1
Q
What are the most common constitutional symptoms?
A
-Fatigue
-Malaise
-Weight loss
-Nausea
-Weakness
-Fever, chills, night sweats
-Numbness/tingling
-Dizziness/lightheadedness
-Mentation/cognitive deficit
2
Q
What are pain descriptors that may indicate a non MSK source?
A
-Throbbing
-Pounding
-Pulsating
-Sharp
-Lancinating
-Shocking
-Burning
-Aching
-Gnawing
3
Q
What describes cutaneous pain from delta fibers?
A
-Sharp, localized, fast pain
-Prickly, pulsating, sharp, burning
4
Q
What describes cutaneous pain from C fibers?
A
-Dull, diffuse, aching
-70% of pain is from C fibers
-1:2 delta to C fiber in cutaneous tissues
5
Q
What describes visceral sources of pain?
A
-Poorly localized and diffuse
-More C fiber involvement
-Delta to C fiber 1:10 in viscera
6
Q
What describes neuropathic sources of pain?
A
-Pain is steady and can be increased by normal stimulation
-Caused by tissue pathology to the nerve itself
-Not elicited by nociceptors
7
Q
What causes neuropathic pain?
A
-Diseases, trauma, or insults to the spinal cord and brain
-Information is disrupted leading to changes in transmission
-MS and SCI are at higher risk for neuropathic pain
8
Q
What are the 4 mechanisms of referred pain?
A
-Sympathetic nervous system release neurochemicals that activate afferent nerve endings in remote areas
-Peripheral branching of nerve endings to areas separate from the original location
-Projection theory: pain nerve fibers from the organ site is received in the spinal cord from a somatic site, the brain interprets pain at two sites
-The dorsal horn receives pain responses and amplifies the pain response and activates other regions in the dorsal horns
9
Q
Where can lumbar facets refer pain to?
A
-Buttock area
-Posterior thighs
-Low back
-Groin
-Trochanter area
-Lateral thigh
10
Q
What are aggravating factors for arterial issues?
A
-Exercise or walking
-Fever
-Alcohol intake
-Bending over
11
Q
What are aggravating factors for pleural pathology?
A
-Breathing, laughing, or coughing
-Worse while lying down
12
Q
What are easing factors for pleural pathology?
A
-Rest
-Lying on the affected side
13
Q
What are aggravating factors for neoplasm related pain?
A
Pain at night due to ischemia of local tissue
14
Q
What additional information should be collected when someone complains of night pain?
A
-Awakens from a sound sleep
-Not relieved by change in position
-Accompanied by dyspnea, diaphoresis, or other symptoms
-Relieved by eating food or taking tums
-Shoulder pain that goes away when lying on painful side
-Shoulder pain that is worse when lying supine and gets worse by sitting up
-Night pain that is worse with weight bearing
15
Q
How can night pain assist in staging for MSK disease?
A
-Unable to lie on involved side= acute
-Able to lie on involved side 30-60 minutes= subacute
-Able to lie on involved side for 2 hours= chronic
16
Q
What are potential cardiovascular causes of chest pain?
A
-Myocarditis
-CAD
-Valvulopathy
-Pericarditis
-Endocarditis
-Aortic dissection
17
Q
What are potential pulmonary causes of chest pain?
A
-Bronchitis
-Costochondritis
-Pneumothorax
-Effusion
-PE
-CHF
-Pneumonia
-Mediatinitis
18
Q
What are potential GI/metabolic causes of chest pain?
A
-Esophageal spasm, obstruction, or rupture
-Cholecystitis
-GERD
-Gastritis
19
Q
What are potential musculoskeletal causes of chest pain?
A
Costochondritis
20
Q
What conditions can refer pain to the jaw?
A
Heart attack/angina
21
Q
What organs can refer pain to the L shoulder?
A
-Heart
-Lungs
-Kidneys
-Breast
-Spleen
22
Q
What organs can refer pain to the R shoulder?
A
-Heart
-Lungs
-Kidneys
-Breast
-Liver
-Gallbladder
23
Q
Where can phrenic nerve pain be referred? What are causes of phrenic nerve pain?
A
-C3,4, and 5 dermatomes
-Referred pain patterns are due to irritation of the diaphragm from the gallbladder or liver
-Neoplasms of the lung
-Pleural infections
24
Q
What are symptoms of thoracic aortic aneurysm?
A
-Dyspnea
-Dysphagia
-Cough
-Stridor
-Hoarseness
-Edema in face/neck
25
What are signs/symptoms in the LE that would require immediate referral?
-Decreased pulse in LE
-Skin breakdown and fever
-Loss of motor and sensory/trauma
-Warmth and swelling in legs with fever
26
What is the capsular pattern of the hip?
-Internal rotation
-Flexion
-Abduction
27
What are diagnoses are in the red flag screening for the LE?
-Hx of cancer
-Renal or urologic disease
-Trauma-fracture
-Gynecological conditions
-Alcoholism and avascular necrosis
-Recent femoral artery catheterization
-AIDS
-Sickle cell anemia
-Anticoagulant therapy
28
What is a special consideration for patients with AIDS?
-They are at increased risk of osteoporosis
-10X higher risk of osteonecrosis
29
What is sign of the buttock? What does it indicate?
-Pain in the buttock with SLR < 40 degrees
-Signs of fx, AVN, or cancer of the femur
30
What are other possible causes of hip pain?
-Tumor (Ewing's sarcoma)
-Osteomyelitis
-Septic arthritis
-Appendicitis
-AVN
-SCFE or Legg Calve Perthes
-Stenosis
31
What are signs/symptoms of gout?
-Sudden onset of deep, stabbing pain
-Pain worsening with weight bearing
-Pain subsides after 24 hours
-Affects small joints (big toe)
32
What are signs/symptoms of pseudogout?
