Goodman article review:
Purpose: The purpose of this article was to discuss why medical screening is
necessary for the hand therapist, describe aspects of the screening process, and
review when and how to refer patients when it is warranted.
*Therapists must be able to ID signs and symptoms of systemic disease that can
mimic integumentary, neuromuscular, or musculoskeletal dysfunction.
Ex) PNA, pacemaker complications, liver disease, kidney stones, myocardial
ischemia can cause shoulder or UE signs and symptoms.
Decision-Making Model for Medical Screening:
- Personal and family medical history
- Risk factor assessment
- Clinical presentation
- Associated signs and symptoms of systemic diseases
- Review of systems
Reasons to Screen
- Direct access: going to therapy without a referral
- Referral without appraisal: doctor refers to therapy without doing examination
- Quicker and Sicker: people are released from hospitals sooner these days, and the
chances of patients having chronic diseases has increased
Red and Yellow Flags
-Red: requires immediate attention
- Symptoms bilaterally
- Hx of concern ** Breast and lung cancer 2 most common cancers to
metastasize to the shoulder**
- Hx of heart disease can cause shoulder pain (Hypertension, diabetes, and
hyperlipidemia are other red flag histories associated with cardiac-related
shoulder pain)
- Rash, nodules, skin pigmentation changes, numbness, and tingling
- Constitutional Symptoms: constellation of signs/symptoms that indicate the
presence of a systemic disease
- Pain Pattern: Back or shoulder pain (most common location of referred
pain; other areas can be affected as well, but these two areas signal a
particular need to take a second look).
- Yellow: caution
- Angina (chest pain), heart attack, angiogram, coronary bypass, and
pacemaker
Important Categories on Past Medical Hx:
- Age: primary risk factors for disease, illness, and comorbidity. Number one
predictor of cancer.
- Gender: Men and women experience the same diseases differently with different
onset, presentation, and response to tx. **Today women are more likely to die of a
heart attack then men. More deaths in women by heart disease then cancer and
stroke**A WOMEN WITH FAMILY HX OF HEART DISEASE PRESENTING WITH
SHOULDER, UPPER BACK, OR JAW PAIN, MUST BE SCREENED FOR CV. Men are not
receiving intervention for osteoporosis, and they suffer higher mortality rates after
sever fractures then women.
- Ethnicity: Often minorities are underserved and don’t have access to certain
services. This can increase their risk for disease and illness. * Mexican Americans
with family hx of stroke and heart attack is a red flag*
- General health: red flag if patient reports their health as poor
- Recent infections: recurring symptoms could be underlying a systemic disease
-Substance Abuse: reduces healing time, injecting substances can cause
infection/disease
- Hx of Cancer: History of any cancer is a red flag. The mnemonic caution is a use-
ful guide: Change in bowel or bladder habits, A sore that does not heal in six
weeks, Unusual bleeding or discharge, Thickening or lump in the breast or elsewhere, Indigestion or difficulty swallowing, Obvious change in a wart or mole,
Nagging cough or hoarseness. **Breast, lung, thyroid, and bone cancer often
spread to the neck, shoulder, and/or upper quarter** Unexplained weight loss is a
red flag
- Tobacco use: Causes peripheral vasoconstriction, delayed wound healing, faster
heart rate, narrowing of blood vessels, increase chance of forming blood clots, and
reduce O2 supply to heart and other organs
- Caffeine: tachypnea (rapid breathing), heart palpations, and enhance pain
sensation
- Sleep related hx: sweats at night and waking up from deep sleep because of pain
can indicate systemic disease
Risk factors
- Crucial for therapist to educate patient about risk factors (obesisty, tabacco use,
ect) that can cause systemic disease
Clinical Presentation
- Advised to assesse the areas above and below of area of complaint
- Monitor vital signs (pulse pressure, hr, pulse, and respiratory rate)
Associated signs and symptoms
- Be sure to ask questions about if the patient is experiencing symptoms anywhere
else in the body besides the area of complaint.
- Often times the patient will not see the link between the two symptoms, and not
report them to you
Review of Systems:
- Review occurs after conducting an interview, performing pain assessments, and
reviewing clinical presentation
- Review all data collected (past medical hx, risk factors, clinical presentation
including red flags and associated signs and symptoms) and looks for a systemic
disease
** The review of symptoms looks beyond the primary problem that brought the
client to therapy. Give an overview of the whole person**
The shoulder is unique
- Shoulder pain is difficult to diagnosis because any pain felt in the shoulder
affects the joint as though the pain was coming from the shoulder joint
- Unilateral shoulder pain: Esophageal, pericardial (or other myocardial diseases),
aortic dissection, diaphragmatic irritation from thoracic or abdominal diseases, and
breast disease
Systemic visceral illness indicators
- Cough + increase symptoms with respiratory movement
- Exacerbation with recumbency (state of leaning, resting, or reclining)
- GI symptoms
- Exacerbation with movement not related to shoulder movement
- Urologic symptoms
Medical hx that can impair shoulder ROM
- Frozen shoulder or adhesive capsulitis Diabetes, heart, and lung disease
- CABG shoulder pain, and can eventually lead to frozen shoulder
- Immobile after surgery or pacemaker placement loss of shoulder motion
- Abdominal disorders (spleen or kidney disease, or ectopic pregnancy- embryo
implants somewhere out of the uterus, laparoscopic procedure- air is put in the
peritoneum to expose abdominal contents, left over air can put pressure
diaphragm)