For the professions of physical and occupational therapy the concepts associated with and use of the term differential diagnosis are still evolving and under debate. A recent editorial describes diagnosis in physical therapy as complex and controversial, with diverse views existing.¹ For physical therapists (PTs), the guiding premise is that the differential diagnostic process fits within the Patient/Client Management Model described in the Guide to Physical Therapist Practice² (Figure 7-1) and within The Guide to Occupational Therapy Practice.³ The therapist attempts to organize the history and physical examination (including tests and measures) findings into clusters, syndromes, or categories. There are certain clusters of findings that suggest the presence of disease or an adverse drug event and warrant communication with a physician. There are other symptoms and signs that are consistent with conditions that still fit into the older disablement framework. In the world today, the model of choice of all therapists is the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF), which moves away from the consequences of disease classification to a health focus classification. Thus a shift in how one looks at disease and its impact on health and wellness not only has changed the words used by therapists but also incorporates external societal limitations that our clients face.⁴ These changes do not affect the way a therapist should medically screen before formulating a clinical diagnoses based on movement dysfunction. These conditions are inherent in the interrelationships among impairments, functional or activity limitations, and participation in life and are appropriate for physical or occupational therapy interventions.²,³,⁵,⁶

Figure 7-1 Patient/client management model. (Adapted from American Physical Therapy Association: Guide to physical therapist practice. *Phys Ther* 81:43, 2001, with permission of the American Physical Therapy Association.)

The process of differentiating the cluster of findings that warrant communication with a physician regarding concerns about a patient’s health status compared with those that do not will be called Differential Diagnosis Phase 1.⁷ In this scenario a physician will ultimately diagnose the patient’s illness, but the PT’s and occupational therapist’s (OT’s) examination findings and subsequent patient referral contribute to the diagnosis being generated. For many of these illnesses, the use of advanced imaging, laboratory testing, and/or tissue biopsy is necessary for the diagnosis to be made.⁸ Numerous examples exist in Physical Therapy Journal and Journal of Orthopaedic and Sports Physical Therapy of published case reports and case series describing such action taken by PTs.

If the decision is reached that the symptoms and signs do fall within the scope of practice of PTs and OTs, a second level of differential diagnosis occurs. Now the therapist attempts to categorize the examination findings into the specific diagnostic categories that will specifically guide the choice of treatment interventions and the development of a prognosis. This second level of diagnosis is called Differential Diagnosis Phase 2⁷ and is the focus of Chapters 8 and 9. Figure 7-2 illustrates where Differential Diagnosis Phase 1 and Phase 2 fit into the Patient/Client Management Model.

Figure 7-2 Patient/client management model showing Differential Diagnosis Phase 1 and Phase 2. (Modified from Umphred DA [Chair]: Diagnostic Task Force, State of California, 1996–2000, California Chapter of American Physical Therapy Association.)

The purpose of this chapter is to discuss the medical screening components associated with Differential Diagnosis Phase 1, including identification of patient health risk factors, recognition of atypical symptoms and signs, review of systems, and within-systems review. Methods to collect this information during a patient examination are also presented. The critical importance of therapists developing these visual and analytical skills is that they can lead to identification of the differences between direct causation of movement dysfunction pain syndromes arising from disease versus a system causation that may or may not be directly connected to a specific disease. The therapist referral often plays a critical role in providing the doctor the patient behaviors observed as system causation with or without a disease classification. Patient case scenarios are used to illustrate the important medical screening principles.

Differential diagnosis phase 1: medical screening

The Guide to Physical Therapy Practice²^,⁹ and The Guide to Occupational Therapy Practice³ clearly describe the therapists’ responsibility to refer patients/clients with health concerns to other practitioners. The emphasis of the following discussion is detecting clinical manifestations that suggest the specific need for physician intervention. Typically the initial warning signs associated with these scenarios include a recent onset or exacerbation of symptoms such as pain, weakness, numbness, dizziness, falls, confusion, and so on—common complaints of patients with neurological disorders. Therapists may also detect symptoms or signs unrelated to the primary medical neurological condition but that could be related to an existing comorbidity or a medication side effect. In addition, a general health and wellness screen may reveal a need for a psychological, dermatological, or other nonneurological medical consultation.

As opposed to Phase 2, the goal of Differential Diagnosis Phase 1 is not to formulate a specific diagnosis on the basis of these clinical manifestations. A therapist’s Phase 2 diagnosis is primarily a group of motor behaviors representing movement dysfunction and how it limits independence in life activities and an individual’s ability to participate in life. The Phase 1 process identifies signs and symptoms that are health or disease and pathology driven and, when they have been identified, directs a referral to a medical specialist. In fact, providing a specific diagnosis or labeling a cluster of examination findings when referring a patient to a physician because of health status concerns (e.g., peptic ulcer disease, endometriosis, new or progressive neurological problems) could place the therapist outside the scope of his or her practice. Having the ability to formulate such a specific systemic, neurological, or visceral disease or pathology diagnosis is not necessary to meet the responsibilities described in the Guides to Practice. Once the therapist’s concerns have been communicated, it is then up to the physician to diagnose the presence of such disease entities.

The purpose of the therapist’s medical screening is to (1) identify existing medical conditions, (2) identify symptoms and signs suggesting that an existing medical condition may be worsening, (3) identify neurological manifestations that suggest an acute or life-threatening crisis, and (4) identify symptoms and signs suggestive of the presence of an occult disorder or medication side effect. This medical screening has always taken place within the clinical framework of PTs’ and OTs’ practices, but as practitioners become more autonomous, this screening must become more comprehensive, requiring tools and documented evaluation results. Figure 7-3 is an example of an examination scheme leading to the decision to treat the patient, to treat and refer the patient, or to refer the patient. Phase 2 may also include the decision to refer the patient to another practitioner (e.g., dietician, social worker, clinical psychologist) for services augmenting the therapy or to social programs such as wellness clinics that will encourage the patient to participate in movement activities even though he may need individualized therapeutic intervention. The following material focuses on the components of this scheme most directly related to the medical screening process leading to a patient referral.

Figure 7-3 Patient examination scheme. (Taken from notes from course by W. G. Boissonnault, 1998.)