-Commonly affects large joints such as the knee and hip
-Moderate joint pain and swelling
33
Where is Ewing's sarcoma most common in the LE?
Acetabulum or proximal femur which refers pain to the knee
34
What are signs/symptoms of osteosarcoma? When does it occur most often?
-Insidious pain for weeks or months
-Aggravated by activity
-Occurs during adolescent active bone growth
35
What are signs/symptoms of Ewing's sarcoma?
-Pain in the affected area that may worsen at night or during exercise
-Swelling and tenderness
-Lump that feels soft and warm
-Fever
-10-30 years of age
-Male > female
-Bone or soft tissue
-Primary bone cancer in children
36
What are causes of anterior hip/groin pain?
-FAI
-AVN
-THA with joint loosening
-SCFE
-Legg Calve Perthes
-Iliopsoas bursitis
-Muscle strain (adductor)
-Hip reactive arthritis
-Pelvic inflammatory disease
-Lumbar stenosis
-Insufficiency fx of the femoral neck
37
What are risk factors for SCFE?
-10-14 years old
-Male
-High BMI
38
What is the clinical presentation of SCFE?
-Antalgic gait
-Groin pain with knee pain
-Reduced WB
-No trauma
39
What are signs of hip reactive arthritis?
-1-4 weeks after infection
-Unable to bear weight
-Low grade fever
40
What are causes of anterolateral hip pain?
-Trochanteric bursitis
-Lateral femoral cutaneous nerve entrapment or paresthesia ("tool belt")
41
What is a "tool belt" injury? Who is at higher risk?
-Lateral femoral cutaneous nerve entrapment
-L2-L3 nerve roots
-Males 30-40 years old
-Mechanical compression from tool belt, tight garment, military armor, etc.
-Pain or paresthesia on lateral thigh
42
What are causes of posterior hip pain?
-Sciatica
-Posterior facet joint
-Bursitis
-Spondylolisthesis
-Complex regional pain syndrome
-Reiter's syndrome
-Spondyloarthropathy
-Kidney pathology
-Ischemia/intermittent claudication
-Tumor
-Osteomyelitis
43
What is Reiter's syndrome?
-Infection of joint, urethritis, and conjuctivitis
-Sexually transmitted or food borne bacterial infection
-Joint infection happens weeks later
44
What are red flag screening questions for the hip?
-Has there been any back or abdominal pain concurrent with the hip pain?
-Loss of appetite?
-Skin rash?
-Recent infection?
45
What signs/symptoms require ER visit?
-Body and skin temperature over 100.9
-Pulse > 100 or < 60
-Respirations < 12 or > 20
-Pulse oximeter below 90
-Mental change
-Suspected infection
-Severe pain (>8/10)
46
What are the 3 broad categories of GI system related pain?
-Inflammation
-Organ distension
-Necrosis
47
What is Kher's sign?
Direct pressure on the diaphragm can refer pain to the ipsilateral shoulder
48
What are some questions that can distinguish MSK from visceral?
-Nausea/vomiting
-Fever
-Eating increases discomfort
-Cancer
-Bleeding
-Weight loss
-Early satiety
-Change in bowel or bladder habits
49
What organs refer pain to the epigastric region?
-Heart
-Esophagus
-Stomach
-Spleen
-Duodenum
-Gallbladder
-Liver
-Pancreas
50
What organs refer pain to the periumbilical region?
-Pancreas
-Small intestine
-Transverse colon
51
What organs refer pain to the hypogastric region?
-Ascending and descending colon
-Bladder
-Uterus
-Appendix
52
What are signs/symptoms of esophageal spasm?
-Retrosternal chest pain accompanied by dysphagia
-Precipitated by meals
53
What are aggravating factors of acute pancreatitis?
-Eating
-Drinking
-Lying down
-Walking
54
What is the leading causal risk factors for acute pancreatitis?
-#1 is alcohol consumption
-Tobacco smoking
55
What are aggravating factors of acute cholecystitis?
-Fatty food intake
-Recent fatty meal
56
What is a biliary colic? What aggravates it?
-Sudden blockage of bile ducts
-Pain in upper right quadrant
-Can be mistaken for angina
-Occurs after fatty food or alcohol consumption
57
What are signs/symptoms of spleen pathology?
-Pain in upper L quadrant
-Kehr's sign
-Spleen is tender to palpation
-Fatigue and tiredness
-Frequent infections
-Aggravated by breathing
58
What are relieving factors for the gallbladder?
Leaning forward
59
What are relieving factors for the kidney?
Leaning to affected side
60
What are relieving factors for the pancreas?
-Sit upright
-Leaning forward
61
What is ulcerative colitis? What are signs/symptoms of it?
-Inflammation of the large intestine
-Joint arthralgia and arthritis
-Skin lesions
-Night sweats
-Rectal bleeding
-Clubbing of fingers
62
What is Crohn's Disease? What are signs/symptoms of it?
-Inflammation of any portion of the digestive tract
-Joint arthralgia and arthritis
-Skin lesions
-Night sweats
-Rectal bleeding
-Clubbing of fingers
63
What is irritable bowel syndrome? What are signs/symptoms of it?
-"Common cold of the stomach"
-Associated with loss of circadian rhythm
-Women in early adulthood
-Pain is steady or intermittent in lower left quadrant
-Symptoms come and go
-Defecation relieves pain
64
What are signs/symptoms of appendicitis?
-R lower quadrant pain
-Positive McBurney's point with several exams
-Pain comes in waves but steadily increases over 12 hours
-Low grade fever
-Vomiting
65
What are exams for appendicitis?
