In addition, if the patient cannot offer a reasonable explanation and the physician is unaware of the symptoms, then the therapist should conduct a review of each physiological system implicated and consider consulting with the physician regarding the findings of concern (Boissonnault, 2005; Goodman et al., 2018). The first part of the review of physiological systems begins with the therapist asking the patient ten general health questions (Boissonnault, 2005; Goodman et al., 2018). The premise of each question is “Does the patient currently have or in the past six months has the patient had ...?” The general health questions typically inquire about the presence of the following conditions:
symptoms are present? Is there a reasonable explanation for the malaise? Is there a history of cancer? Has there been a change in medications?). Fevers, chills, and/or sweats are constitutional symptoms that are commonly associated with the presence of an infection. However, there are many other serious reasons these symptoms might be present in a patient. Fever may be present as a consequence of many systemic illnesses, such as rheumatoid arthritis, systemic lupus erythematosus, or an occult infection. In addition, fever has been associated with the presence of metastatic cancer and the acute onset of angina or myocardial infarction (Boissonnault, 2005; Goodman et al., 2018). Fever is defined as a body temperature greater than 99.5°F or a temperature greater than one degree above the normal baseline body temperature for the patient (Boissonnault, 2005). The normal baseline body temperature is often below 98.6°F in elderly people, so an older adult may actually have a fever with a body temperature of 99°F or lower. In addition, most people show circadian variations in body temperature, with a normal range of up to 2°F between their lowest and highest daily body temperatures. The daily low and high in body temperature are typically found in the morning and late afternoon, respectively (Boissonnault, 2005; Goodman et al., 2018). The presence of a fever is a cause for concern when the body temperature is above 99.5°F (or 1°F above baseline) and the fever lasts longer than two weeks (Boissonnault, 2005). Most self-limiting viral infections that cause fever, chills, and sweats last for two weeks or less. Therefore, although the presence of a fever lasting for longer than two weeks is cause for concern, this information must be placed within the context of the entire cluster of signs and symptoms present within the individual. Is there a reasonable explanation for the condition? Is the physician aware of the fever, chills, and sweats? Has there been a change since the person was last seen by the physician? The absence of a fever does not rule out the possibility of an infection. Some infections occur without a fever. In addition, approximately one in three elderly individuals may not exhibit a fever with an infection (Norman, 2000). The presence of pneumonia, as well as other infections in the elderly, may occur without a fever, and the only presenting symptom may consist of confusion or a change in cognitive status (Norman, 2000; Mayo Clinic, 2017). A lower than normal body temperature may be found in the elderly and immunocompromised adults with pneumonia (Mayo Clinic, 2017). Nausea and vomiting are constitutional symptoms commonly associated with disorders of the gastrointestinal (GI) system (e.g., ulcers and stomach flu). However, these symptoms are also associated with serious disorders in the central nervous system (CNS), cardiovascular system, and endocrine system, as well as liver and renal disorders. Other conditions associated with nausea and vomiting include bulimia, pregnancy, and adverse drug reactions. A report of nausea and vomiting should prompt the therapist to ask a series of follow-up questions regarding the circumstances associated with these and other symptoms that may be present concomitantly: ● What activities or behaviors provoke the symptoms? ● How long has this been a problem (self-limiting viral infections last <2 weeks)? ● Does eating provide relief or make the symptoms worse? A change in the patient’s symptoms with eating is a common finding with an ulcer.
● Fatigue. ● Malaise.
● Fever-chills-sweats. ● Nausea-vomiting. ● Unexplained weight loss or gain. ● Dizziness-lightheadedness. ● Paresthesia. ● Weakness. ● Cognitive-emotional change. ● Self-reported health status is “poor.”
Complaints about fatigue account for approximately 10 million primary care office visits per year (Boissonnault, 2005). Fatigue is a common symptom of many disorders. Psychological disorders, including depression and anxiety, present with fatigue as a common complaint. Patients with infections such as endocarditis, tuberculosis, and hepatitis can present with fatigue. Endocrine disorders (e.g., diabetes and hypothyroidism) often result in undue fatigue in a patient. In addition, fatigue may be a consequence of anemia, cancer, renal failure, heart failure, or an adverse drug reaction. Fatigue is a common finding with many comorbidities, including those mentioned earlier in relation to Boissonnault’s study of patients presenting for outpatient physical therapy services (Boissonnault, 1999, 2005; Goodman et al., 2018). The presence of fatigue is not diagnostic of any specific disorder. Fatigue is a common finding in people with and without a serious medical problem, so the question becomes, “When is fatigue significant?” The complaint of fatigue is significant to the therapist when the patient reports that fatigue interferes with his or her ability to complete normal activities of daily living at home, work, and socially. The importance of the finding of fatigue is increased if the capacity to perform activities of daily living has been impaired for more than two to four weeks. This time frame is significant because most viral infections are self-limiting in this time period. Hence, fatigue that interferes with the patient’s capacity to perform his or her normal activities of daily living for more than two to four weeks is unlikely to be the result of a simple, self- limiting, viral infection and requires follow-up questions. Malaise refers to a sense of uneasiness or general discomfort. The patient may report that “Something doesn’t feel right,” “I’m coming down with something,” or “I think my cancer is coming back.” There are many serious conditions that result in the perception of malaise in patients. Serious conditions presenting with malaise include infections, progression of an existing condition (e.g., congestive heart failure), or progression of an occult condition (e.g., cancer or heart disease; Boissonnault, 2005). Does the patient have a history of any of these or other disorders that would explain the malaise? Like fatigue, the presence of malaise is not diagnostic of any specific disorder. Instead, the presence of malaise needs to be placed in the context of the entire clinical presentation of the patient (i.e., in addition to malaise, what other adjunct or constitutional
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