Identifying patients’ health risk factors and previous conditions

Owing to the considerable overlap in symptomatic presentation of impairment-related conditions and those requiring physician examination, identifying existing health risk factors for occult diseases is important. Numerous factors have an effect on the patient’s risk for compromised health status, including age, sex, race, occupation, leisure activities, preexisting medical conditions, medication usage (over-the-counter and prescription drugs), tobacco use, and substance abuse or the interaction of some of these conditions, and family medical history.

Of these, a personal history of a current or recent medical condition, current medication use, and a positive family history (e.g., mother and aunt with a history of breast cancer, father diagnosed with prostate cancer at the age of 58 years) are the most relevant risk factors for the potential presence of an occult condition. For example, the history of a previous episode of depression significantly increases the risk of a second episode compared with the risk that someone who has never had an episode of depression will have his or her first such episode.¹⁰ The greater the number of existing risk factors, the more vigilant the therapist should be for the presence of warning signs suggestive of disease and the more extensive the other medical screening components will need to be. Those increased risk factors, whether within one system or multiple systems, can lead to clinical behaviors that are the summation of the systems problems and their interactions that affect movement. Physicians should be able to depend on the therapist to recognize these interactive symptoms and refer the patient back to either the referring physician or to another specialist.

There are different methods to collect this medical history and patient profile information, including a review of the medical record and use of a self-administered questionnaire, depending on the practice setting and patient population. Figure 7-4 is an example of a self-administered questionnaire that could be completed by the adult patient, a family member, or a caregiver. As noted in Figure 7-3, a quick scanning review of this information should occur, if possible, before the patient interview is begun. The therapist will have a head start in organizing the history and physical examination, knowing what to prioritize and at least initially what parts of the examination can be deemphasized. The utility and accuracy of a self-administered questionnaire in patient populations germane to therapists’ practice, similar to the one illustrated in Figure 7-4, have been described, with the conclusion that such a tool can be a valuable adjunct to the oral patient interview.¹¹

Figure 7-4 Self-administered questionnaire to collect medical history information. (Modified from Boissonnault WG, Koopmeiners MB: Medical history profile: orthopaedic physical therapy outpatients. *J Orthop Sports Phys Ther* 20:2–10, 1994, with permission of the Orthopaedic and Sports Sections of the American Physical Therapy Association.)

Affirmative answers to previous or current illness questions should direct the therapist to consider what the potential impact may be on the patient’s symptoms, choice of examination and treatment techniques, rehabilitation potential, and risk for additional illness. For example, the presence of existing chronic kidney disease (e.g., renal failure) should alert the therapist to numerous potential complications including patient fatigue, weakness, and impaired concentration, all of which could interfere with rehabilitation efforts. Chronic renal failure is also marked by paresthesia and muscle weakness, which could mistakenly be associated with other neurological conditions. Renal osteodystrophy is yet another complication associated with chronic renal failure. The concern of compromised bone density should direct the therapist to use techniques that carry a reduced risk of skeletal injury. A series of follow-up questions for the affirmative answers will assist the therapist in determining the relevance (if any) of each item (see Figure 7-5 for examples of follow-up questions for selected information categories).

Figure 7-5 Potential follow-up questions for affirmative answers on the self-administered questionnaire. (From W. G. Boissonnault, course notes, 1998.)

Having the self-administered questionnaire completed before the scheduled time of the initial visit will improve the therapist’s efficiency. Mailing the questionnaire to the patient before the visit or having the patient arrive 10 to 15 minutes before the appointment would allow for the form’s completion without taking time away from the actual examination itself. Once the questionnaire has been completed, taking 1 to 2 minutes to scan it before the interview should be all that is necessary for the therapist to begin formulating questions and organizing the physical examination. The inability of the patient to recall information or complete the questionnaire may be another sign that medical clearance is necessary before progression to Phase 2.

Symptomatic investigation of functional restriction

The chief presenting symptoms or functional restriction typically provides the reason for therapy services being sought and can provide the initial warning sign(s) of potential medical issues needing to be addressed. Despite pain not typically being the chief complaint of many patients with primary neurological conditions, a relatively mild pain is often the initial complaint associated with a serious pathological condition; a dull diffuse ache is often the initial presenting complaint associated with tumors of the musculoskeletal (MSK) system.¹² This relatively minor complaint can easily be overlooked by therapists working with patients who have neurological involvement and signs and symptoms (e.g., weakness, numbness) that are much more debilitating and cause more functional limitations than the pain complaints do. Although investigating pain complaints may not be the initial priority for these therapists, at a later visit such questioning is very important, especially if it continues, increases in intensity, shifts, or enlarges its region with no causation. Effective medical screening involves the interpretation of a patient’s description of symptoms, functional limitations, and the corresponding physical examination findings. Descriptions of symptoms associated with neuromusculoskeletal impairments (loss or abnormality of physiological, psychological, or anatomical structure or function) generally reveal a fairly consistent and predictable pattern of onset and change over a defined period of time. In addition, the neurological and MSK impairments noted during the physical examination should match with the functional limitations described by the patient or the caregiver. If these expectations are not met, it does not necessarily mean the patient has cancer or an infection, but doubt should be raised on the therapist’s part whether therapy is indicated.

Patients many times are not aware that presenting symptoms or signs suggest a condition better addressed by a physician as opposed to a PT or an OT. For example, Mr. S. had a cerebrovascular accident 6 months ago with resultant mild residual left hemiplegia. At the time of discharge from rehabilitation services he was independent in all activities of daily living, but residual left upper extremity weakness remained. When visiting his internist for a routine checkup, he complained that over the prior 3 weeks he had lost some functional skills and was having difficulty with self-care. The physician then referred Mr. S. to the therapy clinic for evaluation and treatment. Mr. S. states he has been less active and just needs some help regaining his motor function. During the history taking he states that he is experiencing a deep, dull, aching sensation in the lower lumbar spine and right buttock. He assumes it has developed as a result of his inactivity and thus saw no reason to bother the physician with this problem. As Mr. S. continues to describe his difficulties, he also notes a constant deep ache in the right shoulder that he relates to increased use of his right arm to compensate for the left arm weakness. The physical examination of the low back, pelvis, and right shoulder reveals that the existing symptoms do not vary with active or passive range of motion, resisted testing, or postural holding. In addition, quantity of motion is normal for these regions and motor programming appears intact. At this point the therapist cannot explain the symptoms from an impairment standpoint; therefore, depending on other examination findings, including the patient profile and medical history, communication with the internist may be warranted. The following information describes some of the subcategories associated with symptom investigation.

