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:________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________

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?
		HAVE YOU EVER HAD AN INJURY TO ANY OF YOUR JOINTS? SPECIFY ON THE FOLLOWING MEDICAL CHART.
		IF ANSWER TO ABOVE IS “YES,” DID THE INJURY INCAPACITATE YOU FOR 1 WEEK OR LONGER?
		HAVE YOU EVER BEEN TOLD THAT YOU INJURED A MUSCLE OR LIGAMENT?
		DO YOU HAVE A PIN, SCREW, OR PLATE SOMEWHERE IN YOUR BODY AS A RESULT OF BONE OR JOINT SURGERY?
		HAVE YOU EVER HAD A BONE GRAFT OR A SPINAL FUSION?
		HAVE YOU HAD A FRACTURE DURING THE PAST 2 YEARS?
PAST HISTORY
HAVE YOU EVER HAD, OR BEEN TOLD YOU HAD, OR CONSULTED A PHYSICIAN FOR:
Yes	No
		DIABETES, GOITER, OR ANY OTHER DISEASE OF THE GLANDS (E.G., MONONUCLEOSIS)?
		EPILEPSY (SEIZURES)?
		NERVOUS DISORDER OR ANY DISEASES OF THE BRAIN OR NERVOUS SYSTEM?
		HEART TROUBLE OR RHEUMATIC FEVER?
		VARICOSE VEINS, PHLEBITIS, HEMORRHOIDS?
		ANY DISEASE OF THE BLOOD, EASY BRUISING, OR BLEEDING TENDENCY?
		TUBERCULOSIS, ASTHMA, CHRONIC COUGH, COUGHED-UP BLOOD, PNEUMONIA, OR ANY LUNG DISEASE OR RESPIRATORY DISORDER?
		ULCERS, APPENDICITIS, OR ANY DISEASE OF THE STOMACH, INTESTINES, LIVER, OR GALLBLADDER?
		SUGAR, ALBUMIN, OR BLOOD IN THE URINE OR ANY DISEASE OF THE KIDNEYS OR GENITOURINARY ORGANS?
		ARTHRITIS, RHEUMATISM, OR ANY INJURY OR DISEASE OF THE BONES, PERIPHERAL JOINTS, BACK, OR SPINE?
		HERNIA OR ANY DISEASE OF THE MUSCLES OR SKIN?
		CANCER, TUMOR, OR GROWTH OF ANY KIND?
		A HEAD INJURY CAUSING SEVERE DIZZINESS, LOSS OF MEMORY, VOMITING, UNCONSCIOUSNESS, OR REQUIRING MEDICAL ATTENTION OR HOSPITALIZATION?
		CAR, TRAIN, SEA, AIR SICKNESS?
		DEPRESSION OR EXCESSIVE WORRY?
		LOSS OF MEMORY OR AMNESIA?
		GOUT?
		HAVE YOU EVER USED OR ARE YOU PRESENTLY USING ANY HABIT-FORMING DRUGS?
		HAVE YOU EVER BLED EXCESSIVELY AFTER TOOTH EXTRACTION?
		EVER HAD TROUBLE WITH DEHYDRATION (EXCESS LOSS OF SALT AND WATER)?
		BEEN MORE THIRSTY THAN USUAL LATELY?
		EVER HAD HEAT STROKE OR ANOTHER HEAT DISORDER (FAILURE OF BODY’S HEAT-REGULATING SYSTEM RESULTING IN THE BODY TEMPERATURE ABOVE 40.5° C (105° F)?
		WEIGHT CHANGED IN THE LAST YEAR? GAIN_____KG; LOSS_____KG
		ANY EXPLANATION FOR THIS WEIGHT CHANGE? (SPECIFY ON THE FOLLOWING MEDICAL CHART.
		HAD ANY ADDITIONAL ILLNESS, INJURIES (OTHER THAN CHILDHOOD DISEASE)?
		ARE YOU PRESENTLY UNDER A PHYSICIAN’S CARE FOR ANY DIFFICULTY NOT ALREADY DISCUSSED?

MENSTRUAL AND GYNECOLOGICAL HISTORY (IF APPLICABLE)
AT WHAT AGE DID YOU FIRST MENSTRUATE?_________________________________________
AT WHAT AGE DID YOUR PERIODS BECOME REGULAR?________________________________
HOW OFTEN ARE YOUR PERIODS NOW?_______________________________________________
Yes	No
		EVER HAD A PELVIC EXAMINATION (RECOMMENDED ANNUALLY FOR SEXUALLY ACTIVE INDIVIDUALS 18 TO 35 YEARS)?
		DO YOU HAVE PAINS/CRAMPS DURING YOUR PERIODS?
		ANY MENSTRUAL ABNORMALITIES (E.G., ABNORMAL BLEEDING)?
		ANY VAGINAL ITCHING OR DISCHARGE?
		ARE YOU TAKING THE BIRTH CONTROL PILL?
		ANY LUMPS OR PAIN IN YOUR BREASTS?
		PREGNANCY? (PAST OR PRESENT) NUMBER. OF CHILDREN ___________________________________
		OTHER GYNECOLOGICAL PROBLEMS?

