Summary of case study 2 This example points to the importance of taking a thorough subjective exam, medical history, and medication history for each patient. While this patient listed some of his comorbid conditions, he did not mention the presence of multiple comorbidities associated with multiple prescription medications that he reported taking. The prescription medication list alerted the therapist to the presence of multiple serious comorbid conditions that should impact the plan of intervention for the patient. In addition, the presence of potassium chloride and three medications for hypertension suggests the possibility of polypharmacy in this client. The client was instructed to take the list of medications with him to his next appointment and ask his primary care physician to go over the list with him to ensure he is taking the prescription medications he needs and to reduce or remove any medically unnecessary medications he is currently taking. risk factors and signs and symptoms. A patient with low back pain who is age 50 or older, has had cancer, has experienced unexplained weight loss, or who fails to respond to conservative therapy may have cancer. If the patient has a history of cancer, the therapist can better assess the situation if he or she knows the common metastatic sites for that particular type of primary cancer. Having this background knowledge, along with asking the general health questions and the appropriate specific physiological screening questions and evaluating the patient’s response to conservative therapy will help the therapist determine the need for medical referral. Patients who report a change in signs or symptoms when they start a new medication or change the dose of a medication may be experiencing an adverse drug reaction. Therapists should remember which medications produce the largest number of adverse reactions and the physiological systems most frequently affected. Aspirin, the other NSAIDs, and opioids are used frequently to treat the pain and inflammation found in many outpatients with musculoskeletal disorders. These medications often produce adverse drug reactions in the GI system, and as a result, any patient reporting their use should be screened for the presence of GI distress. Adverse Drug Reactions ● Adams, M. P., & Holland, L. N. (2011). Pharmacology for nurses: A pathophysiologic approach (3rd ed.). Upper Saddle River, NJ: Pearson/Epocrates. ● Cohen, J. S. (2001). Dose discrepancies between the Physicians’ Desk Reference and the medical literature, and their possible role in the high incidence of dose-related adverse drug events. Archives of Internal Medicine, 161 (7), 957-964. ● Di Stasi, S. L., MacLeod, T. D., Winters, G. K., & Binder- Macleod, S. (2010). Effects of statins on skeletal muscle: A perspective for physical therapists. Physical Therapy, 90 (10), 1530-1542. ● Kane, S. P. (2017). ClinCalc DrugStats Database, Version 17.0. ClinCalc: http://clincalc.com/DrugStats. Updated February 8, 2017. ● National Institutes of Health (NIH), U.S. National Library of Medicine, MedlinePlus [Internet site]. http://www.nlm.nih. gov/medlineplus/druginfo/meds/
Table 21: Prescription Medications versus Comorbid Conditions Prescription Medications Reported Comorbid Condition Not Reported Levothyroxine Hypothyroidism Pravastatin
Hypercholesterolemia/heart disease
Potassium Chloride
Hypokalemia (occurs with some diuretics given for hypertension) 1. Pain/inflammation at normal dosage. 2. Reduces the risk of thromboembolic event at low dosage.
Aspirin
Course summary In summary, screening refers to the process of finding the suggestion of a disorder before the patient seeks medical attention for the disorder. Screening should include the use of the general health questions regarding the presence of constitutional symptoms. The general health questions are nonspecific indicators of pathology; they suggest that something is wrong, but they do not give a specific diagnosis. When the therapist receives an affirmative answer to one or more of the general health questions, he or she must put the answer or answers into the context of the entire set of findings: Is the physician aware of the problem? If the physician is aware of the problem, has the problem changed since the patient last saw the physician? Are there adjunct symptoms, and if so, what are they? Is there anything significant in the medical history, social history, or use of medications that might offer a reasonable explanation for the situation? The answer to these questions helps the therapist decide whether a review of specific physiological systems is indicated, and if so, which specific system or systems should be screened. In addition, this information can be used to decide whether the problem is outside the therapist’s scope of practice and if a referral to another healthcare provider is indicated. Therapists should identify elements in the medical history that might indicate the possibility of cancer, as well as cancer ● Goodman, C. C., Heich, J., & Lazaro, R. T. (2018). Differential diagnosis in physical therapy (6th ed.). Philadelphia, PA: W. B. Saunders. Cancer Screening ● Ross, M. D. (2005). Cancer as a cause of low back pain in a patient seen in a direct access PT setting. Journal of Orthopaedic & Sports Physical Therapy, 35 (10), 651-658. ● Stout, N. L. (2009). Cancer prevention in physical therapist practice. Physical Therapy, 89 (11), 1119-1122. ● American Cancer Society (ACS). (2017). Cancer Facts & Figures for 2017 . Retrieved from https://www.cancer.org/ content/dam/cancer-org/research/cancer-facts-and-statistics/ annual-cancer-facts-and-figures/2017/cancer-facts-and- figures-2017.pdf ● National Cancer Institute (NCI) http://cancer.gov Resources Symptom Location
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