Friday, March 02, 2012
By David C. Radford, DC, David R. Seaman, DC, James F. Winterstein, DC, and Robert C. Jones, DC. Reprinted with permission from the American Chiropractic Association, www.acatoday.org.
I of this three-part series, we discussed the history of the
chiropractic profession and the issue of primary care, both past
and present (see ACA News, January 2012, Page 29). In Part II, we
discussed the implementation of conservative primary care, the
clinical methods we can use in daily practice to address
co-morbidities and how to move our patients toward preventive
medicine and wellness based upon the elements of a good patient
history (see ACA News, February 2012, Page 28).
In Part III, we look at the physical examination in light of the patient's history and expand on implementation of conservative primary care services that we can provide within our current scope of practice. The utilization of doctors of chiropractic (DCs) to coordinate patient care should help reduce our nation's health care costs by preventing and managing chronic illness.1 The importance of the interview process during the subjective history taking comes to light at the first encounter. The specific details we ferret out during the subjective history taking help us start to make a mental check list of differential diagnoses and what we will need to consider so we may narrow the diagnosis into a rational hypothesis. This mental triage process helps direct us through the patient's examination and to plan the diagnostic procedures we may want to perform or order. Let's use the example of a fairly comprehensive office visit as a review exercise.
The Office Visit
Every new patient encounter, change in condition or break in care should include the vital statistics in the office visit. These objective measurements include the height, weight, body mass index (BMI), heart rate or pulse, respiratory rate, blood pressure and pulse oximeter measurement of oxygen saturation. If any of the vital signs are not within normal limits, they should be tracked on a regular basis to determine if a specialist consultation and/or further medical intervention is needed, as this is part of our role. The health-promoting influence of primary care has been accumulating and holds true in both cross-national and within-national studies.2 In some situations, we may be the only physician seeing the patient on a regular basis, making it even more important that we track abnormal vitals, direct our care to reduce illness, and prevent end-organ damage and premature death. Obesity, adult-onset diabetes, vitamin D deficiency, hyperlipidemia, hypertension, tobacco, alcohol, drugs and use of excessive medications are co-morbidities that we see every day.
Following the patient encounter, we should be able to describe the patient in detail, including his or her emotional state. It is helpful to note if the patient appeared to be pleasant and cooperative, if he or she was well groomed and what his or her mood was like: good, somber, anxious or depressed. Patients frequently present to a DC in pain, and are often seeking manual medicine. The understanding of the patient's emotional state gleaned through the history and examination helps us grasp mental health in relationship to pain, which aids in our biopsychosocial approach to care of the patient.3 Assessing the mental health of our patients also gives indications of whether there may be symptom amplification, symptom modification due to mental overlay (i.e., depression often increases pain and creates avoidance patterns), co-dependence on a practitioner and the overall likelihood of whether the patients will engage successfully in our treatment plan.
If there was trauma, did the patient hit his or her head? If there was head trauma, was there a loss of consciousness, blurred or double vision, an associated headache or changes in the ability to remember things or diffi culty with concentration? Furthering the discussion, has there been any loss of sleep or sleep disturbance? Have there been unusual emotional changes or mood swings? Is the patient clearly oriented to time, place and person, and is the patient a good historian? Are short- and long-term memory, cognition and general fund of knowledge good? Are the attention span and concentration good? At this point, do you need to set aside time for a mini-mental status examination? Does examination of the head and cranial nerves suggest a need for imaging of the head or perhaps a neurological consult?
In general, can you describe the patient as being well developed and well nourished? If not, what is the patient's appearance? A patient who is not nutritionally sound does not have the nutrient building blocks to respond to the physical changes your treatment plan may require. This is an opportunity to discuss diet and lifestyle changes. Based on the patient history, risk factors, vital statistics, appearance of the skin, color of the membranes and body build, do you suspect any cardiovascular problems or chest disease? When you listen, is the chest clear to auscultation in all lobes? Is there any tactile fremitus? Does the cardiac exam demonstrate normal S1 and S2 heart sounds? Are there S3 or S4 sounds? Are the heart rate and rhythm unremarkable, or are there murmurs, rubs or gallops? Is there any peripheral edema? If so, we need to describe the extent and severity in our notes. Based on the auscultation of the heart and lungs, do we need further testing or a specialty consultation? If the female patient is seen regularly by a gynecologist or internist, the breast examination can be discussed as being up to date, and charted as being deferred.
