1C Flashcards
components of PT exam (7)
- review ALL MED HX
- Pt interview/history
- chief complaints
- functional limits
- review relevant med hx
- review systems
- physical exam (vitals, anthropometric measures, UQ/LQ/thoracic scanning, systems review)
what does a physical exam compose of?
vitals
anthropometric measures
Scanning exams (UQ/LQ/thoracic)
systems review!
During patient history, what are you listening for in regards to patient’s symptoms?
SINSS
Severity is….
intensity of symptoms related to functional activity
(high symptoms=low function)
What is irritability?
(how easy/hard to tick off=what activity and time?)
What is Nature of Complaint?
what could it be? Anything that you need to be cautious of during exam…and how does it present based on psych/personality/ethnicity/SES)
Describes acute, subacute, or chronic stages
stage of pathology
time frame for acute, subacute, chronic
acute: 3-7 days
subacute: over 7
chronic: over 3 months
progression of patient’s symptoms over time…is it getting better, worse, or same?
stability
What are RED FLAGS to be cautious of?
- Trauma
- Age over 50
- Cancer
- fever, chills, sweats
- unexplained weight change
- recent infection
- immunosuppression
- rest/night pain
- saddle anesthesia
- bowel/bladder dysfunction
- LE neuro deficits
Why are you worried about unexplained weight loss or fever/chills?
infection or cancer
Why are you worried about night pain?
cancer
infection
AAA
three red flags associated with cauda equina
saddle anesthesia
B&B dysfunction
LE neuro deficits
What is a patient centered interview model?
Exploring pt’s disease/diagnosis & its effect on their life
Understanding the whole person
Finding common ground regarding intervention &/or management
Advocating prevention & health promotion
Enhancing pt-provider relationship
Providing realistic expectations
If someone comes in with cervical and shoulder (shoulder girdle, L/R) pain….what 3 systems should I check first?
- CV
- Pulm
- GI
If someone comes in with thoracic spine/back pain…what 4 systems should i check?
1.CV
2.Pulm
3. GI
4. Genitourinary (T-L junction)
If someone has lumbar-pelvic pain…what 3 systems should I check first?
- GI
- Urogenital
- peripheral vascular
If someone has mid-humerus to hand or femur to foot pain, what system should I check first?
peripheral vascular
What systems have inconsistent symptom patterns?
Psychologic
Endrocrine
Neurologic
Rheumatic disorders
Adverse drug reactions
Referred pain can be mechanical or nonmechanical (T/F)
TRUE
(dermatomal symptoms due to back)
Most common MSK pain that PTs treat
- LBP
- shoulder
- knee
What does MSK pain sound like?
pain fluctuates in 24 hour time period (time frame increases in patients with neuro stuff like CVA, MS, TBI)
AND
motion makes pain change, varies consistently!
NON MSK pain sounds like
inconsistent locations of pain
no obvious MOI
vague, dull ache not located near normal MSK structures
does not fluctuate/change with positions or movement
pain during/after eating or urinating
If its throbbing, pounding, pulsating….could be
vascular disorder
If its sharp, shocking, burning, lancinating….could be
neurologic disorder
If it is aching, squeezing, burning, cramping, gnawing…could be
visceral disorder
If they have LBP, what else could it be?
- tumor
- infection
- cauda equina
- spinal fx
- abdominal aneurysm
LBP that is constant, not changing with position/mvmt
worse at night…DIFF DX is
(age over 50, also weight loss)
TUMOR
LBP, deep constant that is worse with WB
-fever, swelling
-spine rigidity
(pt is IV drug user or immunosuppressed)
DIFF DX is
osteomyelitis (or infection)
Pt has hx of spinal stenosis or DDD.
LBP with weak LEs…what are you worried about
cauda equina
other symptoms:
-urinary retention/B&B
-saddle anesthesia
-LE weakness
-sensory deficits
-ankle DF, toe ex, ankle PF weakness (L4, L5, S1)
What are risk factors for spinal fx?
- over 70
- history of trauma/overuse for osteoporotic pts
- steroid use long term
Patient comes in with LBP, very tender to palpation. Hurts to stand/WB. There is edema.
HX OF TRAUMA.
What is diff dx?
spinal fx
Exquisitely tender w/ palpation over fx site
↑’d pain w/ WB
Edema in local area
Someone comes in with back pain (or ab/groin). They have PVD/CAD and risk factors like over 50, smoker, HTN, DM
pain does not change with movement. What should you be worried about/check?
