Many medications are known to induce nausea and vomiting, so the therapist should ask the patient about all of the medications he or she is currently taking: ● Is there an explanation for the nausea and vomiting (e.g., a change in medication or a history of ulcers)? ● Is the physician aware of the problem? ● Has there been a change since the patient last met with the physician? ● Is the patient taking his or her medication(s) exactly as prescribed? Weight loss or gain greater than 5% to 10% of body weight that occurs over a 6-month time period without explanation is considered to be a significant finding that should be investigated (Boissonnault, 2005). Some therapists prefer to use a change of 5 to 10 pounds as an alternative benchmark. Unexplained weight loss is a sensitive but nonspecific indicator of pathology – that is, the person probably has something wrong, but weight loss as an isolated finding will not indicate what is wrong. The therapist should attempt to determine how much weight has been lost and over what time period the loss has occurred. Other questions to consider include: ● Is there a reasonable explanation for the change, such as a change in diet or exercise habits? ● Is the physician aware of the change in weight? ● What comorbidities or medications could account for the change? Thompson and Morris (1991) examined unexplained weight loss in a classic study of 45 patients with a loss of weight greater than or equal to 7.5% of their body weight occurring over a 6-month time period. Subjects in this classic study were age 63 and older and two-thirds of the subjects were female. The study participants were followed for 24 months or until a cause for the weight loss was determined. The most common diagnosis associated with weight loss was depression, which was found in 18% of the subjects. Cancer was the explanation for weight loss in 16% of the subjects, while disorders of the GI tract accounted for 11% of the diagnoses (Thompson & Morris, 1991). When the patient presents with unexplained loss of 5% to 10% of body weight over a 6-month period, the therapist should review the medical history and attempt to determine if there is a history of a disorder such as depression, cancer, or ulcers that could explain the current situation. These disorders were found with significant frequency in the outpatient study discussed earlier (Boissonnault, 1999). When significant weight loss occurs without explanation, the therapist should consider contacting the physician immediately. Therapists should record a patient’s weight as part of an initial evaluation and track the weight over time to determine if further objective changes occur in the patient’s body weight. Unexplained weight gain is a less sensitive indicator of pathology than weight loss (i.e., weight gain is less likely to be associated with a disease than weight loss; Boissonnault, 2005). However, an unexplained weight gain greater than 5% to 10% of the body weight that occurs over a 6-month time period is a finding that should be investigated because of the seriousness of the pathologies associated with the condition. Rapid weight gain is often associated with fluid retention. Edema and ascites are findings consistent with fluid retention. A weight gain of 5% or more in one week during pregnancy is associated with pre-eclampsia, a dangerous form of toxemia that can occur during pregnancy. Congestive heart failure, renal failure, and liver failure all result in fluid retention that can cause an individual to gain weight rapidly and become edematous in appearance (Boissonnault, 2005). The medical and social history should provide insight into the possibility that one of these disorders could be the basis for the
weight gain. However, fluid retention is not the only explanation for weight gain. Depression is known to result in weight gain that occurs primarily through a change in eating habits but without the edematous appearance. In his classic 1999 study, Boissonnault reported that 15% of patients who presented for outpatient physical therapy services had a history of depression. Hypothyroidism is a condition associated with an increase in body weight, along with several associated signs and symptoms, including hair loss, undue fatigue and myxedema, a form of nonpitting, boggy edema around the eyes. Seven percent of people presenting for outpatient physical therapy services reported a history of hypothyroidism (Table 1; Boissonnault, 1999), and levothyroxine, a thyroid replacement hormone, was the second most prescribed medication in 2017 (Kane, 2017), making hypothyroidism a realistic possibility for unexplained weight gain. Dizziness and lightheadedness can occur as a result of pathology in virtually any physiological system, and the symptoms may result from pathology in multiple physiological systems (Boissonnault, 2005). These symptoms can result from anemia, hypotension, and heart disease, and these disorders were found with significant frequency in the outpatient study discussed earlier (Table 1). In addition, a vestibular disorder or an adverse drug reaction can cause the symptoms of dizziness and lightheadedness to appear. This makes the presence of dizziness and lightheadedness a very nonspecific indicator of pathology. These symptoms become significant when viewed in the context of the medical history and current medication usage. Questions that need to be asked include: ● Is there a reasonable explanation for the appearance of these symptoms? ● Is the physician aware of this problem? ● If the physician is aware of the dizziness and lightheadedness, has it changed since the patient was last evaluated? Paresthesia and weakness can result from many disorders. The level of concern associated with these symptoms is increased markedly if the paresthesia and/or weakness: a. Does not follow the distribution of spinal or peripheral nerves, b. Is distributed bilaterally and symmetrically (stocking or glove distribution), c. Migrates between different regions of the body, d. Is progressive over time, e. Is found in the perianal (saddle) area, and/or f. Is associated with urinary or bowel retention or incontinence (e.g., cauda equina syndrome; Boissonnault, 2005; Goodman, 2018). Serious conditions associated with the presence of paresthesia or weakness include neurological conditions such as multiple sclerosis, endocrine disorders such as hypothyroidism, muscle disorders such as muscular dystrophy, and/or adverse drug reactions. The therapist needs to ask several questions: ● What adjunct symptoms are present? ● Is there anything in the medical history or medication usage that would explain this situation? ● Is the physician aware of this problem? The loss of bowel or bladder control especially associated with perianal paresthesia is considered an emergency that should be evaluated by a physician as soon as possible. The level of cognition should be screened in all patients (APTA, 2014). The onset of, or an increase in, confusion, disorientation, or a change in the emotional state of the individual is associated with many serious pathologies (Boissonnault, 2005; Goodman et al., 2018).
Page 87
Book Code: PTOH1324
EliteLearning.com/Physical-Therapy
Powered by FlippingBook