-Positive hop test
-Rebound tenderness at McBurney's point
-Pinch an inch
-Iliopsoas MMT painful
66
What are risk factors for psoas abscess?
-Crohn's disease
-Pelvic inflammatory disease
-Appendicits
67
What are signs/symptoms of psoas abscess?
-Fever
-Night sweats
-Tenderness
-Antalgic gait
68
What are special tests for psoas abscess?
-Positive hop test
-Rebound tenderness
-Pinch an inch
-Heel tap test
69
Where does the kidney refer pain to?
-Pain under ribs on R or L side
-Ipsilateral shoulder
70
What are signs/symptoms of kidney stones?
Intense stabbing in back, side, or groin
71
What are signs/symptoms of kidney infection?
-Dull ache
-Constant pain in kidney area
-Chills
-Fever
72
What are the 3 most common cancers in males?
-Prostate
-Lung
-Colon & rectum
73
What are the most common cancers in females?
-Breast
-Lung
-Colon & rectum
74
What are early detection techniques for prostate and breast cancer?
-Prostate screening at 50
-Breast cancer screening at 40 every two years
-Self breast exam
-Vitamin B12 and folate intake
75
What is CAUTIONS for cancer signs/symptoms?
-C: changes in bowel/bladder
-A: a sore that does not heal in 6 weeks
-U: unusual bleeding/discharge
-T: thickening/lump in breast
-I: indigestions/difficulty swallowing
-O: obvious change in wart/mole
-N: nagging cough/hoarseness
-S: supplemental signs
76
What are supplemental signs of cancer?
-Proximal weakness
-Trendelenburg
-Deep tendon reflex changes
-Bilateral carpal tunnel syndrome
77
What are the largest risk factors for cancer?
-Age: > 55
-Smoking
-Genetics
-Lack of exercise
-Alcohol
78
What cancers are most common in adults older than 65?
-Prostate
-Colon
-Ovarian
-Chronic leukemias
79
What cancers are most common in 20-40 year olds?
-Testicular cancer
-Colon cancer becoming more common in this population
80
What cancers are most common in adults older than 45?
-Breast
-Ovarian
81
What cancers are most common in children?
-Ewing's sarcoma
-Acute leukemia
-Wilm's tumor
-Retinoblastoma
82
What are the familial and genetic risk factors for cancer?
-Two or more relatives with cancer diagnosis
-Diagnosis of a family member under 50 y.o.
-Occurrence of the same type of cancer in several members of the family
-BRCA1 and BRCA2 gene mutations
-Hereditary colon cancer
83
What cancers are caused by virus/bacterial infections?
-Human papillomavirus (HPV): cervical cancer
-Hepatitis B and C: liver cancer and Hodgkin's lymphoma
-Helicobacter pylori: stomach cancer
-Epstein Barr: stomach, non-Hodgkin's lymphoma, t-cell lymphoma
-Human immunodeficiency virus: Hodgkin's lymphoma, anal, mouth, throat, and lung
84
What are risk factors for cancer recurrence?
-Inadequate surgical margins
-Tumor thrombus
-Lymph node metastasis
85
What are common signs/symptoms of cancer metastasis?
-Deep bone pain
-Decreased WB tolerance
-Personality changes or irritability
-Dyspnea
-Bilateral tarsal/carpal tunnel syndrome
86
What is carcinoma?
Malignant epithelial tissue
87
What is myeloma?
Cancer of plasma cell in bone marrow
88
What is sarcoma?
Cancer of connective tissue and supportive tissue (muscle, bone, synovial, etc.)
89
What is lymphoma?
Cancer that originates in lymph tissue
90
What is leukemia?
Cancer that originates in blood
91
What is the mode of metastasis of carcinomas?
Lymphatics
92
What is the mode of metastasis of sarcomas?
Blood or local invasion
93
What is the mode of metastasis of lymphomas?
Blood
94
What is the mode of metastasis of leukemia?
Blood
95
What are the most common sites of organ metastasis?
-Lymph nodes
-Bone (spine)
-Lung
-Brain
96
What are risk factors for breast cancer?
-Age > 60
-Obesity
-High breast tissue density
-Prolonged use of HRT
-Radiation therapy before age 30
-Black, latin, or asian
-1st degree relative
-Previous hx of cancer
-No children or 1st live birth after 36
-Higher risk with higher education levels and income
97
What are the signs/symptoms of breast cancer?
-Lump or mass in breast
-Swelling in armpit, clavicle, or hand
-Persistent skin thickening, increase in breast size, nipple abnormalities
98
What are the different types of breast cancer?
-Ductal carcinoma
-Lobular carcinoma
-Inflammatory/invasive ductal carcinoma
-Triple negative
-Invasive lobular carcinoma
-Metastatic
99
Where are the most common sites of metastasis from breast cancer?
-Bone
-Brain
-Liver
-Nerve
-Lung
100
What are risk factors for prostate cancer?
-Age > 65
-African american
-Family history
-Smoking and obsesity
101
What are signs/symptoms of prostate cancer?
-Painful or burning urination
-Feeling that bladder has not been emptied
-Urinary frequency
-Slow or weak urinary stream
-Bone and back pain (metastasis)
-Weakness or numbness in legs or feet
-Loss of bladder or bowel control
-Weight loss
102
How does prostate cancer metastasize to the spine?
-Through Baston's plexus which carries cancerous cells through the venous system to the vertebral bodies
-Can cause SC compression and will present as back pain with LE weakness and sensory loss
103
Where does prostate cancer most commonly metastasize to?
-Brain
-Bone
-Liver
-Lung
104
What are signs/symptoms of advanced prostate cancer?
-Constant back or rib pain
-Difficulty walking
-Numbness and weakness in LE
-Anemia and fatigue
105
What are the major risk factors for lung cancer?
