect they need to see ortho our require further imaging?  I was once told by a mentor that we should be careful what we suggest to the patient and on a report what we want the doctor to do.  I will often write requires further investigation and offer the physician to call me if they have any questions.  They rarely do.  But what if we suspect something specific like AS and they require blood work to identify HLA-B27 gene?

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RE: PT Diagnosis - November 3, 2008 12:58:49 PM   
TexasOrtho


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I'll go along with Tom and Rob as well.  Just say what you think based on the clinical information you have and feel comfortable enough to put yourself out there.  You may be wrong or not entirely right, but thats ok.  Docs get it wrong too, but they still say what they think.  If you are examining / evaluating using the same skill as the physician and probably performing a more thorough exam, there should be no problem with you giving an accurate and concise diagnosis.

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RE: PT Diagnosis - November 3, 2008 1:16:12 PM   
Sebastian Asselbergs

 

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I tend to use the old diplomatic way when I want a physician I don't know to do something:
"In light of these findings, would you consider doing "X"...?" 
And having explained to the patient what my diagnosis is, what I think needs to be done, and all the rationale behind it, the patient becomes the driving force for any physician actions.

Over time, when they are the referral source, doctors will begin to just send patients with a descriptor (i.e. "back pain") and "eval and treat please" - and expect a report back with the details of your conclusion and treatment plan.

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RE: PT Diagnosis - November 3, 2008 2:25:50 PM   
torques

 

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     PT can never diagnose pathology. I wish we do. That's why physicians are the ones ordering imaging studies and lab works to confirm pathology.  Our diagnostic language will never be as simple as just stating a few worded impressions. PT's diagnose dysfunction (which may or may not be related to specific pathology). For example, rotator cuff tear/tendinosis (pathology confirmed by imaging). Patient comes to PT with disability with ADL's  due to (dysfunction) loss of function of R shoulder. The PT impression maybe  classified as localized inflammation or connective tissue dysfunction consistent with pathology-RTC. However, the diagnosis does not stop there. If one follows the algorithm. PT should rule out/ rule in  other probable causes of patient's disability by formulating hypotheses-this is where our diagnostic skills comes in, integrating medical differential diagnosis, imaging and clinical findings to sum up impairments which may have lead to the pathology (e.g. forward head posture, weak scapular stabilizer, elevated first rib, cervical dysfunction, cervical/midthoracic joint, AC/G/H joint restriction et al). More and more clinical tests are showing good validity in correlating patient's dysfunction with patient's symptoms/"pain". I wish our language can be more simplified but unfortunately, this is how we should write out our impressions. In clinic, I don't hesitate to request additional diagnosis if needed, say a patient showing signs consistent with cervical pathology. I may ask further imaging to cervical spine (to r/i DJD/DDD cervical spine). PT's can add  cervical radiculopathy to  existing diagnosis since this is more of a sign rather than pathology. I back it up with reliable/valid tests (spurling test,cervical endurance test, ULTT,  neuro tests (DTR), dynamic radiography for cervical instability et al). Other healthcare providers/physicians may not be as familiar with our language. I guess they just need to adapt. I do the same thing when I am not familiar with  medical terms.  I read and I research. Our language is really not that different from medical language.
    APTA is doing a great job leading us to standardization of PT practice (e.g. neck pain, heel pain guidelines). I don't think it dumb us. Although some PT's are used to using a lot of technical jargons which are not relevant. APTA helps  weeding out tools/treatment that are not known to be effective.

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Julius Quezon PT DPT MTC CPed

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RE: PT Diagnosis - November 3, 2008 2:56:45 PM   
Tom Reeves DPT ATC

 

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Julius, I ask again.  What ICD-9 code do you put on the billing documentation when someone comes to you with a diagnosis of "shoulder"???  when the PCP is not fluent in the orthopedic assessment of a shoulder what do you do? Do you refer everyone back? do you defer to the orthopedists? Do you just not get paid? 

I disagree that we should expect others to adapt to our language.  It will not happen.  If we expect that then we will disappear as a profession or lose all credibility.  (see the DC subluxation, some of them refuse to conform to science and expect us to adapt to their terminology.  Has that helped integrate or ostracize their profession?)

Further, we are professionals, not technicians.  We are responsible for our assessments and the consequences of our interventions so we need to be concise and precise in our language.  If it takes three sentences to say supraspinatus tear then we are not being clear.  AND we need to justify the value of our interventions to the person or company who pays the bill.  We need to conform to their language, not the other way around.