Continuing with the thoracic/chest examination, is the trachea in midline? Is there thyroid enlargement or a palpable nodule? Is there hoarseness? Does the patient need an EENT consult? Does auscultation of the carotid arteries reveal good up strokes, and are they negative for bruit? Is there any jugular vein distention? Is there any indication that the patient would be at increased risk for spinal manipulation of the neck?
Before we palpate the abdomen of the patient, we should have determined through the history if there were any reported bowel, bladder, liver, gallbladder, spleen or pancreatic concerns? It is not at all uncommon for pathology of the abdomen to refer pain to the flank and back. Are the bowel sounds normal, or is there an absence of normal bowel sounds that could suggest an obstruction? Are the superficial reflexes present at the four quadrants? Is the abdomen non-tender or tender to palpation, and if tender, where? Is the liver or spleen enlarged? Are there any abnormal pulses or masses on abdominal palpation? If there is flank or chronic back pain, should we order a routine urinalysis, a CBC and ESR or imaging studies? If the patient is seen regularly by a family practice doctor or an internist, the male's prostate and for both sexes the rectal examination, can be discussed and charted as being deferred, or the exam can be performed if necessary based upon the chief complaint.
A wide variety of abnormalities contribute to indigestion and to the development of gastrointestinal complaints. This is sometimes a complex issue, and the role of testing for H. pylori infection in GERD remains controversial. The implications of test results with false positive and false negative results remain incompletely understood. Patients with chronic digestive problems may have had diagnostic testing, including endoscopy and colonoscopy with biopsy. If these studies have been done, do we know that life-threatening pathologies have been ruled out? We suggest looking at the role of obesity, diet and lifestyle in our patients with gastrointestinal complaints, and refer the reader to the relevant patient education resources provided at eMedicine's website for heartburn, GERD and reflux disease. In difficult cases that are non-responsive to conservative care, a referral to a gastroenterologist for co-management is most appropriate.
On your intake paperwork, did the patient complete a pain drawing? Was the severity of the pain indicated on the 11-point 0 to 10 centimeter pain scale, or did you simply ask the patient to rate the pain on a 0 to 10 scale for you? It is important to chart the description as to the nature and character of the pain problem, either using a key to types of pain on the pain diagram, or simply ask the patient to describe the nature and character of the pain. As you watched the patient move, did facial expressions during testing suggest pain; did he or she grimace, or show a facial expression of distress? As the patient sat still or moved, did he or she moan or cry out in pain? It is important to chart how pain was characterized by the patient for our record. Is the patient's pain drawing anatomical; is it free from signs of embellishment? Do we see or suspect Waddell signs; are there any issues of secondary gain?
Describe the patient's standing or sitting posture and movement from sitting to standing. Is it normal or is there a Tripod or Minor's sign? Is the stance and gait normal/abnormally wide, stable or unstable? Do we want our patient to do a tandem walk to better assess balance? Is he or she able to walk on his or her heels and toes and squat with good strength? To test proximal muscle strength, is the patient able to duck walk? Is Patrick's figure four sign negative for hip disease?
Palpate the area of concern for tenderness with appropriate pressure and percussion. Does the patient have a facial expression of distress with this type of provocative testing? Note the patient's skin color and turgor. Are they normal? Is any lymphadenopathy noted? Is there any palpable mass or tenderness in the supraclavicular fossa, axilla or groin?
It is helpful as a starting point in care to record all abnormal spine or joint motions using the appropriate measuring device, goniometer for joints and the inclinometer for the various regions of the spine. Based on the history and red flags, is imaging indicated? Are there signs of inflammation? Is the problem unilateral and focal, or is it bilateral and symmetrical, involving multiple joints and tissues? Is there an indication to look at the serum biomarkers for inflammation or autoimmune disease? The medications routinely used should be discussed, and while botanicals and more natural alternatives may be useful, we realize they are not all entirely free from side effects and they can interact with prescription medications and represent a good topic for further discussion.