-Smoking
-Radon gas exposure
-Second hand smoke
-Asbestos
-Occupational: painters, rubber manufacturer, paving, roofing, etc.
106
What are the signs/symptoms of lung cancer?
-Symptoms do not present until advanced stages and metastasis
-Fatigue
-Persistent cough
-Blood in sputum
-Chest pain
-Hoarse voice
-SOB
-Recurrent pneumonia
107
Why does lung cancer not show symptoms until late stages?
The lungs and visceral pleura does not have sensory receptors, but the parietal pleura does
108
What are signs/symptoms of colon cancer?
-Rectal bleeding
-Blood in stool
-Changes in bowel habits
-Abdominal cramping
-Decreased appetite or weight loss
109
Where does colon cancer most commonly metastasize to?
Lumbar and thoracic spine
110
What are the 4 types of leukemia?
-Acute lymphocytic leukemia (ALL)
-Acute myeloid leukemia (AML)
-Chronic lymphocytic leukemia (CLL)
-Chronic myeloid leukemia (CML)
111
What age groups does ALL affect? How aggressive is it?
-Children and adults
-Aggressive
112
What age groups does AML affect? How aggressive is it?
-Adults
-Aggressive
113
What age groups does CLL affect? How aggressive is it?
-Older adults
-Slow, not aggressive
114
What age groups does CML affect? How aggressive is it?
-Adults
-Slow, not aggressive
115
What are signs and symptoms of leukemia?
-Weight loss
-Bone or joint pain
-Swelling in lymph nodes or abdomen
-Bleeding or bruising easily
-Repeated infections
116
What is leukemic arthritis?
-Joint pain and significant swelling in association with peripheral blood or bone marrow leukemia
-Occurs in the acute stage
117
What are the different types of lymphomas?
-Non-Hodgkin's lymphoma
-Hodgkin's lymphoma
118
What is non-Hodgkin's lymphoma?
-Inflammatory origins
-Can occur anywhere there are T cells/lymphocytes or B cells
119
What is Hodgkin's lymphoma?
-Cancer that originates in the lymph nodes
-Incidence peaks in late adolescence or early adulthood
120
Which type of lymphoma has a worse prognosis?
Non-Hodgkin's
121
What are the most common risk factors for lymphoma?
-Infectious agents
-Environmental toxins
-Round up/glyphosate
-Insecticides
-Hair dye
122
What are the signs/symptoms of Hodgkin's lymphoma?
-Swollen lymph nodes
-Fatigue
-Chest pain
-SOB
-Rash
-Loss of appetite
-Petechiae
123
What are risk factors for pancreatic cancer?
-Smoking
-Type 2 DM
-Family history of pancreatic cancer
-Heavy alcohol consumption
-Chronic pancreatitis
124
What are signs/symptoms of pancreatic cancer?
-Symptoms do not appear until advanced disease
-Weight loss
-Abdominal discomfort
-Jaundice
-Nausea and vomiting
125
What are cancer red flags from the subjective reports?
-Atypical pain patterns
-Progressive and unremitting over several weeks or months
-Doesn't quite fit by descriptors/location
-No movement or positionally based aggravating or alleviating factors
-Worse at night
-Patient unable to be still
126
What are cancer red flags from the objective exam?
-Overall appearance: malaise, fatigue, etc.
-Cannot be mechanically reproduced
-Unexplained proximal muscular weakness
-Bilateral trendelenburg
-Functional deficits
-Difficulty with sit to stand
-Difficulty with stairs
-SOB
-Changes in DTR's
127
What is a stress/fatigue fracture?
-Tiny cracks in bone caused by repetitive force often from overuse
-Non-displaced fx
-Submaximal repetitive forces
128
What are risk factors for stress fractures?
-Female
-Older age
-Tall
-Lower aerobic fitness
-Menstrual disturbances
-Vitamin D deficiency
-Sports or activities with repetitive impact
-Impared LE biomechanics: high arches, leg length discrepancy, genu valgum
129
What is the treatment for stress fractures?
-Relative rest
-NSAIDs
-Address contributing impairments
130
What is required for a diagnosis of a stress fracture?
-Early diagnosis requires MRI as it will not be seen on X-ray
-After 2-3 weeks, it will appear on X-ray
131
What are the signs/symptoms of a stress fracture?
-Reduced WB
-Pain increases in intensity over time
-Point tenderness
-Antalgic gait
-Minimal ROM decrease
-+ tuning fork test
-Swelling
132
What are the most common sites of stress fractures?
-Tibia
-Fibula
-Navicular
-Metatarsal
133
Where are tibial stress fractures most common?
Posterior medial to lower 1/3 of tibia
134
What are the signs/symptoms of shin splints?
-Diffuse, dull aching
-Relieved with activity
-Muscle testing provokes pain
-Often bilateral
135
What test can be used for suspected femoral stress fractures?
Hang test/fulcrum test
136
What are risk factors for femoral stress fractures?
-Metabolic bone disorders
-Long term bisphosphonate use
-Osteopenia/osteoporosis
137
What are complications of stress fractures?
-Progression to fx
-AVN
-Compartment syndrome
-Chronic pain
138
What is a fragility fracture?
-A type of pathologic fracture due to compromised bone density
-Fractures with little to no trauma
139
What diseases can lead to compromised bone mineral density?
-Hyperthyroidism
-Hyperparathyroidism
-Cushing's syndrome
-Chronic renal failure
-ETOH dependence
-Ankylosing spondylitis
-GI malabsorption syndrome
140
Where are the most common locations of fragility fractures?
-Vertebral bodies
-Femur
-Wrist
-Distal radius
141
What are risk factors for fragility fractures?