Location of symptoms

A body diagram can be a valuable tool to document the location of symptoms expressed verbally or nonverbally by patients with identified neurological deficits. Besides pain and altered sensation, patterns of abnormal tone, asymmetrical posturing, and areas of weakness can also be noted on the body diagram (Figure 7-6). Numerous body structures are potential pain generators, including visceral structures. Figure 7-7 and Table 7-1 illustrate local and referred pain patterns from various visceral organs. Although the presented pain patterns illustrate those most commonly noted, clinicians should be aware of other potential patterns. For example, ischemic heart disease—the complaint of left chest wall and left upper extremity pain, pressure, or tightness—is not the classic presentation for women and many of the elderly. Besides what is noted in Figure 7-7 and Table 7-1, pain from the heart can also be experienced in the right shoulder or biceps, jaw and tooth, epigastric, and interscapular regions.¹³^,^13a

TABLE 7-1

VISCERAL PAIN PATTERNS

STRUCTURE	SEGMENTAL INNERVATION	POSSIBLE AREAS OF PAIN REFERRAL
PELVIC ORGANS
Uterus including uterine ligaments	T10-L1, S2-4	Lumbosacral junction
		Sacral
		Thoracolumbar
Ovaries	T10-11	Lower abdominal
		Sacral
Testes	T10-11	Lower abdominal
		Sacral
RETROPERITONEAL REGION
Kidney	T10-L1	Lumbar spine (ipsilateral)
		Lower abdominal
		Upper abdominal
Ureter	T11-L2, S2-4	Groin
		Upper abdominal
		Suprapubic
		Medial, proximal thigh
		Thoracolumbar
Urinary bladder	T11-L2, S2-4	Sacral apex
		Suprapubic
		Thoracolumbar
Prostate gland	T11-L1, S2-4	Sacral
		Testes
		Thoracolumbar
DIGESTIVE SYSTEM ORGANS
Esophagus	T6-10	Substernal and upper abdominal
Stomach	T6-10	Upper abdominal
		Middle and lower thoracic spine
Small intestine	T7-10	Middle thoracic spine
Pancreas	T6-10	Upper abdominal
		Lower thoracic spine
		Upper lumbar spine
Gallbladder	T7-9	Right upper abdominal
		Right middle and lower thoracic spine, including caudal aspect scapula
Liver	T7-9	Right middle and lower thoracic spine
Common bile duct	T6-10	Upper abdominal
		Middle thoracic spine
Large intestine	T11-12	Lower abdominal
		Middle lumbar spine
Sigmoid colon	T11-12	Upper sacral
		Suprapubic
		Left lower quadrant of abdomen
CARDIOPULMONARY SYSTEM
Heart	T1-5	Cervical anterior
		Upper thorax
		Left upper extremity
Lungs and bronchi	T5-6	Ipsilateral thoracic spine
		Cervical (diaphragm involved)
Diaphragm (central portion)	C3-5	Cervical spine

Modified from Boissonnault WG, Bass C: Pathological origins of trunk and neck pain, I. Pelvic and abdominal visceral disorders. J Orthop Sports Phys Ther 12:192–207, 1990, with permission of the Orthopaedic and Sports Sections of the American Physical Therapy Association.

Figure 7-6 Body diagram illustrating symptom location. Body areas with no known symptoms or abnormalities are marked with a checkmark. (From Boissonnault WG, editor: *Examination in physical therapy practice—screening for medical disease,* ed 2, New York, 1995, Churchill Livingstone.)

Figure 7-7 Possible local and referred pain patterns of visceral structures. (From Boissonnault WG, editor: *Examination in physical therapy practice—screening for medical disease,* ed 2, New York, 1995, Churchill Livingstone.)

Because there is so much overlap between pain locations associated with visceral disease and neuromusculoskeletal conditions, the results obtained in and of themselves have minimal use in differentiating MSK from non-MSK conditions. Being familiar with the visceral pain patterns will be extremely important, however, when deciding which body systems to screen during the review of systems. Besides noting where symptoms are located, it is equally important to document areas of no complaints (see Figure 7-6). Once the patient has reported symptoms (e.g., low back and right buttock aching, see Figure 7-6), therapists should clarify. Screening to eliminate the possibility of symptoms being present down the back and up the front of the legs; in the pelvis, stomach, chest, neck and face areas; or between the shoulder blades and in the arms is critical. If there is one body area so involved that all the patient’s and practitioner’s attention is focused on it, a relatively mild but potentially serious symptom may be overlooked elsewhere. Placing a checkmark over each body region devoid of symptoms or other abnormal findings is one way to document such information and record change over time.

Symptom pattern

Aspects of the patient’s chief complaint other than symptom location are very relevant to the process of differential diagnosis, in particular a description of how and when the symptoms changed over a defined period of time. Complaints of pain, paresthesia, and numbness associated with primary MSK conditions typically change in a consistent manner over a 24-hour period. The patient will report that the symptom intensity increases with the assumption of specific postures such as left side lying or sitting or with specific activities such as walking, driving, or 2 hours of computer work. Conversely, patients typically can relate paresthesia or pain relief with avoiding certain postures or activities, the assumption of certain postures, wearing an arm sling, and so on. Night pain investigation also falls under this subcategory of patient data. Pain that wakes an individual from sleep and for which changing positions in bed does not provide relief is more concerning than if the pain is positionally related. If the pattern of symptom aggravation and alleviation is that there is no consistent pattern, such as pain that comes and goes independently of the patient’s posture, activities, or time of day; night pain is the patient’s most intense pain; or paresthesia or pain moves from one body region to another inconsistently with common pain referral patterns or identified medical conditions, then the therapist should start thinking whether physical or occupational therapy is what the patient truly needs.¹⁴

In general, when symptoms such as weakness or numbness associated with primary neurological conditions are investigated, the 24-hour reference point to assess symptom change is not realistic. Except for an acute onset or exacerbation, these symptoms tend not to fluctuate that quickly with change in posture or position. Understanding the pathogenesis of primary neurological disorders will allow for detection of symptom change unusual for the patient. This will lead to follow-up questions to determine whether this change may represent a medically serious situation. Similarly, a change in the biomechanical alignment of a joint (e.g., the shoulder), may immediately alter the patient’s pain response, indicating a direct relationship between MSK imbalance in joint stabilization and gravitational pull, for which therapy would be appropriate.