AAA
ascultate for bruit
Patient is over 50, has pain in pelvis that is tender to touch in abdomen. may have ascites. unexplained weight loss, bowel issues….
diff dx is
COLON CANCER
Patient is woman over 70 with hip/thigh pain.
In constant pain, hurts more when moving it. Walking with leg in ER.
MOI: fall…
Diff dx is
pathologic fx in femoral NECK
AVN patient looks like…
osteonecrosis of femoral head
-long term steroid use (has SLE, asthma, RA)
-has had osteonecrosis in opp hip before
-trauma hx
Patient has gradual onset of pain in hip and medial knee, worse with WB.
Hip is stiff and restricted in IR and flexion. DIFF DX is
AVN
-gradual
-groin, thigh, medial knee referred pain
-stiff hip restrict: IR, flex
Patient is 5-8 yr old boy LIMPING with groin pain.
Pain hurts more with hip abduction/IR. Diff Dx is…
Legg-Calve-Perthes
(head of femur loses blood supply)
-young boy
-antalgic gait
-hurts with hip abd, IR
Patient is overweight adolescent that fell on bike…pain in groin, hurts to put weight on it. Leg is held in ER, can’t IR.
Diff dx is…
SCFE (epiphysis/head slips off femoral neck)
-groin ache, worse with WB
-leg in ER
-ROM limits in IR
What are knee/leg/ankle/ft red flags conditions to be aware of?
- peripheral arterial occlusive disease
- DVT
- compartment syndrome
- septic arthritis
- cellulitis
Risk factors for peripheral arterial occlusive disease
- over 60
- Hx of DM, heart disease
- smoking
- sedentary
- intermitt. claudication
Pt is 60 year old, diabetic smoker: comes in with pain in leg. Leg is cool to touch with decreased pulses. Prolonged vascular filling time.
What are you worried about
peripheral arterial occlusive disease
-unilat cool extremity or bilateral if its aorta
-capillary refil time over 2 seconds
-decreased arterial pulses
-long vascular filling time
-Ankle brachial index below 0.9
Patient has calf pain, edema, tenderness. Warm to touch.
Hurts more to stand/WB, better with rest/elevation
Leg is pale, no pulse.
DIFF DX
DVT
-edema, tender, warm
-worse with WB, better w rest
-pale, loss of dorsalis pedis pulse
recent sx, cancer, immob, trauma, pregnancy
Leg pain that is severe, worse with stretching.
Edema, tender, tension/hardness
Leg is also weak, numb, and pale. No pulse.
DIFF DX
compartment syndrome!
Severe, persistent leg pain that is intensified w/ stretch applied to involved muscles
Swelling, exquisite tenderness & palpable tension/hardness of involved compartment
Paresthesia, paresis, pallor, pulselessness
Hx: trauma, crush injury, new exercise
Patient has constant throbbing pain, joint swelling, warmth in knee/ankle. They have had a recent infection/Sx/injection.
Diff dx is…
septic arthritis!
*joint pain/swelling
*fever
*immunosuppressed or recent infection
patient has pain in leg
swelling, warmth, reddish streaks.
They also have fever, malaise, weakness.
What could it be?
cellulitis!
Hx of recent skin ulceration or abrasion, venous insufficiency, CHF or cirrhosis
Pain, skin swelling, warmth, advancing irregular margin of erythema/reddish streaks
Fever, chills, malaise & weakness
If patient has chest pain, pale, sweating, can’t breathe well, nauseous, palpitations
-not relieved by nitroglycerin, longer than 30 min symptoms
DIFF DX IS
MI
Risk factors for MI
-Presence of risk factors: previous hx of CAD, HTN, smoking, DM, elevated blood serum cholesterol (>240 mg/dL)
Men >40 yr
women >50 yr
unstable angina pectoris looks like
Chest pain that occurs outside of predictable pattern
Not responsive to nitroglycerin
(Hx of CAD)
stable angina pectoris looks like
Chest pain/pressure that occurs w/ predictable levels of exertion
responds w/ rest or sublingual nitroglycerin
(common in 65+, esp men. Hx of CAD)
If someone has hx of MI, renal failure, open heart surgery, radiation
autoimmune disease like RA/SLE….
what could their chest pain be caused by?
pericarditis
Often associated w/ autoimmune disease (SLE, RA)
Hx of myocardial infarction
Hx of renal failure, open heart surgery or radiation therapy
Patient has sharp/stabbing pain in shoulder and/or neck
sidelying on left side increases pain
sitting and leaning forward decreases pain
DIFF DX
pericarditis
Sharp/stabbing chest pain that may be referred to lateral neck or either shoulder
↑’d pain w/ L sidelying
Relieved w/ forward leaning while sitting (supporting arms on knees or a table)
Patient has chest/shoulder/upper ab pain.