-Elderly women
-Osteoporosis
-RA
-Paget disease
-Diabetes
-Bisphosphonate use
-Osteomalacia
142
Where do 50% of fragility fractures occur?
Thoracic spine
143
What are the signs/symptoms of fragility fractures?
-Decreased WB over time
-Point tenderness
-Antalgic gait
-Minimal decrease in ROM
-+ percussion or tuning fork test
144
What are risk factors for vertebral insufficiency fractures?
-Post menopausal women
-Men age > 70
-Predisposition for osteoporosis
-Hx of corticosteroid use
145
What are pathologic fractures?
Fractures that occur from bone being weakened by a disease process such as osteomyelitis, tumor, or multiple myeloma
146
What diagnostic imaging should be used for pathologic fractures?
-MRI is gold standard for cancer detection, and complex axial skeleton fx
-X-ray is better for traumatic fractures of long bones
147
What are the Ottawa knee rules?
X-ray required if any of the following are present
-Age 55 or older
-Isolated tenderness of patella
-Isolated tenderness of fibula
-Inability to flex knee to 90
-Inability to bear weight both immediately and in the ER (4 steps)
148
What are the Pittsburgh knee rules?
X-rays are required if any of the following are present
-Age < 12 or > 50
-Inability to walk 4 steps or more at the time of the visit
149
What are the Ottawa ankle rules?
-Bone tenderness at medial or lateral malleolus, navicular, base of 5th metatarsal
-Inability to weight bear both immediately and during exam
150
What are X-ray indication following a shoulder trauma?
-FOOSH for patients > 40
-Blunt trauma
-Bone deformity/instability
-Ecchymosis or swelling with weakness
-Focal bone tenderness
151
What are common monoarticular types of arthritis?
-OA
-Gout
-Septic
-Psoriatic
152
What are common polyarticular types of arthritis?
-RA
-JIA
-Psoriatic
-Lupus
-Ankylosing spondylitis
-Reactive
153
What are aggravating foods/drinks of gout?
-Purine rich foods
-Beef
-Seafood
-Alcohol
-Caffeine
-Some medications such as penicillin, insulin, and thiazide diuretics
154
What are the stages of rheumatoid arthritis?
-Synovitis
-Pannus (cartilage loss, pitted bones)
-Fibrous ankylosis
-Bony ankylosis
155
What are common signs/symptoms of systemic and autoimmune arthritis?
-Morning stiffness
-Warmth of joint
-Rotational malalignment
-Improves with movement
156
What can be used to diagnose rheumatoid arthritis?
-Blood tests: rheumatoid factor, ESR, C-reactive protein
-Radiographs
157
What is psoriatic arthritis?
-Chronic inflammatory asymmetrical arthritis with chronic skin conditions
-Appears 10 years agyer onset of psoriasis
-Characterized by thick, reddened, irritated skin, with flaky, silver-white patches and psoriatic nails
158
What are signs/symptoms of Lupus?
-Arthralgia
-Arthritis
-Skin rashes/butterfly rash
-Pulmonary involvement
-Anemia
-Kidney involvement
-Mostly in women
159
What are signs/symptoms of Sjorgen's syndrome?
-Arthralgia/arthritis
-Peripheral neuropathy
-Raynaud's phenomenon
-Fatigue
160
What are the most common causes of septic arthritis?
-Staphylococcus aureus
-Streptococcus pneumoniae
-Hemophilus influenzae
161
What is the clinical presentation of septic arthritis?
-Aysmmetrical
-2-5 joints
-Rapid onset
-Severe pain
-Redness and warmth
162
What is Reiter's syndrome?
-Reactive arthritis
-Conjunctivitis
-Nausea, vomiting, diarrhea
163
What are the 3 main categories of low back pain? What percent of cases are in each cases?
-Non-specific LBP 85-93% of cases
-LBP with radiculopathy or stenosis 4% of cases
-Back pain from another cause 3% of cases
164
What are indications for lumbar radiographs?
-Hx of trauma
-Hx of cancer
-Older adults with minimal trauma
-Failure to respond to treatment
165
What percent of LBP is non-specific LBP?
85%
166
What are some non-mechanical causes of LBP?
-Ankylosing spondylitis
-Cancer
-Vertebral fx
-Vertebral infection
-Depression
-Cauda equina
-Spina bifida
-AAA
167
What are some common signs/symptoms of ankylosing spondylitis?
-Begins as SIJ
-Unilateral, bilateral, or alternating pain
-Fatigue and malaise
-Insidious onset before age 35
-Morning stiffness > 1 hour
168
What are symptoms of AAA?
-Severe LBP
-No aggravating or relieving factors
-Pain, pallor, pulselessness below the level of AAA
-Pain may radiate to chest. between scapula, or posterior thighs
-"Tearing" or "ripping"
-Temperature change/cold distally
169
What are the phases of ankylosing spondylitis?
-Normal spine
-Inflammation and local hypermobility
-Formation of syndesmophytes
-Fusion
170
What is the diagnostic criteria of ankylosing spondylitis?
If 2/4 are + Sn 70%, Sp 81%
-AM stiffness > 30 minutes
-Improvement with exercise, not rest
-Nocturnal awakening, 2nd half of night
-Alternating buttock pain
171
What are signs/symptoms of cancer in the low back?
-Significant weight loss (10lbs within 3 months)
-Night pain
-Fever, sweats
-Fatigue
-Organ/system dependent
172
What are risk factors for vertebral osteomyelitis?
-Immunocompromised
-Hx of injection drug use
-Recent UTI
173
What are signs/symptoms of vertebral osteomyelitis?
-Progressive neurologic deficit
-Saddle anesthesia
-Urinary or fecal incontinence
-Difficulty with urination or urinary retention
174
What are psychogenic causes of LBP?
