“listen to the patient’s stories. they are telling you their problems.”
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“Listen to the patient’s stories. They are telling you their problems.”. - PowerPoint PPT PresentationTRANSCRIPT
““Listen to the patient’s Listen to the patient’s stories. They are telling you stories. They are telling you their problems.”their problems.”
A student was sitting for her third patient evaluation and treatment analysis. She was at the top of the class, with only a rare grade below an A, and her clinical practicum reports appeared faultless. Consequently, a difficult patient was assigned to her. We were amazed when she appeared in less than a half-hour, seemingly pleased and smiling proudly, with supreme confidence in the evaluation summary she completed.
I asked her how she could be so confident, to which she replied that she remembered the good advice of the faculty to “listen to the patient.” She walked up to the patient and, in kindly and empathic terms, softly asked him, “What troubles you?” His reply was a radial nerve injury at the elbow, complicated by bilateral carpal tunnel entrapment of ulnar and median nerves and an older history of repaired trigger fingers.
She remembered. She listened. She quickly found her answer. She got an A.
- Helen J. Hislop, Sc. D., F.A.P.T.A
Problem IdentificationProblem Identification
Mark David S. Basco, PTRP
Department of Physical Therapy
College of Allied Medical Professions
University of the Philippines Manila
ObjectivesObjectivesAt the end of the session, you should be
able toIdentify patient identified (PIP) and
non-patient identified problems (NPIP)Justify relevance of PIPs and NPIPs in a
caseIdentify existing and anticipated
patient problems / concernsJustify existing and anticipated patient
problems / concerns
ObjectivesObjectivesAt the end of the session, you should be
able toClassify patient’s problems into
impairments, activity limitations, and participation restrictions.
Identify testing and predictive criteria for a given problem.
This is the case ofThis is the case ofSam, 24 y/o male diagnosed with
incomplete T12 SCIUsed to work as a call center
agentNewly wed, and hopes he could
still have kidsUsed to play badminton for the
team in their office
Major types of patient Major types of patient problemproblemExisting problemAnticipated problem
Existing problemExisting problemIdentified by the patient, PT, or
any other personsStatements that describe deficits
in a person’s function (disability)Exist when the patient is being
seen and that require remediation
Can be tested because changes could be measured
Existing problemExisting problem
For Sam,Inability to walk independentlyDifficulty in performing ADLsWeakness of both legsInability to work as a call center
agentInability to participate as a
member of the office’s badminton team
Anticipated problemAnticipated problemIdentified by the patient, PT, or
any other personStatements that describe deficits
that may occur if an intervention is not used for prevention
Usually risk factors for future pathologies, impairments, functional limitations, and disabilities
Anticipated problemAnticipated problemProblem recurrence is prevented
with correct identification and management.
For Sam,Pressure ulcersContractures
Anticipated problemAnticipated problemJustification can only be based on
theory or evidenceIf there is no evidence or lack of
it, PT may provide too much intervention or vice versa.
Evidence-based arguments are preferred
Therefore...Therefore...Management for the 2 types of
problems as well as the assessment of treatment outcomes must differ.
Therefore...Therefore...
Justification for the 2 types of problem differ
Anticipated problem◦Based on evidence / sound theory
since it cannot be tested or measured
Existing problem◦Hypothesis that guide intervention to
eliminate the problem can be tested based on outcomes such as changes in patient’s function
Ways that problems are Ways that problems are identifiedidentifiedPatient Identified Problems
◦PIPsNon-Patient Identified Problems
◦NPIPs
PIPsPIPsProblem identified by the clientCan be existing or anticipatedUsually functional limitations /
disabilitiesCannot be removed from the
problem list without consent from the patient
PIPsPIPs
For Sam,Inability to walk independentlyInability to go back to workInability to have a child with her
wifeLoss of sensation in the LEs
NPIPsNPIPsIdentified by people other than
the patientAdded to the problem list after
consultation with the patientCan be existing or anticipated
NPIPsNPIPs
For Sam,Knee and ankle joint contracturesPressure ulcersWeaknessDepression
So what do you do?So what do you do?Therapist must generate
hypothesis to determine cause of the problems and establish criteria for existing and anticipated problems.
Hypothesis generated will provide link between diagnosis (PT) and intervention
I have mentioned I have mentioned Hypothesis...Hypothesis...Let’s define what is a hypothesis...The therapist’s conjecture as to
the cause of a patient’s problem.
Therapist’s idea as to the underlying cause of a patient’s problem
Mechanism for therapists to test whether ideas about the causes of the problems may be correct
For each problemFor each problemExistingAnticipated
Existing problemExisting problemGenerate a Hypothesis as to why
the problem exists
All hypothesis must be verifiable through obtainable measurements
Anticipated problemsAnticipated problemsIdentify the rationale
◦Theory◦Evidence
For believing anticipated problems are likely to occur unless intervention is provided
How do you confirm if How do you confirm if your hypotheses are your hypotheses are correct?correct?Testing criteriaPredictive criteria
Testing CriteriaTesting CriteriaExisting problemsEvaluates the outcome of
interventionThese represent critical values for
measurements which, if achieved, would suggest the hypothesis is correct if the associated problem is resolved
Can be measured in clinical practice
Testing criteriaTesting criteria
For Sam,Problem: Inability to walk independentlyHypothesisProbably due to weakness of the
LE and trunk musclesTesting criteriaMMT grade: ≥ 3/5 of both hip
flexors and trunk flexors.