History of symptoms

The therapist must also scrutinize the patient’s report of the onset of the symptoms. Pain and paresthesia or numbness associated with neuromusculoskeletal impairments typically can be related to trauma, either on a macro or a micro level, or to a medical event such as a cerebrovascular accident. More often than not it is repetitive overuse or cumulative trauma that leads to tissue breakdown and inflammation (see Chapter 18). Patients with neurological impairments resulting in postural abnormalities and abnormal movement patterns are at risk for such conditions. If a patient’s symptoms are truly insidious, meaning not related to macro or micro trauma, or there has not been a significant change in activity level that reasonably accounts for the complaints, the therapist should again be concerned about the source of the symptoms. A worsening of symptoms (e.g., numbness, weakness, spasticity, swelling) associated with an existing medical condition should be investigated by the therapist with the same scrutiny. The therapist always needs to ask, “Is there a reasonable explanation for the worsening?” An increase in the intensity of the complaints or the involvement of additional body regions could signal a progression of the disease.

Review of body systems

By design, review of systems screening allows the therapist to detect symptoms secondary (and maybe unrelated) to the reason therapy has been initiated.¹⁵ The review of systems allows for a general screening of body systems for symptoms suggesting the presence of an adverse drug reaction, occult disease, or worsening of an existing medical condition. Suspicions of any of these scenarios would warrant communication with a physician. Checklists of symptoms and signs for each body system can be used by the PT or OT during the patient interview (Box 7-1). To keep the checklists manageable in length, the therapist should investigate presenting complaints and symptoms and the patient’s medical history before the review of systems, as noted in Figure 7-3. For example, on review of the cardiovascular and peripheral vascular system checklist items associated with heart conditions in Box 7-1, important items appear to be omitted, such as chest pain, claudication, a history of heart problems, hypertension, high cholesterol levels, and circulatory problems. If symptoms have already been investigated by use of a body diagram, the therapist would already know whether the patient has chest pain. If symptom change (aggravation or alleviation) over a 24-hour period has already been investigated, the therapist would know whether claudication is an issue. Finally, if the patient’s medical history has already been discussed, the therapist would know whether heart problems, hypertension, or circulatory problems existed.^13a

BOX 7-1 REVIEW OF SYSTEMS CHECKLISTS

Cardiovascular and peripheral vascular

peripheral sensory loss

skin discoloration

open wounds or gangrene

cough

Gastrointestinal

difficulty with swallowing

heartburn, indigestion

specific food intolerance

bowel dysfunction

color (black and tarry, light slate colored)

frequency

shape, caliber (flat ribbon-like, thin-caliber pencil-like)

constipation or diarrhea

reduced force of stream

difficulty initiating or attention needed to urinate

dysuria

color (hematuria, dark, brownish tea color)

change in menstruation

frequency and length of cycle

dysmenorrhea

blood flow

date of last period

number of pregnancies

number of deliveries

menopause

Psychological (depression)

depressed or irritable mood

psychomotor agitation or retardation

feelings of worthlessness

impaired concentration

suicide ideation (recurrent)

recent loss of family member

clubbing of the nails

stridor

wheezing

Sensory and motor (nervous)

sudden or slow onset of sensory loss

impaired balance

unexplainable frequent falls

impaired gross movement patterns

decrease in or difficulty with fine motor skill

impaired mentation

tremors: intentional or unintentional

muscle atrophy: symmetrical vs asymmetrical

asymmetrical facial features

asymmetrical tongue patterns

cold or heat intolerance

All of the checklists in Box 7-1 need not be used for every patient. The location of symptoms will direct the therapist in deciding which checklists should be included in the initial examination. Figure 7-7 and Table 7-1 can be used to link pain location with visceral systems that could be the source of the complaints. Table 7-2 provides a summary of potential pain locations and diseases of the pulmonary, cardiovascular, gastrointestinal, and urogenital systems. Other symptom characteristics can also alert the therapist to the possible involvement of the endocrine, nervous, and psychological systems. Symptoms, including pain and paresthesias that come and go irrespective of posture, activity, or time of day and that appear to move among the various body regions, can be associated with these systems as well as the visceral systems. In addition to the identification of the location and characteristics of symptoms, a patient’s medical history will also help the therapist decide which systems to screen. A positive medical history, such as a heart problem, would direct the therapist to investigate the patient’s condition, including possible use of the cardiovascular and peripheral vascular checklist as well as the questions listed in Figure 7-5. The therapist also needs to be aware of the medications taken by the patient to medically manage these pathological conditions. Similarly, therapists need to be able to analyze how the drugs potentially affect functional movements and functional loss. Often, that means a therapist must have a working professional relationship with a clinical pharmacist (see Chapter 36). Use of a general health checklist (Box 7-2) can assist the therapist in prioritizing the inclusion of the checklists in the systems review checklists box during the initial visit. The symptoms noted in this checklist can be associated with disease of most of the body’s systems, as well as with systemic disease and adverse drug events.