INDICATE DATE OF YOUR LAST PAP TEST	___________________________	___________________________
	MONTH	YEAR
WHAT IS THE INTENSITY OF YOUR PAIN?

PATIENT-SPECIFIC FUNCTIONAL SCALE¹⁵⁰
Baseline Assessment Please identify important activities that you are unable to do or are having difficulty with as a result of your problem today.

Activity 1 (specify): _____________________________________________________________________________________________
Patient-Specific Activity Scoring Scheme (circle one number):
0	1	2	3	4	5	6	7	8	9	10
Unable to perform activity									Able to perform activity at same level as before injury or problem
Activity 2 (specify): _____________________________________________________________________________________________
Patient-Specific Activity Scoring Scheme (circle one number):
0	1	2	3	4	5	6	7	8	9	10
Unable to perform activity									Able to perform activity at same level as before injury or problem
Activity 3 (specify): _____________________________________________________________________________________________
Patient-Specific Activity Scoring Scheme (circle one number):
0	1	2	3	4	5	6	7	8	9	10
Unable to perform activity									Able to perform activity at same level as before injury or problem

MEDICAL CHART DETAILS IN CONNECTION WITH QUESTIONS ANSWERED “YES”
Date	Name and Address of Physicians, Hospital, etc.	Nature of Illness/Injury

CERTIFICATION
I certify that I have answered this questionnaire and all questions of the attending health professional completely and correctly to the best of my knowledge. I certify that I have not had any prior illnesses or injuries other than those I have listed on this questionnaire.
Date___________________	________________________________
	Patient’s signature
	________________________________
	Print name

CONSENT FOR TRANSMITTAL OF INFORMATION
I, ______________________, give my permission for the transmittal of the results of this medical examination to the appropriate health care professional. The confidentiality of these medical records is to be preserved.
Date___________________	Signed__________________________
Place__________________	Witness_________________________

RECORD OF CONSENT FOR MINORS
I, ______________________, give my permission for emergency medical/surgical care to be given by the appropriate health care professional to
________________________who is my son /daughter.
It is understood that wherever possible I shall be contacted, informed of the problem, diagnosis, treatment required, and the hoped-for results.
Date__________________	Signed________________________
Place_________________	Witness________________________

150. Stratford PW, Spadoni GF: Assessing improvement in patients who report small limitations in functional status on conditions-specific measures. Physiother Can 57:234–239, 2005.

APPENDIX 17-2

Primary Health Care Examination

DATE____/____/____
TEMP___________° F___________° C HEIGHT___________METERS___________CM WEIGHT___________KILOGRAMS
MENTAL STATUS ______________________________________________________________________________________________
SKIN	PERSONALITY	MOOD	GAIT

PRESENT HISTORY

PLEASE ENTER IN BOXED AREAS “N” IF NORMAL, “A” IF ABNORMAL.

Central Nervous System
REFLEXES	PROPRIOCEPTION	BALANCE
MYOTOMES	SENSORY	NERVE ROOT	PERIPHERAL NERVE
________________________________________________________________________________________________________________
IF ABNORMAL FINDINGS ARE PRESENT, PLEASE SPECIFY

Ear, Eye, Nose, and Throat
EYE—VISUAL ACUITY	L	R
NYSTAGMUS
HEARING
TONSILS
FALSE TEETH ______________________________________________________________________________________________
	IF ABNORMAL FINDINGS ARE PRESENT, PLEASE SPECIFY.
________________________________________________________________________________________________________________
IF ABNORMAL FINDINGS ARE PRESENT, PLEASE SPECIFY.

Respiratory
LUNGS	CHEST—SYMMETRY AND WALL	CHEST AUSCULTATION
CHEST EXPANSION___________________
________________________________________________________________________________________________________________
IF ABNORMAL FINDINGS ARE PRESENT, PLEASE SPECIFY.

Cardiovascular
BLOOD PRESSURE:______/______	HEART RATE:	__________	___________	SITE:____________
		SUPINE	UPRIGHT
PERIPHERAL PULSES _________________________
CHARACTER RHYTHM

PRECORDIUM	ABNORMAL SOUNDS		ATYPICAL BEAT		THRILLS
	ABSENT	PRESENT	NORMAL	DISPLACED	ABSENT	PRESENT
VARICOSITES	______________________________________________________________________________________________
	IF ABNORMAL FINDINGS ARE PRESENT, PLEASE SPECIFY.

Abdominal
ABDOMINAL WALL		TENDERNESS		ORGANOMEGALY		MASSES
NORMAL	ABNORMAL	ABSENT	PRESENT	ABSENT	PRESENT	ABSENT	PRESENT

Genitourinary
HERNIA		GENITALIA
ABSENT	PRESENT
BLOOD IN URINE
RECTAL
SACRAL		COCCYX

Musculoskeletal System
CERVICAL	THORACIC	LUMBAR
CHEST/RIBS
________________________________________________________________________________________________________________
IF ABNORMAL FINDINGS ARE PRESENT, PLEASE SPECIFY.