-FABQ > 15
-Clients with anxiety
-Depression
175
What are signs/symptoms of psychogenic LBP?
-Stocking and glove anesthesia
-Reflexes inconsistent with presenting problem
-Cogwheel motion of weak muscles
-SLR + PF more painful than SLR + DF
-PHQ-2 ≥ 3
176
What are risk factors for AAA?
-Male
-Age > 65
-Smoking
-Anticoagulant therapy
-Atherosclerosis
-Connective tissue disorders such as Marfan's
177
What should the aortic pulse width be?
Between 2.5-4 cm wide above the umbilicus
178
What is Stiff Person syndrome?
-Rare autoimmune disease
-Females > males
-Progressive muscle stiffness and spasms
-Triggered by light, sound, tactile stimulation, or cold
-Targets brain, spinal cord, and brainstem
179
What are signs/symptoms of Stiff Person syndrome?
-Aching discomfort in low back, hips, and legs
-Spasms predominantly in legs
-Symptoms are on and off
-Progression leads to asymmetrical presentation
-Vertigo
-Ataxia
-Dysarthria
-Confusion
-Seizures
-Autonomic dysfunction
180
What can spasms in stiff person syndrome lead to?
-Falls
-Respiratory compromise
-Abdominal spasms
-Spasms can last several minutes and can cause fx
-Rigidity
-Myoclonus
181
What is the pathophysiology of stiff person syndrome?
-Antibodies to a protein called glutamic acid decarboxylase (GAD) which creates GABA
-This leads to less GABA and inhibition in the CNS
182
What is Creutzfeld Jakobs Disease?
-Subacute spongiform encephalopathy
-Prion disease caused by misfolding of the protein/amino acids
-Diseased prions are infectious causing rapid changes
183
What is the etiology of Creutzfeld Jakobs Disease?
-Genetic
-Ingestion of infected tissue (mad-cow)
-Infected instruments from surgery
-85% of cases have unknown etiology/sporadic
184
What is the clinical presentation of Creutzfeld Jakobs Disease? What is the prognosis?
-Memory loss
-Stroke
-Vision changes
-Ataxia
-Cognitive
-Myoclonus
-70% die within one year of diagnosis
185
What are the risk factors of Creutzfeld Jakobs Disease?
Having at least one living or deceased family member with the disease
186
What is included in the differential diagnosis of Creutzfeld Jakobs Disease?
-Encephalitis
-Chronic meningitis
-Huntington's disease
-Alzheimer's disease
-Sjorgen's syndrome
187
What is normal pressure hydrocephalus? What are the signs/symptoms?
-Excessive cerebrospinal fluid builds up in the brains ventricles
-Triad of symptoms: gait problems, urinary incontinence, and rapid cognitive impairment
188
What is a seizure?
-Caused by neuronal circuit hyperextensibility
-Reduction of excitation/inhibition balance
-Loss of blood brain barrier
-Impaired astrocyte function
189
What are the different etiologies of seizures?
-Structural brain issues
-Trauma/inflammation such as CVA or TBI
-Systemic and metabolic conditions such as abnormal blood sugar, high fever
-Kidney or liver failure
-Autoimmune diseases such as SLE or Sjorgen's
-Drugs, sleep deprivation, photosensitivity, etc.
190
What are the different types of seizures?
-Focal or part seizures where people remain conscious or semi-conscious and start in one hemisphere
-Generalized that start in both hemispheres
-Epilepsy
191
What are the different types of generalized seizures?
-Absence
-Tonic-clonic
-Myoclonic
-Clonic
-Tonic
-Atonic
192
What is epilepsy? How is it diagnosed?
-More than two or more unprovoked seizures more than 24 hours apart
-Disorder of brain neurons transmitting incorrect signals
-Diagnosis: EEG, CT or MRI, or PET scan
193
What should someone do if they witness a seizure?
-Calm, cushion, call
-Cushion the persons head
-Call an ambulance if the seizure lasts more than 5 minutes, if it is their first seizure, or have trouble breathing
-Loosen tight clothing
-Turn on side
-Time seizure
-No food or drink after
-Check for seizure bracelet
194
What is meningitis?
-Inflammation of the meninges
-Viral, bacterial, or fungus etiology
-Bacteria has poorer long term outcomes including 50% infant mortality, septicemia, and peripheral emboli
-Viral meningitis has better outcomes with 7-10 day recovery
195
What are signs/symptoms of meningitis?
-High fever
-Stiff neck or nuchal rigidity
-Unable to flex c-spine
-Nausea or vomiting
-Confusion and altered mental status
-Meningococcal meningitis is more severe and presents with a rash
196
What is encephalitis?
-Inflammation in the brain tissue
-Mostly caused by viruses
-Can be caused by diseases such as diabetes, kidney or liver failure
197
What are possible etiologies of encephalopathy/itis?
-Solvents or chemicals
-Viruses
-Chronic traumatic encephalopathy (CTE)
-Mitochondrial/anoxia
-60% have unknown etiology
198
What are common viruses that cause encephalopathy?
-Herpes simplex
-Epstein Barr
-HIV
-Varicella
-Influenza A and B
-Japanese virus
199
What are the main symptoms of encepahlopathy?
-Headache
-Fever
-Seizure
-Acute disorientation
200
What disease processes cause increased risk of encephalopathy?
-Diabetes mellitus
-Alcoholism
-End stage renal disease
-SLE
-CVA
201
What is the clinical presentation of fibromyalgia?
-Widespread pain
-Fatigue
-Sleep disturbances
-Impaired cognition
-Psychological stress
-Abnormal pain processing > 3 months
-Hypersensitivity: central and peripheral sensitization
-Sensitive to light, temperature, and sound
202
What is the incidence of depression?