TABLE 7-2

LINKING PAIN PATTERNS AND VISCERAL SYSTEMS

PAIN LOCATION	VISCERAL SYSTEMS
Right shoulder (including shoulder girdle)	Pulmonary Cardiovascular Gastrointestinal

Left shoulder (including shoulder girdle)

Cardiovascular

Pulmonary

Upper thoracic or midthoracic spine

Cardiovascular

Pulmonary

Gastrointestinal

Lower thoracic and upper lumbar or midlumbar spine

Lumbopelvic region

If the patient or caregiver (on the patient’s behalf) replies yes to any review of systems question, the therapist must determine whether there is a reasonable explanation for the complaint, whether the physician is aware of the complaint, and, if so, whether the complaint has worsened since the patient last saw the physician. When the given explanation is not satisfactory, the physician is unaware of the complaint, or the symptom is worsening, communication with the physician is warranted. Similarly, most physicians look at direct causation: complaint to disease. Therapists need to look at system causation because we see the end result of the combinations of the problems: disease, maturation, environmental factors, and other nondisease causations. All the checklists do not need to be covered during the initial visit. If the patient says “no” for each of the general health items, the patient’s health history is uneventful, and the therapist is comfortable with the description of the chief complaints (including pattern and onset), then the therapist can proceed with the evaluation of specific impairments and functional limitations with some confidence that Differential Diagnosis Phase 2 and therapy intervention are very likely appropriate. The review of systems then takes a lower priority. The result is that the therapist could decide to delay the use of the appropriate systems review checklists until the patient’s second or third visit. If the patient answers “yes” to general health items and has an inconsistent pain pattern, the appropriate review of systems then takes a higher priority and should be covered during the initial visit.

Musculoskeletal system

Box 7-3 provides the checklist for the MSK system. In addition, as with all other body systems, the general health checklist also provides a level of screening for conditions of the MSK system such as infections, metastatic cancers, and rheumatic disorders (e.g., rheumatoid arthritis). Identifying patient risk factors for these conditions is a key for recognizing when to be suspicious. For example, those at highest risk for MSK cancers are those (1) over the age of 50 years and under 20 years, (2) having a previous history of cancer (e.g., breast, lung, prostate, thyroid, and kidney—the most common cancers to metastasize to the axial skeleton), (3) having a positive family history of cancer, and (4) having had exposure to environmental toxins. Those individuals at highest risk for MSK infections report or demonstrate (1) current or recent infection (e.g., urinary tract, tooth abscess, skin infection), (2) history of diabetes with use of large doses of steroids or immunosuppressive drugs, (3) elderly age, and (4) spinal cord injury with complete motor and sensory loss.¹⁶ Last, the primary risk factors for rheumatoid arthritis include (1) female sex, (2) age (peak) 30 to 40 years, and (3) positive family history.¹⁷

The other category of MSK conditions for which therapists need to be vigilant is fractures. The pain and deformity associated with most sudden-impact, traumatic fractures make for an obvious presentation. However, trauma sufficient to cause a fracture may not be so obvious in a patient with decreased bone density. Lifting a gallon of milk, experiencing a mild slip or bump, or trying to open a window that is stuck may be sufficient to cause a fracture in a patient with a history of chronic renal failure, multiple sclerosis, rheumatoid arthritis, hyperparathyroidism, gastrointestinal malabsorption syndrome, and long-term corticosteroid, heparin, anticonvulsant, and cytotoxic medication use. The most common locations for such fractures include vertebral bodies, the neck of the femur, and the radius. Observation of posture and body position may provide a clue that something may have changed structurally. For example, with vertebral compression fractures the thoracic kyphotic curve may be accentuated, accompanied by a very pronounced apex of the curve that was not present before. With femoral neck fracture the lower extremity is often positioned in external rotation and appears shortened compared with its counterpart.¹⁸

Causing potential confusion for the clinician are diseases (especially in the early stages) of the MSK system, which may mimic mechanical MSK conditions. The patient may report a specific event or time of onset of symptoms, and a pain pattern of increasing pain with weight bearing on the involved extremity over time and lessoning relief of pain with assumption of non–weight-bearing positions—all typical findings with impairment-driven symptoms. The therapist may also be able to provoke symptoms during the physical examination as the involved bony area is mechanically loaded. When the history and physical examination findings are evaluated, an unusual finding or pattern will emerge, or the patient will not respond to treatment as expected, making the therapist step back and consider alternative hypotheses regarding the origin of patient symptoms, especially if the risk factors listed earlier are present.

Integumentary system

Screening of the integumentary system is not typically based on the presence or absence of pain, paresthesia, or numbness. As with the nervous system, some degree of screening of the integumentary system occurs with every patient regardless of the presenting diagnosis. Skin cancer has the highest incidence of all the cancers,¹⁹ and therapists generally see a number of exposed body areas during the postural assessment and regional examination that make up the physical examination. In fact, as noted in Figure 7-3, screening the skin begins during the patient interview. During the interview the therapist can be looking at areas of exposed skin such as the face, neck, arms, and feet. As with screening of the other body systems, the therapist’s goal is not to identify a melanoma or differentiate squamous cell and basal cell carcinoma but simply to identify skin lesions with atypical presentations. Once the patient has been referred to the physician, disease will be ruled out or diagnosed. Box 7-4 can be used to assess any mole or other skin marking. The items noted are atypical for a benign lesion, more suggestive of a pathological condition.²⁰ Selected items from Box 7-4 have been highlighted, resulting in an acronym—A (asymmetry), B (borders), C (color), D (diameter), and E (evolving)—that has been used to educate the public for self-screening.²¹ If the therapist notes any of these findings and the patient reports a recent change in the size, color, or shape of the lesion and that a physician has not looked at the lesion, a referral would be warranted.

Besides skin lesions, abnormal general skin color can be a manifestation of a number of conditions. Table 7-3 summarizes abnormal skin color changes. Occasionally, some of the most obvious abnormalities are the most difficult to note when one is so focused on items more directly related to therapeutic intervention.

TABLE 7-3

ABNORMAL COLOR CHANGES OF THE SKIN

COLOR CHANGE	PHYSIOLOGICAL CHANGE	COMMON CAUSES
White, pale (pallor)	Absence of pigment or pigment changes	Albinism, lack of sunlight
	Blood abnormality	Anemia, lead poisoning
	Temporary interruption or diversion of blood flow	Vasospasm, syncope, stress, internal bleeding
	Internal disease	Chronic gastrointestinal disease, cancer, parasitic disease, tuberculosis
Blue (cyanosis)	Decreased oxygen in blood (deoxyhemoglobin)	Methemoglobinemia (oxidation of hemoglobin), high blood iron level, cold exposure, vasomotor instability, cerebrospinal disease
Yellow	Jaundice, excess bilirubin in blood, excess bile	Liver disease, gallstone blockage of bile duct, hepatitis pigment (conjunctivae are also yellow)
	High levels of carotene in blood (carotenemia)	Ingestion of food high in carotene and vitamin A
Gray	High level of metals in body	Increased iron, bronze-gray; increased silver, blue-gray
Brown (hyperpigmentation)	Disturbances of adrenocortical hormones	Adrenal pituitary
		Addison disease

From Shapiro C, Skopit S: Screening for skin disorders. In Boissonnault WG, editor: Examination in physical therapy practice—screening for medical disease, ed 2, New York, 1995, Churchill Livingstone.