Joints
PLEASE EXAMINE FOR PATHOLOGY, RANGE OF MOTION, SWELLING, STABILITY, TENDERNESS OF EACH JOINT. PLEASE ENTER IN BOX “N” IF NORMAL, “AB” IF ABNORMAL.
	LEFT		RIGHT
	N	AB	N	AB
SHOULDER
STERNOCLAVICULAR
CLAVICLE
ACROMIOCLAVICULAR
SCAPULA
GLENOHUMERAL
INSTABILITY TESTING
ROM
ROTATOR CUFF
SCAPULAR CONTROL
MUSCLES
BURSA
END FEELS
UPPER ARM
ELBOW
ROM
MEDIAL EPICONDYLE
LATERAL EPICONDYLE
OLECRENON BURSA
RADIAL HEAD
END FEELS
FOREARM
WRIST
CARPAL JOINTS
END FEELS
HAND AND FINGERS
END FEELS
PELVIS
SACROILIAC
PUBIS
ABDOMINAL MUSCLES
GROIN
HIP JOINT
MUSCLE BALANCE
PATTERNS
END FEELS
OTHER
THIGH
QUADRICEPS
HAMSTRINGS
FEMUR
KNEE
ROM
EFFUSION
ANTERIOR STABILITY
POSTERIOR STABILITY
MEDIAL STABILITY
LATERAL STABILITY
MENISCUS
JOINT LINE
TENDERNESS
CREPITUS
END FEELS
-PATELLA
-LATERAL APPREHENSION
-TENDERNESS
-Q-ANGLE
-PATELLA CREPITUS
-POPLITEAL FOSSA
LOWER LEG
TIBIA OR FIBULA
ANT. COMPARTMENT
POST. COMPARTMENT
TENDO ACHILLES
ANKLE
ROM
MEDIAL OR LATERAL MALLEOLUS
ANT. DRAWER
BURSA
END FEELS
FOOT
INVERSION
EVERSION
MEDIAL LONGITUDINAL ARCH
LATERAL LONIGTUDINAL ARCH
PES PLANUS
PES CAVUS
METATARSAL ARCH
END FEELS
TOES
LOWER LEG ALIGNMENT

LABORATORY STUDIES
	Urinalysis		Hematology
SG	______________	_______RECORD TIME OF EXAM
ALBUMIN	______________
GLUCOSE	______________		SERUM FERRITIN__________
MICROSCOPIC	______________		HEMOGLOBIN_____________
	Pelvic		Blood Chemistry
CYTOLOGY	______________		SMA 12 (OPTIONAL)________

VACCINATIONS
POLIO VACCINE	______________	DATE__________________________
TETANUS TOXOID	______________	DATE__________________________
OTHERS	_______________________________________________

DIAGNOSTIC IMAGING
RECOMMEND:
	RADIOGRAPHS		VIEWS:________________________________
	CT SCAN		_______________________________________
	MRI		_______________________________________
	BONE SCAN		_______________________________________
	OTHER	_____________	_______________________________________
		(SPECIFY)
TENTATIVE DIAGNOSIS

ACTION TAKEN
TREATMENT AS INDICATED	NO FOLLOW-UP	REFERRAL:	GENERAL PRACTITIONER
			SPECIALIST (SPECIFY:___)
NOTES:_______________________________________			NURSE
______________________________________________			DENTIST
______________________________________________			NUTRITIONIST
______________________________________________			PSYCHOLOGIST
______________________________________________			PHYSICAL THERAPIST
______________________________________________			OCCUPATIONAL THERAPY
______________________________________________			SPEECH PATHOLOGIST
			OTHER	_____________________________
				SPECIFY:
			________________________________________
			SIGNATURE
			PRINT NAME:__________________________

Ant., Anterior; CT, computed tomography; MRI, magnetic resonance imaging; Post., posterior; ROM, range of motion; SG, specific gravity.

Some general questions can be asked initially, and these can be used to cross-reference questions asked in specific areas of assessment:²⁹

1. Have you ever been a patient in a hospital, emergency room, or clinic?

2. Have you ever seen a physician for an injury or illness?

3. Have you ever had x-rays?

4. Have you ever had an operation?

5. Are you presently taking any medication or pills?

6. Do you have any allergies (to medications, insects, food, or other things)?

7. When was your last vaccination? What was the vaccination for?

8. Have you ever been unable to work or participate in exercise or sports?

9. Have you ever experienced chest pain, dyspnea, or syncope during work, exercise, or activity?

10. Have you ever had a seizure?

11. Have you ever been told you had high blood pressure?

12. Have you ever been told you had high cholesterol?

13. Do you have trouble breathing or do you cough during or after activity?

These general questions cover wide areas, and the specific parts of the assessment should corroborate the answers given to these general questions. In addition, the examiner must consider the effect of psychosocial issues on both the patient and his or her reported symptoms. Haggman et al.³⁸ believed two questions were useful to screen for symptoms of depression:

1. During the past month, have you often been bothered by feeling down, depressed, or hopeless?

2. During the past month, have you been bothered by little interest or pleasure in doing things?

If the answer to both questions is yes, further psychological investigation may be warranted.^39,40 Waddell and Main⁴⁰ talked about illness behavior, a normal and reasonable behavior, which is what people do and say to communicate that they are ill. The examiner should always keep in mind the role psychosocial issues may have in anyone seeking primary care help.