1. abnormal, fast breathing
2. heart rate over 100 bpm
DIFF DX
PE
risk factors: DVT, immob, cancer, trauma
Patient has severe, knife pain with inhaling. Abnormal breathing, decreased chest wall excursion.
Hx of infection/respiratory disorder (pneumonia, TB, tumor)
DIFF DX
Pleurisy/pleuritis
Patient has chest pain, worse with inhaling.
difficulty expanding ribs
decreased breath sounds
hyperresonance percussion
DIFF DX
pneumothorax
hx: coughing, strenous exercise/trauma
Patient has chest and shoulder pain
fever, chills, headache, malaise, nausea.
What could it be….
pneumonia
(hx of bacterial, viral, fungal, infection)
-pleuritic pain referring to shoulder too
Patient is middle age woman.
Pain in R upper ab with R scapula pain
Worse with eating fatty foods.
Pain is not worse/better with activity/rest.
DIFF DX
cholecystitis (gall bladder!)
*WBC count elevated
*common in middle age women
colicky pain
R upper ab quad with R scap pain!
Dull or gnawing pain or burning sensation in epigastrium, mid-back or above clavicle
Symptoms relieved w/ food****
Hx of infection (H. pylori)
Hx of multiple stressors, poor coping skills, persistent anxiety & depression
peptic ulcer
Patient is tender to touch in Right abdomen, and they are having poop problems (bleeding, vomiting, tarry colored stool, coffee ground emesis)
peptic ulcer!
Patient has positive murphy’s sign (tender over costovertebral angle)
fever, chills, headache, flank pain
DIFF DX
pyelonephritis! UTI/KIDNEY INFECTION
Patient has UTI symptoms with SUDDEN, SEVERE BACK PAIN
chills, fever, nausea, vomiting
renal colic
DIFF DX
nephrolithiasis (kidney stones!)
*hot climates, past episode of stones
Patient presents with tenderness in mid back, bruising, LE neuro deficits like sensory and weakness.
increased thoracic kyphosis
DIFF DX
spinal fx!
esp if Hx of fall of MVA
Hx of osteoporosis
Long-term steroid use
Age >70 yrs
Loss of function or mobility
most common thoracic fx levels
T11-L1
What are red flag conditions to look out for with head/face/TMJ pain?
- meningitis
- tumor
- subarachnoid hemorrhage
Patient presents with flu like symptoms.
Then, head/face pain.
+ slump test
headache, fever, nausea/vomiting
photophobia, confusion, sleepy, seizures
DIFF DX
meningitis!
*STIFF NECK, FEVER, confusion, vomiting, seizures, light sensitivity, headache
Patient presents with:
headache
altered mental status
speech deficits
ataxia
visual changes, seizures, GI issues, sensory issues
BRAIN TUMOR
(age 20-64 yrs old)
Patient suddenly has severe headache. Then, brief LOC.
fever, photophobia, nausea, vomiting, stiff neck (like meningitis)
brain tumor signs like nausea, vomit, neuro dysfunction
DIFF DX
subarachnoid hemorrhage!
If someone has pain in neck and shoulder, what are red flag conditions?
MI
cervical ligament instability
cervical/shoulder peripheral nerve entrapment
pancoast’s tumor
Patient hx:
-trauma (major)
-RA or AS
-uses birth control
presents with:
dizziness, nystagmus, vertigo with neck movement
+clonus
+babinksi
Cervical liagamentous instabilities w/ possible cord compromise
If patient has neck/shoulder pain and muscles are tender to touch, muscles/sensory distribution follows specific nerve pattern
-patient reports paresthesias (numb/ting) and PAIN AT REST with possible retrograde distribution
Cervical & shoulder girdle peripheral entrapment neuropathies
what are ways to injury spinal accessory nerve?
