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Consultation, Screening & Delegation Module Part 1 (Online)
Consultation, Screening & Delegation Module Part 1 (Online)
With the increasing specialization of medicine, more and more patients have direct access to a
medical specialist who may not recognize the underlying systemic disease. The physical
therapist may have primary responsibility or may become the first contact for some clients in
the health care delivery system. On the other hand, patients may obtain a prescription for
physical therapy from their primary care physician, based on similar past complaints of
musculoskeletal systems without actually seeing that physician.
Diagnosis is the recognition of disease. It is the determination of the cause and nature of
pathologic conditions. Differential diagnosis is the comparison of symptoms of similar
diseases so that a correct assessment of the patients actual problem can be made.
The dysfunction is identified by the physical therapist based on the information obtained
from the following:
1) history
2) signs & symptoms
3) examination & tests
The therapist must establish a diagnosis in a way that allows him/her to intervene within
the LEGAL SCOPE OF PRACTICE.
In 1984, the house of delegates of AMERICAN PTA passed the following motions: PHYSICAL
THERAPISTS MAY ESTABLISH A DIAGNOSIS within the SCOPE OF THEIR KNOWLEDGE,
EXPERIENCE and EXPERTISE.
Within this context, physical therapists communicate with physicians and other health
practitioners to request or recommend further medical evaluation. Furthermore, whether
in a private practice or in a home health, acute care hospital, or rehabilitation setting,
physical therapists may observe some important finding outside the realm of neuromuscular
disorders requiring additional medical evaluation and treatment.
B. Direct Access
Prior to 1968, a physicians referral was necessary for a client (patient) to be treated by a
physical therapist. Now, more than half of the U.S. states permit direct access to physical
therapy. The PT Practice Act is being changed in many more states to provide for
independent practice of physical therapists. Thus, a patient/client can be evaluated by a
physical therapist in those states with a direct access without previous examination by a
physician or other practitioner and subsequent referral to a physical therapist.
INDEPENDENT PRACTICE requires that the physical therapist be able to evaluate a clients
or patients complaint knowledgeably and determine whether the client/patient has signs &
symptoms of systemic disease or a medical condition that should be evaluated by a more
appropriate health care provider.
C. Decision-Making Process
To help physical therapists with their decision-making process, these four parameters are
used in evaluating a patient:
1) Client History (Diagnostic Interviewing)
This interview with the patient will help the physical therapist distinguish between
problems that he/she can treat and problems that should be referred to a physician
for diagnosis and treatment.
For example, the person with chest pain should be asked specifically about both
systemic and musculoskeletal origins of the present pain and symptoms.
The interview regarding the patients perception of pain is a critical factor in the
evaluation of signs and symptoms. Questions must be understood by the patient and
should be presented in a non-judgmental atmosphere. To elicit a more complete
description of symptoms from the patient, the PT may wish to use a term other than
pain, for example hurt or soreness. The use of alternative terms may help the
patient refocus his/her attention away from the pain and more toward
improvement of functional abilities.
3) Systems Review
for e.g. Any woman with a past medical history of cancer now presenting with
shoulder or back pain should be questioned closely regarding latest
check-up results with oncologist.
Symptoms are reported indications of disease that are perceived by the patient but
cannot be observed by the naked eye. Pain or discomfort, numbness or tingling or
creeping sensations are symptoms that are difficult to quantify but are most often
reported as the chief complaint.
Changes in the skin and nail beds indicate systemic involvement and can occur
with involvement of a variety of organs.
Signs:
4.1.a. Skin Changes - texture, color and temperature
Texture changes include shiny, stiff, coarse, dry or scaly skin. Skin
mobility and turgor are affected by the fluid status of the patient. Edema
decreases skin mobility.