Nervous system

As with the integumentary system, the nervous system is screened to a degree for all patients. The systems review checklists in Box 7-1 include items that provide a very gross, general screening of the nervous system. The therapist should be vigilant for the presence of any of these items in all patients during the initial and subsequent visits. For patients with preexisting findings from this checklist, the therapist must be vigilant for a worsening of the observed abnormalities. Covering the items in the nervous system checklist should add little time to the therapist’s initial examination. Assessing for facial asymmetries and tremors can take place during the interview. Observing balance, movement patterns, and muscle atrophy can occur while watching the patient ambulate into the examination area, during the interview, and as the patient changes positions during the physical examination. Last, impaired mentation may become apparent during the interview or the physical examination as the patient struggles to appropriately answer questions or follow directions. Case Studies 7-1 and 7-2 illustrate the importance of this general screening.

CASE STUDY 7-1

A 55-year-old elementary school teacher was referred with a diagnosis of cervical degenerative disk disease at C5-6 and C6-7. Her chief complaint was posterior cervical aching and a sense of neck weakness. Functionally, the patient’s primary concern was her increasingly difficult time making it through her workday. She taught first-grade students, so much of her workday was spent with her neck and trunk in a forward flexed position. The patient stated that this persistent flexion posturing was a significant factor for the worsening of her symptoms as her workday progressed. As the interview continued, a tremor of the patient’s right hand and forearm was observed as the arm rested on her thigh. When questioned about the observed tremor she stated it started 4 or 5 months ago. She admitted the tremor appeared to be getting worse and that she did not mention it to her physician. No other positive neurological findings were noted. After the initial examination was completed, the concern about the tremor was discussed and the patient consented to allow her primary care physician (the referring physician) to be called to discuss the finding. The physician facilitated a referral of the patient to a neurologist. Approximately 1 month later, after the neurology consultation and tests, the patient was diagnosed with Parkinson disease. During that month the patient continued to receive physical therapy care for her cervical complaints. In this example, performance of Differential Diagnosis Phase 1 showed the presence of a new symptom (tremor of the right hand) that was not consistent with the medical diagnosis of degenerative disk disease. This symptom triggered the decision by the therapist to refer the patient back to the physician for that specific clinical sign, which led to the additional diagnosis of Parkinson disease. With the patient having been referred to the physician, therapy was also initiated. Differential Diagnosis Phase 2 was performed, which resulted in the decision to treat the cervical complaints of the patient.

CASE STUDY 7-2

A 75-year-old woman was sent to physical therapy with the diagnosis of moderate to severe osteomalacia of the spine. The physician referred her to a PT. The therapist evaluated her spine and noted weakness, pain, and tightness. The plan of care included strengthening and stretching, with the assumption that the pain would subside once the muscles could better support the spine. The therapist did not do a medical screen, and for much of the therapy program the patient exercised without supervision. Both the patient and the husband felt physical therapy was not helping at all. The patient and her husband discussed this problem with a neighbor who was also a PT. The neighbor referred them to another PT who had extensive manual therapy background and used the Guide to Physical Therapy Practice as a cornerstone to practice. The new therapist performed a medical screen as part of the examination and noticed that the woman had some general weakness in her left side that did not coincide with the original diagnosis. The symptoms were very subtle and the therapist asked her if she was having any difficulty with daily living activities. She said “no,” so the therapist treated her for her back impairments but monitored her neurological signs. The treatment went far beyond strengthening and stretching muscles, and the patient was very excited about therapy and how much improvement she was making. At the next treatment session her neurological signs were still subtle but enhanced, so the patient was told that she needed to see her primary care physician for examination and consideration of diagnostic imaging. She continued with PT for three more sessions with her pain almost resolved. Per the therapist’s recommendation she saw her physician after the second treatment. The physician ordered magnetic resonance imaging, and it revealed a grapefruit-sized nonmalignant tumor in her right lower frontal-temporal area. The tumor was removed and the patient recovered after 2 weeks of rehabilitation. The woman and her family believe that it was the PT that saved not only her quality of life, but also her life itself. The first PT, by not doing a medical screening examination, did not identify the occult neurological problem. If the second therapist’s medical screening and referral to the doctor had not been performed, the first therapist could have been deemed negligent and cited in a liability suit; importantly, the patient’s tumor may have caused more permanent damage as it grew undiagnosed within her cranium.

Depression.

Depression is a commonly encountered psychological disorder that is associated with significant morbidity and mortality.¹⁰^,^22–24 The systems review checklists in Box 7-1 contain items the therapist can use to help make the decision to refer a patient for consultation. If the patient has suicide ideation, the physician should be contacted before the patient leaves the clinic. For the first eight items on the depression checklist, concern should be raised when the therapist detects four or five of the items present daily for a minimum of 2 weeks and resulting in the patient having difficulty functioning at home, work, or school, socially, or in rehabilitation. Of the four or five items, one of them should be depressed or irritable affect or apathy. An exception to the 2-week time frame is during periods of bereavement. When people are faced with a significant loss, it is not uncommon for them to experience a number of the checklist items as they work through the grieving process (refer to Chapter 6).¹⁰ It is reasonable for these people to experience these symptoms for up to 2 months. A neurological event such as a cerebrovascular accident could easily trigger a major clinical depressive disorder, and the depression could significantly impede rehabilitation progress. The therapist may be in a position to facilitate a psychological consultation.

