These three important considerations—past medical history, clinical presentation, and pain pattern—demonstrate how important it is to get a thorough medical history and to spend time during the interview to dig deep into the onset and nature of the client’s symptoms and pain. Anecdotally, the author remembers an instructor of an advanced manual therapy class stating that the more knowledgeable and skilled a therapist is, the more time they will spend on the subjective part of the initial examination as a means of understanding the etiology of the client’s symptoms. A tool that clinicians can use to help identify yellow flags is the Optimal Screening for Prediction of Referral and Outcome Review of Systems (OSPRO-ROS). This tool includes standard symptom descriptors used to aid in screening for potential systemic involvement. It includes questions related to the cardiovascular, gastrointestinal, endocrine, nervous, integumentary, pulmonary, and musculoskeletal systems (George et al., 2018). ● Diabetes and client is confused or lethargic, or demonstrates a change in mental status. ● Positive McBurney’s sign (pain with pressure over McBurney point, or two-thirds the distance between the umbilicus and the anterior superior iliac spine one the right side of the abdomen) indicating appendicitis or rebound tenderness (the presence of pain when pressure is removed from the abdomen, rather than when it is applied) indicating inflamed peritoneum. ● Sudden worsening of intermittent claudication. ● Throbbing chest, back, or abdominal pain that increases with exertion accompanied by a sense of a heartbeat when lying down and palpable pulsating abdominal mass (consistent with an aneurysm). ● Change in size, shape, tenderness, and consistency of lymph nodes; detection of a mass in the breast or axilla in the presence of a previous history of cancer. or 96.8 to 99.5 degrees Fahrenheit (with an average of 98.6 degrees Fahrenheit). Older adults are less likely than younger adults to develop a fever in the presence of an infection (Heick et al., 2023). Oximetry An oximeter can be used to measure the oxygen level (oxygen saturation) of the blood. Values between 95% and 99% are considered normal. Oxygen saturation less than 90% is a cause for concern (Heick et al., 2023). Self-Assessment Quiz Question #3 A client presents to your clinic complaining of right-sided shoulder pain that came on two weeks ago. The client is a 65-year-old retired male who is also an avid golfer. Which of the following pain descriptions might be considered a red flag for this situation? a. The client reports that the onset of pain is related to a day when he played 36 holes of golf, which was far more than his usual routine of 9 holes. b. The client reports that the pain is sharp, almost knifelike; that it wakes him up at night; and that he is unable to find a position that relieves his pain. c. The client reports that the pain is worst in the morning when he awakens with stiffness in his shoulder but that it lessens as he “gets moving.” d. The client reports that he had this same thing a few years ago and that it improved greatly with physical therapy exercises.
Healthcare consideration: When evaluating a client presenting to physical therapy complaining of musculoskeletal symptoms, it is easy to become focused on identifying musculoskeletal factors that confirm this suspicion or presentation. Effective differential diagnosis involves adopting a stance of openness to all the possible explanations for a client’s condition. Observation of and questioning about all the factors possibly related to the origin of symptoms includes exploration of such things as the presence of fever, abnormal vital signs, gastrointestinal symptoms, painless muscles weakness, diaphoresis, visual disturbances, skin lesions, and bowel/ bladder symptoms, among many others. Immediate medical attention Cavallaro Goodman et al. (2018) have constructed a list of symptoms that require immediate medical attention. When these symptoms are present, immediate medical attention is advised: ● Angina symptoms: Angina symptoms that do not resolve after 20 minutes of rest; angina symptoms that do not resolve after administration of nitroglycerin. ● Angina symptoms accompanied by nausea, vomiting, and/or profuse sweating. ● Bowel and/or bladder incontinence with or without saddle numbness. ● Symptoms of inadequate ventilation or C02 retention (shallow breathing with dizziness, drowsiness, fatigue, headache). ● Anaphylactic shock (feeling light-headed, breathing difficulties, wheezing, fast heart rate, clammy skin, confusion) Vital signs Vital signs are an important part of physical therapy assessment because they can serve as early indicators for systemic illness and disease (Heick et al., 2023). In addition, they provide important information about the pulmonary and cardiovascular systems, two systems that are often challenged through the course of physical therapy treatment. Blood pressure Normal blood pressure for adults is systolic less than 120 mm Hg and diastolic less than 80 mm Hg. If systolic is greater than 180 mm Hg and/or diastolic is greater than 120 mm Hg, this is considered a hypertensive crisis (Heick et al., 2023). Pulse Normal pulse rate for adults, assessed via either the carotid or radial arteries, is 60 to 100 beats per minute. The normal response to physical activity is an increase of approximately 10 beats per minute for each MET (metabolic equivalent) of increased activity (Heick et al., 2023). Normal recovery is a decrease of greater than 12 beats per minute following one minute of seated rest and a return to baseline after three minutes. Respiratory rate Normal respirations are 12 to 20 breaths per minute (Heick et al., 2023). Temperature An increase in core body temperature is usually an indication of an infection. Normal temperature is 30 to 37.5 degrees Celsius (with an average of 37 degrees Celsius)
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