-Common mental health disorder
-Affects more women than men
-More than 264 million people have depression
203
How many people die of suicide each year?
-About 800,000 people
-Suicide is leading cause of death in 15-29 year olds
204
What age groups is suicide most prevalent in?
10-34
205
What is the definition of depression?
A common and serious mood disorder with persistent feelings of sadness and hopelessness and loss of interest in activities that they once enjoyed
206
What is the DSM-V diagnostic criteria for depression?
At least one of these, most days, most of the time
-Depressed mood
-Loss of interests or pleasure
-Weight loss or gain of 5%
-Insomnia or hypersomnia
-Psychomotor agitation
-Fatigue
-Low self-confidence
-Poor concentration
-Suicidal thoughts or acts
-Guilt or self blame
207
What are risk factors for depression?
-Adverse life events
-Stress
-Poor physical health
-Women
-Other psychiatric problems
-Chronic health conditions
-Pain
-Family history
-History of substance abuse
208
What are signs and symptoms of depression?
-Dsyphoria
-Disruption in personal relationships
-Sleeping disturbances
-Eating disturbances
-Psychomotor disturbances
-Feelings of worthlessness, hoplessness, helplessness, guilt, and despair
-Inability to experience pleasure
-Loss in interest in activities
209
What is the role of the PT in screening for depression?
-Required by practice act
-Negatively impacts rehab outcomes
-Avoid contributing to the inaccurate diagnosis of this disease
210
What are common screening tools for depression?
-9 item Patient Health Questionnaire (PHQ-9)
-2-item Patient Health Questionnaire (PHQ-2)
-Geriatric depression scale
211
What are the psychometrics for the PHQ-2?
Score ≥3 has a sensitivity of 83% and specificity of 93% for major depression
212
What are treatment options for depression?
-Cognitive behavioral therapy
-Antidepressant medications
-Psychotherapy
213
When is follow up with MD required for depression?
PHQ-2 scores ≥ 3
214
What is the largest risk factor for suicide?
A previous suicide attempt
215
What are other risk factors for suicide?
-Previous attempt
-Mental disorders
-Caucasian
-Male
-High income countries
-Older than 85
-Single
-Experiencing conflict or disaster
-Vulnerable groups: LGBTQ, refugees, etc.
216
What are signs that someone may attempt suicide?
-Statements such as "I don't know how much longer I can take this"
-Abrupt improvement in mood
217
What are some prevention techniques for suicide?
-Reducing the means
-Reporting by media
-School based interventions
-Alcohol policies to reduce harmful use
-Early identification of mental and substance use disorders
-Training of non-specialized health workers in assessment and recognition of suicidal behavior
-Follow up care for those who have attempted suicide
218
What is the role of the PT in suicide prevention?
-Ask if they have a plan
-Never leave the patient alone
-Call 911
219
What percent of cases of dizziness is persistent dizziness?
75%
220
What is persistent postural perceptual dizziness (PPPD)?
-Dizziness or unsteadiness most days ≥ 3 months
-No specific provocation but exacerbated by upright posture, active or passive motions, and visual stimuli
-Triggered initially by any event that causes dizziness, unsteadiness, or imbalance
-Symptoms cause significant distress and functional impairment
221
What percent of acute dizziness turns into PPPD?
25%
222
What are signs and symptoms of PPPD?
-Increased conscious attention to balance
-Visual and motion sensitivity
-Stiffening of gaze and posture
223
What are major psychosocial aspects of PPPD?
-Disrupted agency and identity
-Invalidation
-Difficulties intrepreting symptoms
-Struggle for control and coherence
-Emotional distress
-Uncertainty about the future
224
What is peripheral vestibular hypofunction?
-Sudden disruption of unilateral vestibulocochlear nerve function resulting in vertigo, nausea, imbalance, and hearing loss
-Can be caused by acute vestibular labyrinthitis
225
What impairments and activity limitations are caused by PPPD?
-Interruption in daily activities
-Avoidance of leaving the home
-Increased healthcare utilization
-Sick leave
-Anxiety and depression
-Increased falls in elderly
226
What is the best predictor of recovery for PPPD?
Beliefs about recovery
227
What is the purpose of the vestibular evaluation?
-Rule out red flags
-Establish a diagnosis
-Formulate a prognosis
-Build a rapport/therapeutic alliance
-Devise a treatment plan
228
What is the A.TT.ES.T. framework for dizziness evaluation?
-Associated symptoms
-Timing and triggers
-Exam signs
-Testing (additional, as needed)
229
What is acute vestibular syndrome (AVS)?
-Acute onset of constant dizziness associated with nausea or vomiting, gait instability, nystagmus, head-motion intolerances for days to weeks
-Highly symptomatic
-Focused examination is often diagnostic
-Vestibular neuritis is the most common cause
-Posterior circulation stroke to brainstem or cerebellum accounts for 25% of cases
230
What is a red flag symptom with AVS? What does it indicate?
-Hearing loss
-Indicates either labyrinthitis or AICA stroke
231
What are the signs and symptoms of AVS?
-Dizziness
-Nausea and vomiting
-Gait instability
-Head-motion intolerance
-Hearing loss
-Acute onset
-Sponataneous
-Constant and exacerbated by movement
232
What abnormal oculomotor test is an indicator of a central vestibular issue?
-Smooth pursuits
-Anything not smooth
233
What is saccades?
-Rapid ballistic movement of eyes to change point of fixation
-Voluntary or reflexive
234
What is skew deviation? Which direction is a red flag?
-Ocular misalignment
-Vertical: new vertical deviation is a red flag!!!