Considering that approximately 15% of people with true major clinical depression commit suicide,¹⁰ therapists need to be vigilant for warning signs that the patient may be considering this action. See the suicide screening shown in Box 7-5 for a list of warning signs. Once the patient acknowledges suicidal ideation, follow-up questions would be appropriate to investigate the patient’s plan and how readily available the resources are regarding the reported method of attempt. This is all-important information to be reported when the therapist contacts the physician. Therapists should be very familiar with their facility’s “suicide protocol or procedure” in terms of what information should be collected from the patient and who should be contacted.

BOX 7-5 SUICIDE WARNING SIGNS

History of major clinical depression, chemical dependency, schizophrenia, or previous suicide attempt

Expressions of hopelessness

The sense that the patient is “giving up”

An abrupt improvement in patient mood

Physical examination

In addition to this discussion of observation screening for the integumentary and nervous systems, other screening principles are associated with the physical examination. The therapist should have expectations of physical examination findings based on the existing medical diagnosis and data from the history. There should be a correlation between the described functional limitations and the noted impairments. Using the clinical example previously described, the right shoulder pain Mr. S. was experiencing would be expected to increase or decrease in intensity with palpation, movement assessment, or special tests. Not only was the therapist unable to alter the ache, but the shoulder motion and motor control also appeared intact. Essentially there is nothing for the therapist to treat. The inability to alter a patient’s complaints and the lack of neuromusculoskeletal impairments one would expect with the medical diagnosis and the reported functional limitations should again raise concern about the source of the symptoms. The physical examination also includes elements of the systems review.

The Guide to Physical Therapy Practice describes the systems review, in part, as a brief or limited examination of the anatomical and physiological status of the cardiovascular and pulmonary, integumentary, MSK, and neuromuscular systems.¹ For the purposes of this chapter the discussion will focus on assessment of height and weight and assessing heart rate and blood pressure. Being overweight or obese can significantly increase the risk of development of a number of serious conditions (Table 7-4). Using patient height and weight to calculate body mass index (BMI) can be a valuable measure to identify patients who may need a dietary consultation to prevent disease states or minimize morbidity associated with current illnesses. BMI is calculated by dividing body weight (in kilograms) by height (in meters). Table 7-4 provides a summary of disease risk associated with BMI and waist circumference.

TABLE 7-4

DISEASE RISK RELATIVE TO NORMAL WEIGHT AND WAIST CIRCUMFERENCE

	BMI (KG/M²)	OBESITY CLASS	MEN ≤102 CM (≤40 INCHES)WOMEN ≤88 CM (≤35 INCHES)	>102 CM(>40 INCHES)>88 CM (>35 INCHES)
Underweight	<18.5		—	—
Normal	18.5-24.9		—	—
Overweight	25.0-29.9		Increased	High
Obesity	30.0-34.9	l	High	Very high
	35.0-39.9	ll	Very high	Very high
Extreme obesity	≥40	lll	Extremely high	Extremely high

BMI, Body mass index. Classification by Body Mass Index (BMI), waist circumference, and associated disease risks.

From the National Heart, Lung, and Blood Institute: Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Available at: www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/risk.htm/. Accessed July 20, 2011.

Resting blood pressure and pulse rate and rhythm are also important values to be routinely measured. See Table 7-5 for a summary of blood pressure values for adults. Table 7-6 presents normal resting pulse rate parameters for therapists to consider when examining a patient. A 30-second monitoring period after a 2- to 5-minute rest period is recommended to obtain baseline rate values.²⁵ Resting blood pressure values can also provide important screening information. As with assessing pulse rate, resting blood pressure should be assessed after a 5-minute rest period. Variations from the normative values may lead therapists to additional assessment of the vascular system and the central autonomic nervous system and then to a patient referral.

TABLE 7-5

CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS 18 YEARS OLD OR OLDER *^†

CATEGORY	SYSTOLIC BLOOD PRESSURE (mm Hg)		DIASTOLIC BLOOD PRESSURE (mm Hg)
Optimal^‡	<120	and	>80
Normal	120-129	and	80-84
High normal	130-139	or	85-89
Hypertension Stage 1 Stage 2 Stage 3
	140-159	or	90-99
	160-179	or	100-109
	≥180	or	≥110

^*Not taking antihypertensive drugs and not acutely ill. When systolic and diastolic blood pressures fall into different categories, the high category should be selected to classify the individual’s blood pressure status. In addition to classifying stages of hypertension on the basis of average blood pressure levels, clinicians should specify presence or absence of target organ disease and additional risk factors. This specificity is important for risk classification and treatment.

^†Based on the average of two or more readings taken at each of two or more visits after an initial screening.

^‡Optimal blood pressure regarding cardiovascular risk is less than 120/80 mm Hg. However, unusually low readings should be evaluated for clinical significance.

From The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 23:275–285, 1994, and The Sixth Report of the U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, MD, 1997.

TABLE 7-6

RESTING PULSE RATE IN BEATS PER MINUTE

	AVERAGE	LIMITS
Norms	120-160	—
Fetal	120	70-190
Newborn	120	80-160
1 year old	110	80-130
2 years old	100	80-120
4 years old	100	75-115
6 years old	90	70-110
8-10 years old
12 years old
Female	90	70-110
Male	85	65-105
14 years old
Female	85	65-105
Male	80	60-100
16 years old
Female	80	60-100
Male	75	55-95
18 years old
Female	75	55-95
Male	70	50-90
Well-conditioned athlete	50-60	50-100
Adult	—	60-100
Aging	—	60-100

Modified from Jarvis C: Physical examination and health assessment, ed 4, Philadelphia, 1992, WB Saunders.

Examination summary

For many patients a single red flag finding does not warrant a referral, but a cluster of history and physical examination findings does increase disease probability to the point where a referral is indicated. Two examples that are germane to a number of individuals with neurological conditions are deep venous thrombosis (DVT) and pulmonary embolus (PE). DVT affects approximately 2 million individuals in the United States annually, making it the third most common cardiovascular disease.²⁶ A sobering estimation is that approximately 50% of those with a DVT are asymptomatic in early stages.²⁷ Clinicians are challenged to identify patients at greater risk for this condition who do not have the obvious signs and symptoms of calf pain, swelling, and redness. The following clinical decision rule has been validated in ambulatory patient populations (Table 7-7). Of note for the neurological population, a history of spinal cord injury does not appear in this rule even though it is considered a strong risk factor for DVT. The authors assume there were very few patients with spinal cord injury in the validation research.

