Primary Care Assessment

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Primary Care Assessment

Although it would be ideal for a family physician who is familiar with the patient’s and the family’s history to perform a primary care assessment because he or she would more likely be aware of any congenital or developmental problems, the patient’s immunization status, and any recent injuries or illnesses and therefore could provide continuity of care,^1–3 many people today do not have a family physician. As health care changes occur, more and more health care professionals are becoming involved in assessment of patients who come to them as first-level providers of medical care. This may involve nurse practitioners, physician assistants, and other health care providers, as well as physicians in primary care facilities, physical therapists with direct access in private practice, clinicians in sole-charge facilities, and sports therapists working and traveling with teams.^4–8 Thus it becomes important for clinicians to be able to evaluate and recognize the potential for health care problems, including systemic disease as a disease entity itself or a disease masquerading as neuromuscular dysfunction, that must be referred to the appropriate health professional.^9,10 Primary care assessment is a form of triage in which the clinician decides whether the patient’s problem or problems fall within his or her scope of practice or should be referred to other health care professionals.^11–15

In many ways, a primary care assessment is similar to a preparticipation examination used in sports because both assessments are used to clear patients of having certain problems that could affect activity and also to provide a mechanism in which problems can be referred to the appropriate health care professional.^16–22 This process involves an understanding of disease as well as an ability to distinguish what system may be affected through a detailed history, observation and examination, and an understanding of different levels of reporting ability of the patient.^9,23 It also requires the clinician to understand his or her limitations, the scope of practice of his or her chosen profession, and why the patient has come to see the clinician. For example, what is the patient’s complaint? Is it related to how the patient feels? Is it related to his or her occupation? Is it related to a certain population, age, or gender?^18,24,25

If the patient has symptoms, several questions should be asked that relate to the symptoms²⁶:

1. Where is the symptom, and does it radiate?

2. What does the symptom feel like?

3. How bad is the symptom?

4. Where does (did) the symptom start?

5. How long does the symptom last?

6. How often does the symptom occur?

7. What brings the symptom on?

8. What makes the symptom better or worse?

9. Are there other symptoms associated with it?

Once these questions, and the ones discussed under the different systems as outlined later in the chapter, are answered, the examiner can decide to treat the patient or refer on to another health care professional, usually a physician. Goodman and Snyder²⁷ clearly outline cases in which referral to a physician is necessary (Table 17-1). This chapter is not meant to be all inclusive of conditions and systems that may need referral. Complete systems assessment is left to other sources.^26,27