The following assessment sections outline questions pertaining to specific body systems that may lead to further examination or testing and possible concerns or issues that must be dealt with if the patient is going to take part in a particular activity. The examiner may want to cover all of the systems or only those that appear pertinent to the problem.

Examination

The medical examination must be not only thorough but also applicable to the job, activity, exercise, or sport to which the person hopes to return or take part in. Health care professionals should always be alert for concealment, denial, or invention of problems on the part of the patient.

Parts of Primary Care Examination

• Vital signs

• Head and face examination

• Neurological examination and convulsive disorders

• Musculoskeletal examination

• Cardiovascular examination

• Pulmonary examination

• Urogenital examination

• Gastrointestinal examination

• Dermatological examination

• Examination for heat illness

• Laboratory tests

• Physical fitness profile

Body composition

Maturity index

Flexibility

Strength, endurance, and power

Agility, balance, and reaction time

Cardiovascular fitness

Vital Signs

The initial part of the examination is performed to establish the patient’s baseline physiological parameters and vital signs (see Chapter 1, Table 1-7), including pulse or heart rate, respiratory rate, blood pressure (systolic and diastolic), weight, and temperature (normal: 98.4° F [37° C], range: 96.5° F [35.8° C] to 99.4° F [37.4° C]). This part of the examination may be performed by any health care professional who has knowledge or an understanding of the techniques, and it is part of any primary care examination.^41,42

Table 1-8 (see Chapter 1) outlines guidelines for blood pressure measurement.⁴³ High blood pressure values should be checked several times at 15- to 30-minute intervals with the patient resting in between to determine whether a high reading is accurate or is being caused by anxiety (“white coat syndrome”) or some similar reason. If three consecutive readings are high, the patient is said to have high blood pressure (hypertension) (see Chapter 1, Table 1-9). If the readings remain high, further investigation may be warranted.^1,43,44 Table 17-3 outlines the risk factors of hypertension.

Complications of Hypertension

• Cardiovascular disease

• Heart failure

• Left ventricular hypertrophy

• Stroke

• Intracerebral hemorrhage

• Chronic renal insufficiency

• Renal disease

TABLE 17-3

Risk Factors of Hypertension

Primary	Secondary
• One or both parent with hypertension • Increased salt intake • Excessive alcohol consumption • Obesity • Race (Black individuals are more commonly affected.) • Personality traits (tense, hostile) • Smoking • Diabetes • Physical inactivity • Cholesterol > 6.5 mmol/L or low-density lipoprotein cholesterol > 4.0 mmol/L	• Renal disease • Oral contraceptives • Cushing syndrome • Sleep apnea syndrome • Endocrine (thyroid, parathyroid conditions) • Coarctation of aorta • Renovascular disease • Adrenal cortex dysfunction

The following examination sections may be part of the primary care examination, but this will depend on what has been found from taking the history and vital signs. Only those sections that the examiner feels are relevant or are areas of concern would normally be investigated.

General Medical Problems

There are general systemic problems that the examiner must always keep in mind when doing an assessment. Some of the general medical (systemic) questions include the following 13,27,45:

1. Have you ever been diagnosed with a systemic disease (e.g., diabetes)?

2. Have you ever been diagnosed with a progressive disease (e.g., muscular dystrophy, multiple sclerosis)?

3. Have you ever been told you have cancer?

4. Have you ever had anything similar to what you have now? How often?

5. Where exactly is your pain? What is the quality, frequency, and pattern of the pain?46 What have you tried to do to alleviate the pain? On a scale of 1 (no pain) to 10 (pain is bad as it could possibly get), how would you rate your pain level?

6. Do you have any other symptoms?

7. Have you ever had any infections? How were they treated?

8. Do you have unexplained fatigue?

9. Have you ever had any unexplained weakness?

10. Do you bruise easily?

The presence of systemic disease (e.g., diabetes) does not rule out work or activity, but the examiner must ensure that there is either good control by the use of medication or that the disease will not cause undue risk to the patient or his or her well-being. It must also be determined whether the extent or intensity of the activity the patient has to do poses a significant threat to the patient’s physical condition.⁴⁷ The examiner also has to be concerned about problems, such as acute infection and malignancy, and progressive diseases, such as multiple sclerosis.

Acute illnesses tend to be self-limiting and usually require only that the patient temporarily withdraw from work or activity, often to prevent spread to others.²⁹ Dehydration is made worse by febrile illness, which could, in certain circumstances, lead to heat disorders.

Head and Face

Eye Examination

Visual acuity is usually examined with the use of a Snellen or common eye chart. Peripheral vision and depth perception may also be tested. Questions related to the eye examination include the following 29,48:

1. Have you had any problems with vision or your eyes?

2. Have you ever injured your eyes?

3. Do you wear glasses, contact lenses, or protective eyewear?

4. Are you color-blind?

5. Do you have a peripheral vision problem?

6. Have you ever used medications for an eye problem?

7. Have you ever had an eye infection?

Any abnormalities found or positive answers may require further examination. Uncorrected vision of less than 20/40 should be checked further.³⁴ Visual loss of 20/50 means that the patient can read at 20 feet what the average person can read at 50 feet. The health care professional should watch for problems that may preclude work, preclude participation in the chosen activity or sport, or affect the safety of the patient. Vision in only one eye results in lack of depth perception, which can be detrimental in certain activities. Patients with sight in only one eye should work at specific jobs or participate in physical activities only if they have an understanding of the dangers of participating and accept the risks. Such patients should not work or participate in sports for which there is no adequate eye protection.