TABLE 7-7

CLINICAL DECISION RULE FOR DEEP VENOUS THROMBOSIS (DVT)

CLINICAL CHARACTERISTIC	SCORE
Active cancer (treatment ongoing, or within previous 6 months or palliative)	1
Paralysis, paresis, or recent plaster immobilization of lower extremities	1
Recently bedridden >3 days, or major surgery in past 12 weeks requiring general or regional anesthesia	1
Localized tenderness along distribution of deep venous system	1
Swelling of entire leg	1
Calf swelling >3 cm greater than asymptomatic side (measured at 10 cm below tibial tuberosity	1
Pitting edema confined to symptomatic leg	1
Collateral superficial veins (nonvaricosed)	1
Alternative diagnosis is as likely as or more likely than DVT	−2
Key
SCORE	SIGNIFICANCE
−2 to zero	Low probability of DVT: 5% (95% confidence interval [CI], 4.0%-8.0%)
1-2	Moderate probability of DVT: 17% (95% CI, 13%-23%)
3 or greater	High probability: 53% (95% CI, 44%-61%)

From Wells PS, Anderson DR, Bormanis J, et al: Value of assessment of pretest probability of deep-vein thrombosis in clinical management, Lancet 350(9094; Dec 20-27):1795-1798, 1997.

Similarly for PE, a clinical decision rule exists for screening (Table 7-8). PE is associated with high morbidity and mortality, highlighting the critical nature of timely detection. Hull describes PE as one of the “great masqueraders” of medicine because of the often nonspecific presenting symptoms and signs.²⁸ Wells and colleagues estimate that 50% of PEs go undiagnosed.²⁹

TABLE 7-8

“WELLS” CRITERIA FOR DETERMINING PROBABILITY OF PULMONARY EMBOLISM (PE)

CRITERION	POINT VALUE FOR CRITERION
Clinical signs of deep venous thrombosis (DVT)	3.0
Heart rate >100 beats per minute	1.5
Immobilization for 3 days or longer, or surgery in previous 4 weeks	1.5
Previous diagnosis of PE or DVT	1.5
Hemoptysis	1.0
Patients with cancer receiving treatment, treatment stopped in past 6 months, or receiving palliative care	1.0
Alternative diagnosis less likely than PE	3.0
Pretest probability of PE is low with a score <2 points; moderate with a score 2 to 6 points; and high with a score >6 points.

Data from Wells PS, Anderson DR, Rodger M, et al: Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and a d-dimer. Ann Intern Med 135:98–107, 2001.

Clinician concern regarding the possibility of a DVT and/or a PE being present would warrant urgent communication with the patient’s physician.

Response to treatment

Frequently during Differential Diagnosis Phase 1 the therapist will decide referral of the patient to a physician is not warranted and will proceed to Differential Diagnosis Phase 2 and determine whether physical therapy is warranted or no intervention recommended. As treatment is initiated and progresses, the therapist must remain vigilant for the appearance of symptoms and signs discussed throughout this chapter. In addition, correlating subjective and objective changes as treatment progresses will help the therapist decide whether further intervention is warranted or whether referral back to the physician or other health care practitioner is appropriate. For example, if a patient reports a significant improvement or worsening, one would expect the therapist to note a corresponding change in posture, movement ability, palpatory findings, or neurological status. If the expected correlation between patient report and physical examination findings is not found, the therapist should begin considering that therapy may not be warranted. A careful review of systems and symptom investigation would again be necessary as part of the return to Differential Diagnosis Phase 1.

Conclusion

If all diseases manifested with a high fever, coughing up blood, and blood in the urine, the medical screening process would be a simple one. Unfortunately, many diseases initially manifest with subtle complaints, intermittent symptoms or mild pain, stiffness, subtle weakness or paresthesias, or acute dementia. If these complaints are brought to a physician’s attention by the patient, they often are not severe enough to warrant extensive diagnostic testing. Many patients or family members simply ignore symptoms or physiological changes, rationalizing that everything is okay, the family member is just old, or he or she simply does not like to see physicians or is too busy. All of the scenarios can account for patients with occult disease seeing therapists. The fact that PTs and OTs tend to spend a moderate amount of time with patients over a period of weeks or months can facilitate the detection of subtle manifestations. In addition, as therapists develop rapport with patients and family members, information may be shared that they were uncomfortable disclosing initially. Always remember that acute dementia is never normal and is reflective of an acute problem rather than simply of aging.

The responsibilities of the PT and OT related to screening for symptoms and signs that indicate the involvement of another health care practitioner are clearly stated in the Guide to Physical Therapy Practice² and The Guide to Occupational Therapy Practice.³ The process associated with Differential Diagnosis Phase 1 allows for the appropriate medical screening yet keeps therapists within their scope of practice. The therapist simply communicates to the physician the list of clinical findings. The physician will determine whether new or additional medical tests are needed to rule out or diagnose specific diseases. Facilitating the timely referral of patients to physicians is an important role for therapists working within a collaborative medical model. It is this model that best serves the needs of our patients. For additional information related to the medical screening process, the readers are directed to four other textbooks.²⁵,^30–32

With changes in health care delivery and physicians also being asked to see more patients in less time, it is critical that all health care practitioners include an adequate medical screening component to their examinations. If quality-of-life issues are truly an important component of health care delivery, then Differential Diagnosis Phase 1, medical screening, has and will continue to be a professional expectation and responsibility placed on each PT and OT. Because consumers are accessing therapeutic services through more direct means, that responsibility will remain and grow in importance as part of both professions’ education and practice. Over the next few years PTs’ and OTs’ roles will continue to evolve in the arena of primary care. Medical screening performed by the therapist will guide patients to a physician and could become a key component of maintaining the health and quality of life of that consumer.

In the future another choice will have to be considered as part of the role of a movement specialist. The results of Phase 1 and 2 assessments may determine that neither a medical referral nor therapeutic intervention itself is appropriate. In this situation, the patient might benefit from community activities but would not need a movement specialist, especially if the physician also has determined that medical intervention is not necessary.