Vascular disorders that impede cerebral blood flow can result in the patient becoming confused and disoriented. Several neurological disorders, infections, liver disease, renal disease, psychiatric disorders, and adverse drug reactions can produce these symptoms in patients, and many of these disorders were present to a significant degree in the outpatient study discussed earlier (Tables 1 and 2). Based on the patient’s medical history and medication usage, is there a reasonable explanation for these symptoms? Is the physician aware of the problem? The presentation of infections in elderly subjects provides an unusual insight into the need for assessing confusion, disorientation, and cognitive/emotional changes in patients. In nonelderly people, infection is typically associated with the onset of a fever. However, in about one in three older adults, infections occur without a fever. Often the first presenting symptom in an older adult with an infection is a change in the person’s cognitive and emotional state (i.e., the onset of confusion and disorientation; Norman, 2000). Self-reported health status refers to simply asking a client to report his or her health status as excellent, very good, good, fair, or poor. Self-reported health status is a strong and independent predictor of mortality (Schnittker & Bacak, 2014) and functional limitation (Galenkamp et al., 2013). Clients that reported their health status as “poor” have a two- fold increase in the rate of dying compared to clients reporting Systems review According to the Guide to Physical Therapist Practice (APTA, 2014), a systems review should be conducted on all patients. The systems review is a limited examination of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and the communication ability, affect, cognition, and learning style of the individual. The data collected allow the therapist to screen for impairment(s) in the person’s ability to initiate, sustain, and modify purposeful movement for the performance of an action, task, or activity. The systems review is one of three components of the examination, along with history and tests and measures. Screening the cardiovascular/pulmonary systems includes examination of the heart rate, respiratory rate, and blood pressure, as well as looking for evidence of edema. Integumentary screening focuses on examining the integrity of the skin, assessing pliability and color of the skin, examining scars, and looking for suspicious lesions. Considering the high incidence of diabetes, this assessment should include an examination of the feet, including a protective sensory screen in patients deemed to be at risk for diabetes. Screening of the musculoskeletal system should include examination of the patient’s gross symmetry, range of motion, and strength, as well as recording the patient’s height and weight. The height and weight can be employed to calculate the body mass index and used as an indicator of body composition. Screens for specific physiological systems While some conditions (e.g., hypertension) could be found utilizing the systems review noted above, many other conditions (e.g., occult cancer or an adverse drug reaction) may or may not be found using these screens. The alternative is to utilize the information gained from the patient history, risk factor assessment, general health questions, and the systems review to determine if additional screening of a specific physiological system is indicated. Screening of specific physiological systems is employed to identify symptoms of occult disease, medical conditions, and adverse drug reactions that may mimic some conditions
their health as “excellent” (Schnittker & Bacak, 2014). Therapists should view the report of “poor” health from a client to be a red flag and give serious consideration to a referral to a physician or another healthcare provider for follow-up (Goodman et al., 2018). In summary, the general health questions are nonspecific indicators of pathology; they suggest that something is wrong, but they do not give a specific diagnosis. A therapist who receives an affirmative answer to one or more of the general health questions must put the answer into the context of the entire set of findings: ● What is the duration of the symptoms? ● 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? ● Is the physician aware of the problem? ● If the physician is aware of the symptom, has it changed since the patient last saw the physician? The answer to these questions helps the therapist decide whether a review of specific physiological systems is indicated and, if so, which systems should be screened. This information can be used to decide if the problem is outside the therapist’s scope of practice and if a referral to another healthcare provider is indicated. The neuromuscular system is assessed by examining the patient’s gait, locomotion, balance, transfers, transitions, motor control, and motor learning and performing specific upper motor tests. The level of cognition includes examination of communication, orientation, and emotional responses. Any barriers to or preferences for learning (e.g., vision and hearing impairments) should be included in the examination (APTA, 2014). As noted above, the systems review is a limited examination to screen for impairment(s) to purposeful movement. Positive findings on the systems review suggest the need for additional screening using the screens for specific physiological systems. However, two situations require additional consideration for using specific physiological screens: incontinence and ulcers. Many patients with low back pain suffer from incontinence. As a result, patients with low back pain should be screened for problems related to the urogenital system and incontinence even in the absence of overt signs and symptoms or patient complaints of the problem. In addition, many patients seeking physical therapy take nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief. However, NSAIDs are notorious for being ulcerogenic. As a result, therapists should consider screening the gastrointestinal system in every patient reporting the use of NSAIDs for potential problems related to the presence of an ulcer. The typical questions used to screen the gastrointestinal and urogenital systems are presented in the next section of the course and can be found in Tables 9 and 10, respectively. commonly treated by therapists. The physiological systems that therapists screen include the cardiovascular, pulmonary, endocrine, GI, urogenital, nervous, psychological, integumentary, and hematological/lymphatic systems (APTA, 2014; Boissonnault, 2005; Goodman et al., 2018). If the cluster of clinical findings implicates a potential disorder in one of the physiological systems, then the therapist should ask a series of screening questions to determine the likelihood that the system is impaired and determine the need for a referral to another healthcare provider.
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