Examples of Eye Conditions or Signs and Symptoms Requiring Further Examination

• Sudden vision loss

• Visual loss greater than 20/40

• Vision in one eye only

• Severe myopia

• Retinal detachment

• Retinal tear

• Corneal abrasion

• Iritis

• Conjunctivitis

• Proptosis (protrusion) of eye

If the patient wears glasses, the health care professional should ensure that the lenses are plastic, polycarbonate, or heat-treated (safety) glass to prevent them from shattering during work or activity.

Myopia, or nearsightedness, should be noted on the chart; such patients are more likely to suffer retinal degeneration, which increases the possibility of retinal detachment. Patients who have had a retinal detachment are sometimes excluded from contact sports or high-exertion jobs. People who have a retinal tear should be allowed to do strenuous activities only if cleared by a physician or specialist, and they should have a qualifying letter allowing them to return to work.

Pupil size should also be evaluated. In some patients, the pupils are of obvious different sizes (anisocoria). This difference should be noted in case the patient has to be evaluated for a head injury at a later date.⁴⁹ Assessment of the eyes is shown in Chapter 2.

Dental Examination

Questions to be asked concerning the patient’s dental record include the following 48:

1. When did you last see a dentist?

2. Have you ever had any problems with your teeth or gums?

3. Have you ever had any teeth knocked out, damaged, or extracted?

4. Do you wear a mouth guard?

5. Do you smoke or chew tobacco?

6. Have you ever had an injury to your face or jaws?

When looking for dental problems, which is usually done by a dentist, it is important to determine how many teeth the patient has and the last time he or she saw a dentist.

Ear Examination

Questions to be asked concerning the patient’s ear problems include the following:

1. Do you have any problems with hearing?

2. Do you have an earache? (What was the onset? How long is the duration?)

3. Is the earache associated with a cold, flu, or trauma?

4. Is there pain in the ear?

5. Is there any discharge from the ear?

Ear problems are commonly referred to a physician or an ear, nose, and throat specialist. Assessment of the ear is shown in Chapter 2.

Nose Examination

Questions to be asked concerning the patient’s nose problems include the following:

1. What is the problem with your nose?

2. Can you breathe through the nose?

3. Do you have any discharge from the nose (e.g., blood, mucus)?

4. Do you use any medication through your nose (nose drops, nasal spray)?

5. Are both nostrils affected?

Assessment of the nose is shown in Chapter 2. Nose problems other than colds are commonly referred to a physician.

Neurological Examination and Convulsive Disorders (Including Head Injury)

The neurological examination is very important, especially in contact or collision activities or when there is a suspected head injury. Some of the more common questions asked in the neurological examination include the following 13,29:

1. Have you ever been knocked out or been unconscious?

2. Have you ever had a head injury?

3. Have you had or do you have frequent or severe headaches?

4. Have you ever had a stinger or burner?

5. Have you ever had a time when one or more of your limbs went numb or “to sleep” during activity?

6. Have you ever fainted (syncope)?

7. Have you ever had a paralyzed limb?

8. Have you ever lost feeling or muscular control of your arms or legs?

9. Have you ever had a seizure?

10. Have you ever been in a motor vehicle accident or fallen and hit your head?

A positive answer to any of these questions could have a significant impact on what the patient is allowed to do and whether the patient is allowed to return to work or participate in contact or collision activities.

In the neurological examination, the examiner may assess the status of a head injury (see Chapter 2), perform a cranial nerve assessment (see Chapter 2) and sensation scan, and evaluate the different reflexes (see Chapter 1) if problems are suspected. The examiner must check for concussions and nerve palsies. Any positive neurological signs and symptoms uncovered in the examination, such as recurrent concussions or nerve palsies, should preclude strenuous activity until investigated further by a specialist before clearance to return to previous activities is given.

Examples of Neurological Conditions or Signs and Symptoms Requiring Further Examination

• More than one concussion

• Post-concussion syndrome

• Any history of head injury

• Expanding intracranial lesion

• Any history of seizure

• Neurological symptoms of undetermined cause

• Any history of stinger, burner, or neurapraxia

• Persistent weakness, numbness, or arm or leg pain

• Any history of transient quadriplegia

• Upper motor neuron symptoms

• Any history of nerve palsy

With convulsive disorders, the examiner needs to know the frequency of the episodes; how or whether control of the convulsions has been achieved; the use of routine medication; any circumstances that activate the convulsions; and whether the patient understands the disorder, its hazards, and its predisposing factors. Patients with epilepsy should be discouraged from activities, such as skiing, scuba diving, parachuting, and climbing, because of their inherent dangers.²⁹ If the activity involves water sports (e.g., swimming alone, scuba diving), auto racing, or any activity in which recurrent head trauma or unexpected falls may cause serious injury (e.g., mountain climbing, working at heights), then the patient with convulsive disorders should be discouraged from doing these activities. Patients whose activities should be restricted include those who experience daily or weekly seizures, those who display bizarre forms of psychomotor epilepsy, and those whose postconvalescent state is prolonged or typically includes marked abnormal behavior. It is important to understand whether the medication taken can maintain good control of the patient’s condition, not only in everyday situations but also in stress situations. For example, hyperventilation may precipitate an epileptic seizure, and seizures tend to occur after exercise, not during the event. In addition, it is important to know whether the extent or intensity of the participation poses a significant threat to the patient’s physical condition.