For the motor and sensory examination, we record muscle strength by the Medical Research or Kendall Scales (graded 0 to 5) (R/L). In the assessment, are the limbs symmetrical in bulk, strength and tone? If you record the grip strength by dynamometer, always indicate if the patient is right- or left-handed. Are the muscle stretch reflexes symmetrical at the deltoid, biceps, triceps, brachioradialis, wrist, patella, hamstring and ankle? Is the radioperiosteal reflex normal? Is side-to-side evaluation of sensation over the dermatomes using pinprick and light touch intact or altered? Are good joint position and vibratory sense observed distally at the great toes?
Do the patient's feet look healthy? Is there an indication for further testing, metabolic laboratory or electrodiagnosis? If these are abnormal, is an internal medicine consultation indicated? The number of specialist consultations has doubled over the past decade, from 4.8 percent in 1999 to 9.3 percent in 2009. While some policymakers are concerned about this added cost of specialization, many physicians in ambulatory primary care,4 like chiropractic physicians, understand our expertise is primarily musculoskeletal medicine and manual therapies, and while we recognize our limits, we also understand our responsibilities as physicians.
If there is a spine problem, is the Valsalva maneuver provocative for disc occlusion pain in the cervical, thoracic or lumbar spine? Is there evidence of nerve root tension in the arm or leg? The list of orthopedic and neurological tests can be long, and all examination findings help paint a picture that tells the patient's story. If plain films or advanced imaging were deemed clinically necessary, how do they correlate with the chief complaint? If a trial of manual therapy and spinal manipulation is indicated, is the patient responsive?
If it is essential to the examination, do the patient's cranial nerves appear to be grossly intact? Are the sclera anicteric, and are the conjunctiva normal? Are the pupils equal and active? Are they reactive to light and accommodation? Is visual acuity corrected? Are the visual fields full? If a funduscopic examination was not performed, was it because there was no complaint to suggest increased intracranial pressure? If it was performed, was the funduscopic examination benign with no exudates? Is there hemorrhage or papilledema to suggest increased intracranial pressure? Are the teeth in good repair? Is a consultation needed with an eye specialist or a dentist?
Are there any Long Tract signs? Is the plantar response flexor or extensor, and is Oppenheim's sign negative? Is there any clonus, or a Hoffman's sign? Are the finger-to-nose, finger-to-finger and heel-to-shin tests normal? Is there any evidence of downward drift? Is Romberg's sign absent? Is the patient safe at home? Is the patient at risk of falling at home? If so, does the family know, and is further testing or assistance indicated?
Are pulses present at the wrists, ankles and dorsum of the feet? Are the hands and feet warm and dry? Do you observe any cyanosis or clubbing of the distal digits? Do the nails appear smooth with good color and capillary refill? Are there any bruises or cutaneous rashes? Does the bruising reflect a trauma or a clotting problem? If present, does the rash represent a focal response, or is it a more generalized process?
Plan Appropriate Care
You have given this patient a comprehensive physical examination, and based upon the patient's history, your findings and any special tests, you should be able to plan appropriate care and make necessary referrals for secondary or tertiary care. Of course, not every patient being seen in chiropractic medicine needs a comprehensive evaluation, but if we happen to be the first-choice physician, we have an obligation in our role of primary care physicians to triage the patient and provide not only the best possible care, but make appropriate referrals when necessary. This obligation occurs not only at the point of an initial office visit but also when there is a change in symptoms, an additional chief complaint or an office return after a break in care.
The accessibility of the nation's chiropractic physicians for conservative primary care of non-institutional patients5 using the primary care model should enable the DC to become more involved in the discussion of cost-effective health care policy. It has been found that provider continuity is one of the most important explanatory variables related to the total health care cost.
Dr. Radford is the director of the Chiropractic Clinic of Solon, Dr. Winterstein is the president of National University of Health Sciences, Dr. Jones is the president of New Mexico Chiropractic Association and ACA's delegate to New Mexico and Dr. Seaman is a professor of clinical sciences at National University of Health Sciences' Florida campus. Drs. James Lehman and Michael Taylor also contributed to this article.