Predictive criteria Predictive criteria Anticipated problemsTarget levels of measurements or
behavioral alterationsRelate to an observable behavior
by the patientIf it is impossible to achieve goals
with observed behaviors◦Knowledge may be a possible criterion
Predictive criteriaPredictive criteria
For Sam,Problem:Occurrence of a Pressure UlcerHypothesisProlonged immobilization of the
lower extremities and trunk resulting from difficulty in changing positions may predispose him to development of pressure ulcers
Predictive criteria Predictive criteria
Predictive criteriaSam will perform sitting push-ups
on his w/c every 20 minutes.Sam will use a hand mirror to
check his buttocks for redness every after clothing changes.
Predictive criteriaPredictive criteria
If therapist would not be able to visit Sam on his work place to assess risk for injury
Predictive criteriaSam will enumerate at least 3
risk factors for the development of pressure ulcers.
What if?What if?
The concern of the patient is the pathology
For example,Healing of a pressure soreHypothesisThe presence of infection may be
interfering with the healing process
What if?What if?
The concern of the patient is the pathology
Testing criteriaPresence of bacteria on the wound*Could only be tested by taking
wound culture*Outside the scope of PT practice*Referral to MD to confirm
hypothesis
What if?What if?
An undiagnosed pathology is hypothesized
For Sam,Problem: Weakness of both LEHypothesis: May be due to
compression of a central neural structure
- Consultation with or referral to a physician may be required to confirm
Problem ListProblem ListRefining your Problem ListClassifying your problems
◦Pathology◦Impairment◦Activity Limitation◦Participation Restriction
Refining Problem ListRefining Problem List
You now have 2 types of problems derived from 2 types of sources
Determine if problems could be addressed by PT or not
Refining Problem ListRefining Problem List
If patient needs intervention of another practitioner◦REFER and document reason for
referral
Refining Problem ListRefining Problem List
If problem cannot be addressed (no intervention would help)◦Discuss with the patient◦Remove the problem from list that
could be addressed by PTs◦Document why the problem would
be eliminated◦Document the discussion that took
place
Problems can be stated asProblems can be stated asPathologyImpairmentActivity LimitationParticipation Restriction
PathologyPathologyDisruption of body’s homeostasis
as a result of acute/chronic diseaseMedical diagnosisDoes not tell PT how to assess the
patientTwo patient with the same
diagnosis have different impairments and functional limitation
ImpairmentsImpairmentsConsequences of pathologic
conditionsSigns and symptoms that reflect
abnormalities at the body system,organ, or tissue level◦Musculoskeletal◦Neuromuscular◦Cardiovascular / pulmonary◦Integumentary
Activity LimitationActivity LimitationLook at the whole person,
involves whole body movementsResults of impairments Characterized by reduced ability
of a person to perform actions or activities in an efficient or typically expected manner
May be physical, social, or psychosocial in nature
Activity LimitationActivity LimitationFocus on those that are most
important to the patient that are causing disability which affects QOL
Includes BADL and IADL
Participation RestrictionsParticipation RestrictionsProblems an individual may
experience in involvement in life situations
Inability to perform or participate in activities / tasks related to self, home, work, recreation, or community
Participation RestrictionsParticipation RestrictionsPerceived by the patientsBased on the context of physical
environment as well as societal expectations
Establishing connectionsEstablishing connectionsWhat impairments directly
contribute to functional limitations?
What activity limitations are the most important to the patient and what causes participation restriction?
What if ... What if ... You were not able to identify
impairments?
A person has performance problems and capacity limitations without evident impairments?
What will you do?
What will you do?What will you do?Look at the patient’s / client’s
function / activity limitation / participation restriction, if applicable
For example...For example...
A 39 y/o client, who likes to play golf, was referred to you for evaluation and management.
The client wants to increase the distance that his ball travels for each swing.
What do you do?What do you do?
Upon evaluation,- Muscle strength for UE /LE: MMT
grade 5/5- Muscle length of UE/LE was within
normal limits- Endurance testing: results within
normal limits
What do you do?What do you do?Is there any evident
impairment/s?Is there any activity limitation/s?Is there any participation
restriction/s?
What do you do?What do you do?
Let us hypothesize why he could not achieve an optimal golf swing...
Swing technique?Need to enhance muscle
strength?
ARE THERE ANY ARE THERE ANY QUESTIONS...QUESTIONS...
ReferencesReferencesRothstein, J., et al. (2003). The hypothesis-
oriented algorithm for clinicians II (HOAC II): A guide for patient management. Physical Therapy, 83, 455-470.
Problem Identification Handout of Juners M. Mariano, PTRP
Wolf, S.L. (1985). Clinical decision making in physical therapy. Philadelphia: F.A. Davis.