Comper Care Outpatient Physical Therapy with Michael Black DPT

MIKE'S FORMS FROM MEDICAL RED FLAGS ON THE TOPIC OF IMPLEMENTATION OF DIRECT ACCESS

HOW DOES PHYSICAL THERAPY COMMUNICATE MEDICAL RED FLAG FLAGS?

Mike trained the Keystone therapy team in the identification of medical red flags which are inherent to direct access and the doctoral degree. This was followed by training the therapy team on a process he developed for physician communication to facilitate medical intervention using SOAP note forms with physical therapy orders that are to be furnished to the DON to mutually determine the necessary action i.e. if EMS notification is warranted.

Example 1: What does your Physical Therapy progress report look like if a Positive Cervical Quadrant Sign for Carotid Artery Stenosis is detected during The Otago?

Subjective: Patient c/o dizziness with R sided cervical range of motion in sitting and standing. Patient states this results in nausea, confirms PMHx remarkable for atherosclerosis, L LE DVT, and PE.

Objective: Patient demonstrates positive cervical quadrant sign remarkable for carotid artery stenosis risk with reproduction of dizziness during cervical extension with R lateral flexion. Patient demonstrates no s/s BPPV including (-) nystagmus with Dix Hallpike and no s/s orthostatic hypotension with BP analysis before and after sit to stand transfers.

Assessment/Plan: Orders are included for your convenience. Please check boxes and complete prescription as indicated. Defer to your expertise!

_____ Hold physical therapy treatment pending R ECA doppler study

_____ Continue physical therapy and monitor symptoms with additional instructions as follows

Thank you for your trust with this patient! Michael Black PT, DPT

Physician signature ____________________ Date: __________

Example 2: What does your progress report look like if a Positive Cord Sign for Central Spinal Canal Stenosis is detected while taking the subjective history?

Subjective: Patient c/o B UE/LE numbness, tingling s/p fall DOO one week ago. Patient reports PMHx cervical fusion s/p motor vehicle on pedestrian accident while walking in the street at a crosswalk approximately 25 years ago such that a prior TBI is noted.

Objective: Patient reports shooting pain B UE with cervical flexion and (+) cough/sneeze such that a positive Lhermitte’s sign is detected. Patient also c/o acute “increased clumsiness in my arms and legs” since their recent falling incident with severe ambulatory ataxia noted at evaluation.

Assessment/Plan: Patient does present with (+) cord sign which is a red flag for rehabilitation. Patient does have cervical surgical hardware with risk for displacement during the recent repeated falling incidents. Recommend neurology consultation for further neuromuscular differential diagnosis to rule out central cervical spinal stenosis to ensure hardware is intact and nondisplaced. Orders are included for your convenience. Please check boxes and complete prescription as indicated. Defer to your expertise!

_____ Hold physical therapy pending neurology consult, scheduled on the following date

_____ Continue physical therapy and monitor symptoms with additional instructions as follows:

Thank you for your trust with this patient! Mike Black PT, DPT

Physician signature ____________________ Date: __________

Example 3: When does the progress report look like when a Low Back Pain evaluate and treat referral is received and Visceral Quadrant Palpation for referred pain is positive?

Subjective: Patient referred for low back pain of unknown etiology including no physical or mechanical cause. 

Objective: Patient demonstrates low back pain reproduction of symptoms with right lower quadrant visceral palpation. Patient denies symptom reproduction during lumbar orthopedic provocative testing including no pain with lumbopelvic active range of motion or palpation. 

Assessment/Plan: Reproduction of LBP with RLQ visceral palpation does warrant abdominal differential diagnosis to r/o appendicitis, gall bladder, or other gastrointenstinal pathology. Orders are included for your convenience. Please check boxes and complete prescription as indicated. Defer to your expertise!

_____ Hold physical therapy pending lab workup or R abdominal CT imaging studies

_____ Continue physical therapy and monitor symptoms with additional instructions as follows:

Thank you for your trust with this patient! Michael Black PT, DPT

Physician signature ____________________ Date: __________

Example 4: What does a progress report look like when a patient with a DVT of the extremity wants higher level resistance training to a 10 RM in his physical therapy driven functional maintenance plan?

Subjective: Patient reports they are highly motivated to participate in resistance training including the pursuit of 10 RM open and close chain exercise types. Patient denies pain in the involved left arm and left leg at rest and with exertion.

Objective: Patient demonstrates PMHx of L UE DVT x 1 and L LE DVT x 13 although is currently asymptomatic for erythema or edema. Patient receives a physical therapy maintenance plan 3x/week with exercise using body weight resistance only without c/o chest pain, breathlessness or antalgia.

Assessment/Plan: DVT of the extremities is a precaution for open and close chain resistance training using weights. Orders are included for your convenience. Please check boxes and complete prescription as indicated. Defer to your expertise!

_____ Continue current physical therapy exercise treatment, body weight resistance only

_____ Progress physical therapy, open and close chain strength training up to 10-15 repetition maximum

_____ Other orders/instructions: 

Thank you for your trust with this patient! Michael Black PT, DPT

Physician signature ____________________ Date: __________

Example 5: What happens when you discover a skilled rehabilitation patient with a basin containing coffee ground emesis?

Subjective: Patient reports nausea and vomiting of unknown etiology; states this is several weeks in duration with depressed appetite resulting. Denies blood in stool.

Objective: Patient presents with coffee ground emesis with recent weight loss of 10 pounds in the last 5 weeks with diagnosis of failure to thrive observed. Sputum demonstrates yellow expectorate; patient has been refusing to get out of bed, including refusing physical therapy standing treatment.

Assessment/Plan: Patient demonstrates s/s gastrointestinal distress such that differential diagnosis may be warranted to ensure medical stability as a prerequisite to exercise treatment. Orders are included for your convenience. Please check boxes and complete prescription as indicated. Defer to your expertise!

_____ Continue physical therapy, gastrointestinal differential diagnosis not warranted.

_____ Physical therapy is contraindicated, hold exercise therapy until results of gastrointestinal differential diagnosis is received.

_____ Other orders/instructions: 

Thank you for your trust with this patient! Michael Black PT, DPT

Physician signature ____________________ Date: __________

 

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