TABLE 17-1

Physician Referral

Immediate Medical Attention	Patient with anginal pain not relieved in 20 minutes Patient with angina who has nausea, vomiting, profuse sweating Diabetic patient demonstrating signs of confusion, lethargy, or changes in mental alertness and function Patient with bowel/bladder incontinence and/or saddle anesthesia secondary to cauda equine lesion Patient in anaphylactic shock
Medical Attention Necessary	General Systemic Unknown cause Lack of significant objective neuromusculoskeletal signs and symptoms Lack of expected progress with physical therapy treatment Development of constitutional symptoms or associated signs and symptoms over the course of treatment Discovery of significant PMH unknown to physician Changes in health status that persist 7 to 10 days beyond expected time period Patient who is jaundiced and has not been diagnosed or treated Changes in size, shape, tenderness and consistency of lymph nodes in more than one area, which persist more than 4 weeks; painless, enlarged lymph nodes
	For Women Low back, hip, pelvic, groin, or sacroiliac symptoms without known etiology and in the presence of constitutional symptoms Symptoms correlated with menses Any spontaneous uterine bleeding after menopause For pregnant women: Vaginal bleeding, elevated blood pressure, increased Braxton-Hicks contractions during exercise
	Vital Signs (Report These Findings) Persistent rise or fall of blood pressure Blood pressure evaluation in any woman taking birth control pills (should be closely monitored by her physician) Pulse amplitude that fades with inspiration and strengthens with expiration Pulse increase over 20 BPM lasting more than 3 minutes after rest or changing position Difference between systolic and diastolic measurements of more than 4 mm Hg in pulse pressure Persistent low-grade (or higher) fever, especially associated with constitutional symptoms, most commonly sweats
	Cardiac Angina at rest Anginal pain not relieved in 20 minutes More than three sublingual nitroglycerin tablets required to gain relief Nitroglycerin does not relieve anginal pain Rest does not relieve angina Angina continues to increase in intensity after stimulus (e.g., cold, stress, exertion) has been eliminated Changes in pattern of angina Abnormally severe chest pain Patient has nausea, vomiting Anginal pain radiates to jaw/left arm Upper back feels abnormally cool, sweaty, or moist to touch Patient has any doubts about his or her condition
	Cancer Early warning sign(s) of cancer: seven early warning signs plus two additional signs pertinent to the physical therapy examination: proximal muscle weakness and change in deep tendon reflexes All soft tissue lumps that persist or grow, whether painful or painless Any women presenting with chest, breast, axillary, or shoulder pain of unknown etiology, especially in the presence of a positive medical history (self or family) of cancer Bone pain, especially on weight-bearing, that persists more than 1 week and is worse at night
	Pulmonary Shoulder pain that is aggravated by supine positioning Shoulder, chest (thorax) pain that subsides with autosplinting (lying on the painful side) For the patient with asthma: Signs of asthma or bronchial activity during exercise
	Genitourinary Abnormal urinary constituents (e.g., change in color, odor, amount, flow of urine) Any amount of blood in urine
	Musculoskeletal Symptoms that seem out of proportion to the injury, or symptoms persisting beyond the expected time for the nature of the injury Severe or chronic back pain accompanied by constitutional symptoms, especially fever
Precautions/Contraindications to Therapy	Uncontrolled chronic heart failure or pulmonary edema Active myocarditis Resting heart rate > 120 or 130 BPM * Resting systolic rate > 180 to 200 BPM * Resting diastolic rate > 105 to 110 BPM * Moderate dizziness, near-syncope Marked dyspnea Unusual fatigue Unsteadiness Loss of palpable pulse Postoperative posterior calf pain For the patient with diabetes: Chronically unstable blood sugar levels must be stabilized (normal: 80 to 120 mg/dL; “safe”: 100 to 250 mg/dL)

BPM, Beats per minute; PMH, past medical history.

*Unexplained or poorly tolerated by patient

From Goodman CC, Snyder TE: Differential diagnosis in physical therapy, Philadelphia, 1995, WB Saunders, pp. 18–20.

McKeag²⁸ has outlined five specific populations in which special areas of possible concern should be included in an examination. In the prepubescent patient (6 to 10 years of age), assessments should include examination for congenital abnormalities that may not have been diagnosed previously. In the pubescent patient (11 to 15 years of age), the examination should include an evaluation of physical maturity and good health practices. The postpubescent or young adult group (16 to 30 years of age) has the widest variety of skills, levels, and motivation. For this group, the history of previous injuries and any sport-specific or activity-specific problems is particularly important. For the adult population (30 to 65 years of age), injury prevention (e.g., overuse), previous injury patterns, health concerns, and conditioning should be included in the examination. The final group consists of elderly patients (65 years of age or older), who require an examination based on individual requirements, because many of these people take up exercising or increased physical activity after a medical illness.²⁰ Age-related changes and their possible consequences are outlined in Table 17-2.