-Lateral/horizontal
235
How is nystagmus named?
-Slow phase/drift, followed by a fast phase/corrective saccade
-Named according to direction of fast phase
-Directional: upbeating, downbeating, torsional, horizontal
-Context: spontaneous, gaze evoked, optokinetic
236
What is the 3 step HI-N-TS exam?
-Head Impulse test
-Nystagmus evoked by gaze test
-Test of Skew, cross cover test
-More sensitive than early MRI for ruling out brainstem stroke
237
What are central vestibular exam signs?
-Nystagmus of central origin: vertical, direction changing, or doesn't match with VOR
-Normal VOR/negative head impulse test in the context of AVS with central nystagmus
-Vertical ocular misalignment/skew deviation
-Impaired eye movements: saccadic pursuits, weak gaze
-Different direction gaze evoked nystagmus
238
What is the HI-N-TS PLUS sequence?
-HINTS
-Hearing (finger rub)
-Targeted neuro exam (CN, cerebellar finger to nose, Hoffman)
-Gait testing
-Positional tests for BPPV
239
Is VOR a central or peripheral reflex?
Peripheral
240
When is skew deviation usually seen? What is it normally accompanied by?
-Brainstem or cerebellar stroke, MS, or trauma
-Usually accompanied by binocular vision dysfunction, torticollis, and a tilt in the subjective vertical aka ocular tilt reaction
-Occasionally seen in acute peripheral lesions, but should be considered central until proven otherwise
241
What is the triage for vestibular symptoms?
-Acute evolving vestibular symptoms with central findings: call 911
-Persistent/stable vestibular symptoms with central findings: urgent call to referring physician
-Acute onset vestibular symptoms with peripheral findings: urgent call to referring physician
-Occipital headache: emergency
242
What functional tests should be done with vestibular/dizzy patients?
-Gait speed and quality
-Balance static and dynamic
-Functional tasks
243
What is the main mediator of inflammation released by nerves afer noxious stimuli?
Substance P
244
How are C fibers different than delta fibers in the dorsal horn?
C fibers have increased polysynaptic properties through the lamina of the dorsal horn
245
What are associated factors of nociplastic pain?
-Fatigue
-Sleep disturbance
-Cognitive disturbances
-Hypersensitivity to environmental stimuli
-Anxiety and depressed mood
246
What neurophysiologic changes occur with nociplastic pain?
-Hyperactivity in brain regions involved in pain
-Changes in the synapses of pain pathways
-Elevated substance P
247
What are the 6 types of chronic pain?
-Chronic primary pain
-Chronic cancer pain
-Chronic postsurgical and posttraumatic pain
-Chronic neuropathic pain
-Chronic visceral pain
-Chronic MSK pain
248
What types of pain are chronic but NOT nociplastic?
-OA
-Peripheral neuropathy
-Radiculopathy
-Diabetes related pain
249
What are the most common diagnoses associated with nociplastic pain?
-Fibromyalgia
-Complex regional pain syndrome
-Irritable bowel syndrome
250
What are symptoms of nociplastic pain?
-Allodynia
-Sensitivity to touch, pressure, and temp
-Hyperalgesia
251
What is involved in the diagnostic process of nociplastic pain?
-The pain is chronic, regional, and there is no evidence that the pain is solely due to nociceptive or neuropathic mechanisms
-A history of hypersensitivity in the region of pain
-Presence of co-morbidities such as sleep disturbances, fatigue, cognitive problems
-Evoked pain hypersensitivity phenomena can be elicited clinically in the region of pain
252
What is peripheral sensitization?
Increased responsiveness and reduced threshold of nociceptive neurons in the periphery to the stimulation of their receptive fields
253
What is central sensitization?
-Increased responsiveness of nociceptive neurons in the central nervous system to their normal or sub-threshold afferent input
-Associated with fatigue, sleepiness, forgetfulness
254
How does peripheral sensitization develop?
-Develops through negative neuroplasticity
-Nerve receptors on nociceptors increase
255
What blocks nociceptive receptors in the periphery?
Capsaicin
256
What physiologic changes occur with central sensitization?
-Dorsal horn excitability increases
-Gate keeping function is lost
-Increased input by C and delta coupled with increased excitability
-C fibers become dominant
257
What areas of the brain are invovled in the pain response?
-Reticular formation
-Periaqueductal gray
-Spinothalamic tracts connect to limbic system, PAG, and reticular formation
-PAG sends information through the brain to the medial prefrontal cortex, hippocampus, involved in pain and stress, and to the hypothalamus
258
What are risk factors for central sensitization?
-Depression and anxiety
-Childhood event that was painful
259
What is Quantitative Sensory Testing (QST)?
An objective method of testing pain hypersensitivity, where various stimuli are applied to the skin ranging from vibration, light touch, proprioception, and temperature, using standardized testing procedures
260
What is temporal summation?
Repeated stimulation at the same intensity cause build up of pain over time, making it more painful with each stimulation
261
What is spatial summation?
Painful stimulation in one area causes other areas around it to become more sensitive
262
What sensory testing should be done with central sensitization?
-Vibration
-Light touch
-Temp
-Pressure
263
What are questionnaires for central sensitization?
-Central sensitization inventory scale
-Pain catastrophizing scale
-Brief illness perceptions questionnaire
-Fear avoidance questionnaire
264
What is the pharmacologic pain ladder from the WHO?
-Mild: nonopioid +adjuvant therapy
-Mild to Moderate: weak opioid + nonopioid + adjuvant therapy
-Moderate to Severe: Strong opioid + nonopioid + adjuvant therapy
265
What drugs can help with central sensitization?
-Opioids
-Antidepressants*
-Dorsal root local anesthetic
PHTH 539: Physical Diagnosis
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