Musculoskeletal Examination

Like the neurological examination discussed previously, the musculoskeletal examination is often a very important part of an evaluation. Questions in the history related to this examination include the following 31,50–54:

1. Have you ever pulled (strained) or hurt a muscle?

2. Have you ever torn (sprained) or stretched a ligament?

3. Have you ever subluxated or dislocated a joint or had a bone come out of joint?

4. Have you ever broken (fractured) a bone?

5. Have any of your joints ever swollen?

6. Have you ever had pain in the muscles or joints at work or during or after activity, exercise, or sports (Table 17-4)?

7. Have you ever had regular prolonged (more than 30 minutes) morning stiffness?

8. Have you ever had any rashes, eye infections, diarrhea associated with joint pains, and/or swelling?

9. Have you ever had any proximal weakness, excessive cramping, or muscle fasciculations?

TABLE 17-4

Comparison of Systemic and Musculoskeletal Joint Pain

Systemic	Musculoskeletal
• Awakens at night • Deep aching, throbbing • Reduced by pressure • Constant or waves/spasm • Jaundice • Migratory arthralgias • Skin rash • Fatigue • Weight loss • Low-grade fever • Muscular weakness • Cyclic, progressive symptoms • History of infection (hepatitis, streptococcosis, mononucleosis, measles)	• Decreases with rest • Sharp • Ceases when stressful action is stopped • Associated signs and symptoms • Usually none • Trigger points may be accompanied by nausea, sweating

From Goodman CC, Snyder TE: Differential diagnosis in physical therapy, Philadelphia, 1995, WB Saunders, p. 526.

A positive response to any of these questions requires further investigation.

The musculoskeletal examination begins with observation of the patient’s posture (see Chapter 15), looking for any asymmetry. Asymmetry, combined with the history, may lead the examiner to do a detailed assessment of a specific joint (see Chapters 3 to 13). If no problems are noted, the examiner can do a quick upper and lower scanning or screening examination to check for potential problems and abnormal movement (e.g., hypomobility, hypermobility, capsular patterns, weakness, abnormal movement patterns, cheating movements).^41,55

Upper and Lower Scanning Examination

• Cervical spine: flexion, extension, side flexion, rotation

• Shoulder shrug (resistance may be added)

• Shoulder: elevation through abduction, forward flexion and the plane of the scapula; medial and lateral rotation (resistance may be added)

• Elbow: flexion, extension, supination, pronation

• Wrist: flexion, extension, radial, and ulnar deviation

• Fingers and thumb: open hands wide, make a tight fist

• Thoracic and lumbar spine: flexion (touch toes, knees straight—watch for spine versus hip movement), extension, side flexion, rotation

• Tighten quadriceps (quadriceps strength, symmetry)

• Test hamstring tightness

• Hip, knee, ankle, and foot: squat and bounce, heel-toe walking

If any deviation, weakness, or abnormality is found, or if the patient has reported a previous injury to a joint, a more detailed examination may be performed to assess active movements, passive movements, resisted isometric movements, special tests, functional tests, reflexes, sensation, myotomes, joint play, and palpation of that joint or associated joints.

When looking for musculoskeletal problems, it is important to consider whether the patient’s job or what he or she wants to do will exacerbate an existing disease or injury, increase an existing deformity, or cause further bone or joint damage. When looking for musculoskeletal problems, the examiner may look at the patient’s flexibility, strength, and endurance, as well as static and dynamic stability. Spinal instability (especially instability of the cervical or lumbar spine) or spondylolisthesis may preclude the patient from taking part in some activities. Maturation may also have to be considered when dealing with patients who are still growing, as may previous injuries, congenital problems, and growth abnormalities.

Examples of Musculoskeletal Conditions or Signs and Symptoms Requiring Further Examination

• Joint or spinal instability (static and dynamic)

• Joint swelling

• Unhealed muscle or ligament injury (especially 3° or if avulsion suspected)

• Possible fractures or dislocations/subluxations

• Unhealed or healing fracture

• Degenerative diseases

• Inflammatory diseases

• Unusual hypermobility or hypomobility

• Muscle weakness

• Growth or maturation disorders

• Repetitive stress disorders

• Myopathy

• Metabolic disease

Cardiovascular Examination

The cardiovascular examination should be performed in a quiet area because of the need to auscultate. In this part of the evaluation, the examiner looks for subtle but significant cardiac abnormalities to reduce the incidence of unexpected sudden death in sports or similar incidences at work.2,32,56–61 In some cases, electrocardiograms (ECGs) or stress ECGs may be appropriate.⁶² More than 90% of sudden deaths in exercise and sports among participants younger than 30 years of age involve the cardiovascular system.