TABLE 17-2

Organ/System	Age-Related Physiologic Change*	Consequence of Age-Related Physiologic Change	Disease, Not Age
General	↑ Body fat	↑ Volume of distribution for fat-soluble drugs	Obesity
General	↓ Total body water	↓ Volume of distribution for water-soluble drugs	Anorexia
Eyes/Ears	Presbyopia	↓ Accommodation	Blindness
	Lens opacification	↑ Susceptibility to glare	Deafness
	↓ High-frequency acuity	Difficulty discriminating words if background noise is present
Endocrine	Impaired glucose tolerance	↑ Glucose level in response to acute illness	Diabetes mellitus
	↓ Thyroxine clearance (and production)	↓ T₄ dose required in hypothyroidism	Thyroid dysfunction
	↑ ADH, ↓ renin, and ↓ aldosterone	—	↓ NA⁺, ↑ K⁺
	↓ Testosterone	—	Impotence
	↓ Vitamin D absorption and activation	Osteopenia	Osteoporosis Osteomalacia
Respiratory	↓ Lung elasticity and ↑ chest wall stiffness	Ventilation/perfusion mismatch and ↓ pO₂	Dyspnea Hypoxia
Cardiovascular	↓ Arterial compliance and ↑ systolic BP → LVH	Hypotensive response to ↑ HR, volume depletion, or loss of atrial contraction	Syncope
	↓ β-adrenergic responsiveness	↓ Cardiac output and HR response to stress	Heart failure
	↓ Baroreceptor sensitivity and ↓ SA node automaticity	Impaired blood pressure response to standing, volume depletion	Heart block
Gastrointestinal	↓ Hepatic function	Delayed metabolism of some drugs	Cirrhosis
	↓ Gastric acidity	↓ Ca⁺ absorption on empty stomach	Osteoporosis Vitamin B₁₂ deficiency
	↓ Colonic motility	Constipation	Fecal impaction
	↓ Anorectal function	—	Fecal incontinence
Hematologic/ Immune system	↓ Bone marrow reserve (?)	—	Anemia
	↓ T-cell function	False-negative PPD response	—
	↑ Autoantibodies	False-positive rheumatoid factor, antinuclear antibody	Autoimmune disease
Renal	↓ Glomerular filtration rate	Impaired excretion of some drugs	↑ Serum creatinine
Renal	↓ Urine concentration/ dilution (see also Endocrine)	Delayed response to salt or fluid restriction or overload; nocturia	↑↓ Na⁺
Genitourinary	Vaginal/urethral mucosal atrophy Prostate enlargement	Dyspareunia Bacteriuria ↑ Residual urine volume	Symptomatic urinary tract infection Urinary incontinence Urinary retention
Musculoskeletal	↓ Lean body mass, muscle	—	Functional impairment
Musculoskeletal	↓ Bone density	Osteopenia	Hip fracture
Nervous system	Brain atrophy	Benign senescent forgetfulness	Dementia Delirium
	↓ Brain catechol synthesis	—	Depression
	↓ Brain dopaminergic synthesis	Stiffer gait	Parkinson disease
	↓ Righting reflexes	↑ Body sway	Falls
	↓ Stage 4 sleep	Early wakening, insomnia	Sleep apnea

ADH, Antidiuretic hormone; BP, blood pressure; HR, heart rate; LVH, left ventricular hypertrophy; PPD, purified protein derivative, SA, sinoatrial; T4, thyroxine.
The table displays selected changes that occur normally with age and their physiologic consequences. Changes due to disease rather than to age are listed in the last column.

*Changes generally observed in healthy elderly subjects free of symptoms and detectable disease in the organ system studied. The changes are usually important only when the system is stressed or other factors are added (e.g., drugs, disease, or environmental challenge); they rarely result in symptoms otherwise.

From Resnick NM: Geriatric medicine. In Isselbacher KJ, et al, editors: Harrison’s principles of internal medicine, ed 13, New York, 1994, McGraw-Hill.

A primary care assessment may vary from a minimal medical examination or physical to rule out possible systemic problems to a very extensive examination involving laboratory tests, stress testing, profiling, x-rays, and other special protocols.²⁹ History, as well as a physical examination, plays a major role.^30–32 If the patient is going to be asked to do strenuous activity as part of his or her treatment program, various systems (e.g., heart, lungs) must be cleared to ensure the patient is capable of doing the activity.³³

Characteristics of Systemic Symptoms

• No known cause or unknown etiology

• Gradual onset with progressive, cyclical course (worse/better/worse)

• Persist beyond expected time for that condition

• Constant

• Intense

• Bilateral symptoms (e.g., edema, nail bed changes, clubbing, numbness or tingling, weakness, skin pigmentation changes, or rash)

• Unrelieved by rest or change in position

• If relieved by rest or positional change, over time even these relieving factors no longer reduce symptoms

• Do not fit the expected mechanical or neuromusculoskeletal pattern; symptoms are out of proportion to the injury

• Symptoms cannot be altered (provoked, reproduced, alleviated, eliminated, aggravated) during examination

• Constitutional symptoms, especially fever and night sweats

• Disproportionate pain relief with aspirin (red flag for bone cancer)

• Night pain

• Pain described as knifelike, boring, deep, colicky, deep aching

• Pattern of pain coming and going like spasms

From Goodman CC, Snyder TE: Differential diagnosis in physical therapy, Philadelphia, 1995, WB Saunders, p. 16.