< Message edited by Tom Reeves DPT ATC -- November 3, 2008 3:02:52 PM >

(in reply to torques)
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RE: PT Diagnosis - November 3, 2008 4:08:00 PM   
torques

 

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There are 2 issues you have raise Tom. Billing and clinical. Billing- I have not had any billing problem using shoulder pain as an admitting diagnosis (ICD 9 719.41) if confirmatory diagnosis are not available. If billing needs a specific diagnosis, I will have the physician write a more specific impression (rotator cuff tear, DJD et al). Hopefully, US will adapt the use of ICF classification which is more function oriented. Sometimes I do recommend imaging studies to confirm a diagnosis but it is beyond PT scope to write out pathological diagnosis. Again, we cannot use PATHOLOGY as a diagnosis (e.g. rotator cuff tear, osteoarthrosis) even if  we can validate it through a tested clinical method. PT writes IMPAIRMENT DIAGNOSIS or even clustered syndromes.Not being able to supply a pathological diagnosis does not commensurate us with technicians.
We are gaining acceptance in becoming specialists of musculoskeletal conditions/dysfunctions. Our skill set is special and unique. We have specific language that is unique to the profession. APTA goal is to standardize the language so as a profession we agree with  its meaning.(e.g.Mckenzie?s posterior derangement syndrome, Delitto?s extension syndrome and Sahrmann?s flexion syndrome may all mean  similar movement pattern). Without a standardized language, we get lost as a profession.   Research backs up our language. It cannot be compared to chiropractic who lingers on their holistic terminologies.


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RE: PT Diagnosis - November 3, 2008 4:44:12 PM   
Tom Reeves DPT ATC

 

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Forgive my ignorance, but who says we can't use pathology.  Is it the APTA or a practice act? or is it a suggestion by someone (some entity).  If someone has a cut on their leg, do we say that it appears that the function of the skin with regard to infection prevention may be impaired? or do we say they have a laceration?  Same difference, just different system.

The Minnesota Practice Act says that we can't give a medical diagnosis. 

What is diagnosis?

medicinenet.com

Diagnosis: 1 The nature of a disease; the identification of an illness. 2 A conclusion or decision reached by diagnosis. The diagnosis is rabies. 3 The identification of any problem. The diagnosis was a plugged IV.

from thefreedictionary.com





Noun
1.
medical diagnosis - identification of a disease from its symptoms

and  from Answers.com

  1. Medicine.

  2. The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.
  3. The opinion derived from such an evaluation.



  • A critical analysis of the nature of something.
  • The conclusion reached by such analysis.
  • Biology. A brief description of the distinguishing characteristics of an organism, as for taxonomic classification.
    Sounds like nobody except the medical and osteopathic doctors are allowed to name anything.  Oh, wait, so can PAs, NPs, chiropractors, naturopathic healers, etc . . .


    I personally find it hard to stomach that our professional opinion will be limited to "they can't fasten their bra behind their back"  Tell the patient something that they didn't know before they came, then tell them how to fix it.

    If you went to the mechanic because your car made a pinging noise and he told you after you spent $200 on his evauation that your car makes a pinging noise, would you think that was a good investment?

    (in reply to torques)
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    RE: PT Diagnosis - November 3, 2008 5:06:33 PM   
    torques

     

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    It is what it is. Medical physicians are the only one allowed to diagnose medical diseases or "disease pathology". Look at vision 20/20 statement:
                    "By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health."


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    RE: PT Diagnosis - November 3, 2008 5:35:29 PM   
    Tom Reeves DPT ATC

     

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    "diagnosis of",  it sounds like you are arguing for my point of view.

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    RE: PT Diagnosis - November 3, 2008 6:07:28 PM   
    torques

     

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    The statement... diagnosis of impairment and not pathology. I think the argument whether who makes the diagnosis is not as important to me as to whether the PT diagnosis are more reflective to patient's disability versus a medical diagnosis. It is already shown by several studies  that structural anomalies through (MRI/CT) does not correlate to source of LBP and disability.  Several PT diagnostic classifications that are shown to be more relevant (e.g. treatment based, movement impairment, mechanism based classifications) in diagnosis and treatment of LBP. Another  example: rotator cuff tear. Clearly, there is a  histological damage (pathology) to the tissue. However, PT go beyond just focusing on the tissue at fault. PT analyses the kinematics and kinetics of the adjacent structures  which may infact be causing the pathology (effect). This is what make PT's specialists. Without special training, any other practitioners cannot provide biomechanical basis of  pathological mechanical sprain/strain.


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