The following questions should be asked in the history concerning the cardiovascular system^9,13,27,29:

1. Have you ever had a heart attack?

2. Do you have a pacemaker or other device to assist your heart?

3. Have you ever had heart surgery?

4. Have you ever had frequent heartburn?

5. Have you ever experienced dizziness, fainting, or passing out during or after activity, exercise, or sports?

6. Have you ever experienced chest pain, tightness, crushing sensation, squeezing, or pressure in the chest at work or during or after activity, exercise, or sports (Table 17-5 and 17-6)?

7. When working or doing an activity, exercise, or sport, do you tire more quickly than others doing the same things?

8. Have you ever had high blood pressure?

9. Has your heart ever “raced” or skipped beats?

10. Have you ever been told you have a heart murmur?

11. Has anyone in your family ever had or died from heart problems?

12. Has anyone in your family died suddenly before the age of 50 years?

13. Have you had a severe viral infection (myocarditis, mononucleosis) within the last month?

14. Has a physician denied or restricted your participation in any activity for any heart problems?

15. Do your ankles and/or legs swell?63

TABLE 17-5

Causes of Chest Pain

Systemic Causes	Neuromuscular Causes
• Pulmonary Pulmonary embolism Spontaneous pneumothorax Pulmonary hypertension Cor pulmonale Pleurisy with pneumonia • Cardiac Myocardial ischemia (angina) Pericarditis Myocardial infarct Dissecting aortic aneurysm • Epigastric/Upper GI Esophagitis Upper GI index • Breast Breast tumor Abscess Mastitis Lactation problems Mastodynia Trigger point • Other Rheumatic diseases Anxiety	• Tietze syndrome • Costochondritis • Hypersensitive xiphoid • Slipping rib syndrome • Trigger points • Myalgia • Rib fracture • Cervical spine disorders • Neurologic Thoracic outlet syndrome Neuritis Shingles (herpes zoster) Dorsal nerve root irritation

Systemic Causes

Neuromuscular Causes

• Pulmonary

Pulmonary embolism

Spontaneous pneumothorax

Pulmonary hypertension

Cor pulmonale

Pleurisy with pneumonia

• Cardiac

Myocardial ischemia (angina)

Pericarditis

Myocardial infarct

Dissecting aortic aneurysm

• Epigastric/Upper GI

• Breast

Abscess

• Other

Anxiety

• Costochondritis

• Hypersensitive xiphoid

• Slipping rib syndrome

• Trigger points

• Myalgia

• Rib fracture

• Cervical spine disorders

• Neurologic

Thoracic outlet syndrome

Neuritis

Shingles (herpes zoster)

Dorsal nerve root irritation

GI, Gastrointestinal.

From Goodman CC, Snyder TE: Differential diagnosis in physical therapy, Philadelphia, 1995, WB Saunders, p. 532.

TABLE 17-6

Characteristics of Cardiac Chest Pain

Angina	Myocardial Infarct	Mitral Valve Prolapse	Pericarditis
• 1 to 5 minutes • Moderate intensity • Tightness, chest discomfort • Subsides with rest or nitroglycerin • Pain related to tone of arteries (spasm)	• 30 minutes to hours • Severe (can be painless) • Crushing pain; intolerable (can be painless) • Unrelieved by rest or nitroglycerin • Pain related to heart ischemia	• Hours • Rarely severe • May be asymptomatic; unlike angina in quality or quantity • Unrelieved by rest or nitroglycerin • Mechanism of pain unknown	• Hours to days • Varies; mild to severe • Asymptomatic; varies; can mimic MI • Relieved by keeling on all fours, leaning forward, or sitting upright • Pain related to inflammatory process

MI, Myocardial infarct.

From Goodman CC, Snyder TE: Differential diagnosis in physical therapy, Philadelphia, 1995, WB Saunders, p. 94.

If the answer to any of these questions is yes, the examiner must consider the possibility of cardiomyopathy, conduction abnormalities, arrhythmias, valvular problems, coronary artery defects, and lung or related problems.⁶⁴ If cardiovascular problems are suspected, the examiner may organize further tests (e.g., ECG, treadmill stress tests, laboratory tests)⁶⁵ to detect cardiac abnormalities.