Objectives of the Evaluation

Primary care evaluations have many useful purposes.1,9,29,34,35 However, the examiner must remember that the primary purpose of the examination is to determine the patient’s health problem and to either treat the patient or refer him or her to the appropriate health care professional.^1,9 As part of the examination, the examiner can establish baseline values for the patient. These may be compared with normal “textbook” values or used to determine change in the future. In other words, the assessment should not consist of simple “yes/no” questions. Instead, it must be very thorough to establish proper baseline levels.

Objectives of Primary Care Assessment

• Determine if disease is present

• Uncover pre-existing conditions

• Determine unsuspected correctable conditions

• Determine health status

• Prevent injuries

• Avoid misinterpretation of findings

• Establish baseline values

• Act as a screening process

• Foster good health practices

• Develop rapport with the patient

• Establish guidelines

• Develop a musculoskeletal profile

• Counsel the patient

• Classify the patient

• Meet legal and insurance requirements

• Determine if referral is necessary

The primary care assessment is used to determine the health status of the patient. It also helps to prevent injuries through identification of any abnormalities, physical inadequacies, or poor conditioning that may put the patient at risk.³⁶ The examination may identify previously unsuspected conditions that are amenable to correction or that preclude participation in the desired activity. Similarly, the evaluation helps to avoid misinterpretation of findings that appear to be new but existed previously. For this reason, a review of previous health records, if possible, is also part of the primary care assessment.

The primary care assessment is also worthwhile to ensure that treatments have been carried out previously and that conditions previously diagnosed have been properly cared for. In this way, it acts as a screening process to ensure that treatment of potentially serious medical and surgical conditions has taken place. It also helps to rule out potentially serious or threatening conditions that may temporarily preclude the patient from participation in work or recreational activities. For example, with infectious mononucleosis, contact sports may be precluded for a time, because the patient’s spleen is enlarged and is more easily injured or ruptured.

The assessment also gives the clinician an opportunity to foster good health practices and to promote optimum health and fitness. The assessment enables the health care provider to give proper health guidance and to determine the general state of health of the patient.

The assessment also gives the examiner a chance to develop a rapport with the patient. The examiner can learn what motivates the patient and, at the same time, help establish the patient’s confidence in the health care staff. The examination may also be used to establish guidelines for the patient and health care team on questions of health, safety, and care. In addition, it provides an opportunity to counsel the patient.

Primary Care History

For a primary care assessment, the history plays a predominant role to ensure that questions related to the various systems are asked. A complete history can usually identify 60% to 75% of the problems affecting a patient.22,29,37 For the young person or the patient with communication problems, both the patient and his or her parent or guardian should provide the history to ensure completeness. The rest of the assessment proceeds from the information determined in the history. The history provides details regarding health problems and injuries and enables the examiner to focus on any abnormalities that it brings out.²⁹ Generally, the history is completed by the patient’s answering questions in a yes/no format (see Appendix 17-1 on the Evolve website for a generic primary care assessment questionnaire). Using such a format decreases the chance of the patient forgetting something.²³ The “yes” answers then are investigated further in other parts of the assessment (see Appendix 17-2 on the Evolve website). It is important, however, that the “no” answers also be checked for accuracy. Ideally, oral histories, in which the health care professional asks the questions, are more accurate; but usually, because of time constraints, this is not possible. The history should include the patient’s medical history as well as the family’s medical history to rule out any congenital, hereditary, or injury problems. It is important that a complete health history be obtained, because the patient may leave out or hide information that may preclude the patient from taking part in a desired activity or because of possible secondary gain.³⁷

APPENDIX 17-1

Primary Care Assessment Patient Questionnaire

DATE:____/____/____
LAST NAME:	________________________________________________________________________
FIRST NAME:	________________________________________________________________________
PERMANENT ADDRESS:	________________________________________________________________________
TELEPHONE NUMBER:	________________________________________________________________________
DATE OF BIRTH (Day/Month/Year):	________________________________________________________________________
MARRIED (Yes/No/Spouse’s Name):	________________________________________________________________________
NUMBER OF CHILDREN:	________________________________________________________________________
MEDICAL INSURANCE COMPANY AND NUMBER:	________________________________________________________________________
OCCUPATION:	________________________________________________________________________
IN CASE OF EMERGENCY
PLEASE NOTIFY:	________________________________________________________________________
NAME OR NAMES:	________________________________________________________________________
RELATIONSHIP:	________________________________________________________________________
ADDRESS:	________________________________________________________________________
	________________________________________________________________________
TELEPHONE NUMBER:	________________________________________________________________________
FAMILY DOCTOR’S NAME:	________________________________________________________________________
FAMILY DOCTOR’S ADDRESS:	________________________________________________________________________
DATE OF LAST MEDICAL EXAM:	________________________________________________________________________
ALLERGIES:	________________________________________________________________________
	________________________________________________________________________
	________________________________________________________________________
MEDICATIONS PRESENTLY BEING TAKEN:	________________________________________________________________________
	________________________________________________________________________
	________________________________________________________________________
WHY ARE YOU HERE TODAY?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
IF YOU WERE INJURED, HOW DID YOU INJURE YOURSELF?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