Examples of Cardiovascular Conditions or Signs and Symptoms Requiring Further Examination

• Chest pain

• Dizziness with activity or vertigo

• Irregular heartbeat (rate, rhythm)

• Hypertension (labile or organic)

• Heart murmur

• Family history of heart problems

• Hypertrophic cardiomegaly

• Conduction abnormalities

• Arrhythmias

• Myocarditis

• Valvular problems

• Aortic coarctation

• Marfan syndrome

• Enlarged (athlete’s) heart

• Atherosclerotic disease (positive ankle-arm index [AAI])

• Mitral insufficiency

• Anemia

• Enlarged spleen

• Unexplained fatigue

When looking for cardiovascular problems, the examiner should be alert for the following unusual or abnormal findings:

1. Heart rate faster than 120 beats/min or inappropriate tachycardia for a specific activity

2. Arrhythmias or irregular beats 66

3. Midsystolic clicks, indicating a leaky valve or mitral valve prolapse

4. Murmurs that are grade 3 or louder

The loudness of systolic murmurs is graded from 1 to 6 with grade 1 being a very faint murmur requiring concentration to be heard. A grade 2 murmur is a faint murmur but one that is heard immediately after the stethoscope is placed on the chest. Grade 3 is an intermediate murmur louder than grade 2. Most human dynamically significant murmurs are at least grade 3. Grade 4 is a loud murmur, frequently associated with palpable sensation, known as a thrill. A grade 5 murmur is a very loud murmur still requiring at least the edge of the stethoscope to remain in contact with the chest. The grade 6 murmur is a murmur audible with the stethoscope just breaking contact with the chest.⁶⁷ Diastolic murmurs are graded from 1 to 4, 1 representing the faintest and 4 the loudest murmur. A benign functional murmur or systemic mitral valve prolapse does not preclude exercise or sports but must be evaluated on an individual basis.

The examiner must be aware of congenital heart abnormalities, such as aortic coarctation (stenosis of the artery), which may be revealed by a difference in the femoral and brachial pulses. In such a case, strenuous activity is contraindicated. As another example, 90% of patients with Marfan syndrome (an autosomal dominant condition) have cardiac abnormalities. The examiner must be aware of atrial septal defects (an abnormal communication between the chambers of the heart), dextrocardia (the heart is moved within the thoracic cavity), and paroxysmal auricular tachycardia (an abnormal increase in heartbeat for short periods). Patients with these conditions should be cleared by a specialist before any strenuous activity because of the possibility of fainting in a stressful situation. The examiner must also be aware of heart enlargement (athlete’s heart). This condition does not necessarily preclude activity but should be investigated further if found. If any of these abnormalities have been surgically corrected, they should be evaluated by a specialist on an individual basis to determine whether the patient can take part in the proposed activity.

Hypertrophic cardiomyopathy is the most common cause of sudden death in athletes, followed by aortic rupture associated with Marfan syndrome, congenital coronary artery anomalies, and atherosclerotic coronary artery disease.^29,68 If any of these conditions is present, strenuous activity is precluded.

Other cardiovascular problems include thromboembolic disease, pulse irregularities, valvular problems (such as, mitral insufficiency or mitral valve prolapse), and abnormally high blood pressure (hypertension). Systolic pressure of 140 mm Hg on repeated measurements is considered abnormal (see Chapter 1, Table 1-9).⁵⁸ Also, patients with labile hypertension (an unstable condition of free and rapid change in tension) or organic hypertension caused by structural problems should be investigated further. These patients should have a complete comprehensive coronary risk factor work-up. Mild hypertension does not preclude strenuous activity, but this slight abnormality should be noted and evaluated on an individual basis.²⁹ When taking blood pressure, a proper cuff size must be used to ensure an accurate reading. If the initial reading is high, the reading should be repeated two or three times after the patient has been lying supine for 20 to 30 minutes. Only if the blood pressure is elevated after the third reading should the patient be considered hypertensive.

Detecting Cardiac Risks in Examinations

Key Physical Findings of Cardiac Evaluation by Physician

Heart rate faster than 120 beats/min

• If repeated tests on second occasion are high, suggest monitoring and recording of pulse at home by a trained parent or nurse friend.

• Pulse recovery tests after jumping or hopping exercises are useless routines except for multiple extrasystoles or arrhythmias.

Multiple extrasystoles or arrhythmias. Check after jumping or hopping 20 times to ascertain if arrhythmias appear or disappear.

Resting blood pressure higher than 130/80 mm Hg for students aged 6 to 11 years, 140/90 mm Hg for students aged 12 to 18 years.

• For validity, be certain that the pressure cuff covers at least two thirds of the upper arm, from elbow to shoulder (adult cuff = 30 × 13 cm; pediatric cuff = 22 × 10 cm; obese cuff = 39 × 15 cm).

• If high, repeat test three times and take average.

All systolic murmurs grade 3 to 6 or louder at any location; all diastolic murmurs of any intensity at any location; or any continuous murmur. Heart should be auscultated at four chest locations:

• Pulmonic area (second intercostal space at left sternal border)

• Aortic area (second intercostal space at right sternal border)

• Tricuspid area (fourth intercostal space at left sternal border)

• Mitral area (fourth intercostal space at left midclavicular line)

Routinely palpate femoral and brachial pulses. Note if absent or if large discrepancy exists between them.

Modified from Schell NB: Cardiac evaluation of school sports participants: guidelines approved by the Medical Society of New York. NY State J Med 78:942–943, 1978.

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Primary Care Assessment

Objectives of the Evaluation

Primary Care History

Examination

Vital Signs

General Medical Problems

Head and Face

Eye Examination

Dental Examination

Ear Examination

Nose Examination

Neurological Examination and Convulsive Disorders (Including Head Injury)

Musculoskeletal Examination

Cardiovascular Examination

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