FAMILY HISTORY
PLEASE IDENTIFY ANY HEALTH PROBLEMS THAT HAVE OCCURRED IN YOUR IMMEDIATE FAMILY.
Yes	No		Yes	No
		HAS ANYONE IN YOUR FAMILY (UNDER AGE 50) DIED SUDDENLY?			ALLERGIES / ASTHMA
		UNEXPLAINED SEIZURES			ANEMIA
		HIGH BLOOD PRESSURE			DIABETES
		HEART TROUBLE			EPILEPSY
		SUDDEN DEATH			KIDNEY/BLADDER DISORDER
		CANCER OR TUMOR			STOMACH DISORDER
		MIGRAINE HEADACHES			GENETIC DISORDER
		EMOTIONAL PROBLEMS			GOITER
		ARTHRITIS			NEUROLOGICAL DISORDERS
		OBESITY			TUBERCULOSIS
		BLOOD DISORDERS OR EARLY BLEEDING			ABNORMAL NUMBNESS OR ANESTHESIA
SPECIFY:________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________

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YOUR PRESENT HISTORY (HISTORY OF PRESENT ILLNESS)
ANSWER ALL QUESTIONS CAREFULLY!! FOR “YES” ANSWERS, ELABORATE IN THE FOLLOWING MEDICAL CHART. DO YOU AT THE PRESENT TIME EXPERIENCE:
Yes	No
		DIFFICULTIES WITH YOUR EYES OR VISION?
		DIFFICULTIES WITH YOUR NOSE OR THROAT (E.G., TONSILLITIS, SINUSITIS)?
		ANY PROBLEM WITH YOUR TEETH OR GUMS?
		PROBLEMS WITH HEARING?
		HEADACHES, DIZZINESS, WEAKNESS, FAINTING, ANY PROBLEMS WITH COORDINATION OR BALANCE?
		NUMBNESS IN ANY PART OF THE BODY?
		ANY TENDENCY TO SHAKE OR TREMBLE?
		COUGH, SHORTNESS OF BREATH, CHEST PAIN, OR PALPITATIONS?
		POOR APPETITE, VOMITING, ABDOMINAL PAIN, ABNORMAL BOWEL HABITS?
		ANY SYMPTOMS REFERABLE TO THE MUSCLES, BONES, OR JOINTS (I.E., STIFFNESS, SWELLING, PAIN)?
		ANY PROBLEMS WITH THE SKIN, SUCH AS SORES, RASHES, ITCHY OR BURNING SENSATION?
		OTHER SYMPTOMS? (SPECIFY ON THE FOLLOWING MEDICAL CHART).
HAVE YOU EVER OR HAVE YOU NOW:
Yes	No
		WORN GLASSES OR CONTACT LENSES?
		SUSTAINED AN EYE INJURY?
		WORN HEARING AIDS?
		SMOKED OR CHEWED TOBACCO?
		HAD TO STAY IN THE HOSPITAL?
		HAD TO VISIT A HOSPITAL EMERGENCY DEPARTMENT?
		HAD AN OPERATION?
		BEEN ADVISED TO HAVE ANY OPERATION NOT YET PERFORMED?
		HAD PILES OR RECTAL DISEASE?
		HAD CHILDHOOD DISEASES (E.G., MUMPS, MEASLES, CHICKENPOX)?
		HAD SCARLET FEVER?
		HAD HIGH OR LOW BLOOD PRESSURE?
		HAD FREQUENT OR PAINFUL URINATION?
		HAD A KIDNEY STONE, BLOODY URINE?
		HAD VENEREAL DISEASE?
		HAD SKIN TROUBLE?