Hx of penetrating injury, such as stab or gunshot
Direct blow or stretching of nerve during a fall or MVA
Surgical hx of radical neck dissection for tumor or cervical lymph node biopsy
Hx of blow from a hockey stick or lacrosse stick
what are ways to injure axillary nerve?
Pts >40 yrs w/ shoulder dislocation
Hx of traction force or blunt trauma to shoulder
Hx of brachial neuritis or quadrilateral space syndrome
What are ways to injure long thoracic nerve?
Identified in players of many sports, including tennis, volleyball, archery, golf, gymnastics, bowling, weight lifting, soccer, hockey & rifle shooting
Patient has suprascapular nerve injury. What could it be due to?
-Hx of fx of scapula w/ involvement of the notch & blade of scapula
-Traction injury mechanism
-Direct compression of suprascapular nerve at level of scapular notch or at spinoglenoid notch bc of a ganglion cyst or hypertrophied transverse scapular or spinoglenoid ligament
Patient is male, over 50, smoker.
Pain in shoulder and vertebral scapular border. Nagging, burning pain down arm into 4th/5th digits
DIFF DX
Pancoast’s tumor (superior sulcus lung tumor)
Patient has weakness in abduction and ER
-atrophy of supra and infra, just like a rotator cuff tear.
-pain is deep, vague
what is the issue?
suprascapular nerve
Patient has scapular winging
weakness in 45 degree scaption/flexion, protraction
-loss of scap/hum rhythm
SALT!
long thoracic
Patient has drooping shoulder, can’t shrug. Lack of scap stabilization
weak abduction…
spinal accessory nerve
patient has: weakness of shoulder abduction & flexion
Lack of sensation of lateral aspect of upper arm
axillary nerve
Patient has pain, tenderness, swelling, bruising on arm. What are you suspecting
FX
data: Recent fall or trauma
Hx of osteoporosis
Extended use of steroids (i.e. respiratory problem)
Pathologies w/ improper bone remodeling
Patient is holding elbow at 70 degree flexion, slightly supinated.
antero-lat pain and tender at elbow.
unable to supinate or pronate.
WHAT DO THEY HAVE
radial head fx
MOI: FOOSH with supinated forearm. DIFF DX
radial head fx
MOI: FOOSH with forceful wrist extension
woman over 40
hx of osteoporosis
colles fx (distal radius fx)
Patient is holding wrist in neutral, swellling in wrist, and extending wrist is painful
Distal radius (Colles’) fx
MOI: FOOSH
Wrist swelling
Wrist held in neutral position
Pain in ‘anatomic snuff box’
scaphoid fx
MOI: FOOSH or diffuse synovitis
Generalized wrist swelling & pain
↓’d motion
↓’d grip strength (r/o capitate fx)
Lunate fx or dislocation
MOI: fall! FOOSH, forearm pronated.
Ulnar-sided wrist pain
Tenderness & clicking w/ wrist movement (passive ulnar deviation)
Weakness w/ grip strength
Dorsal ulnar head subluxation
TFCC tear
Traumatic fall after slipping or tripping on outstretched hand w/ forearm pronated
*Commonly associated w/ Colles’ fx
Recent puncture of skin
Recent insect bite
Presence of an abscess
Purulent tenosynovitis of tendons that go through a space
what are you worried about
Space infection of the hand
Patient comes in with hand pain.
inflammation: swelling in palm, dorsum of hand or fingertips
Pain, tenderness, warmth, erythema
Signs of long-standing infection: high fever, chills, weakness, malaise
What are you worried about?
Space infection of the hand
PAIN IN HAND>
local tenderness, swelling, muscle spasms, hematoma, pain w/ motion & w/ passive stretch of hand.
Patient has history of RA, steroids, respiratory issues, or trauma
grade 1 or 2 muscle tear of long flexor tendons
HAND PAIN: total loss of motion & palpable defect in muscle, swelling, tenderness, ecchymosis of overlying skin
Long flexor tendon rupture grade III
Hands or feet that blanch, go cyanotic & then turn red when exposed to cold or emotional stress
Pain & tingling in hands & feet when they turn red
PMH significant for RA, occlusive vascular disease, smoking or use of beta blockers
Raynaud’s phenomenon or Raynaud’s disease
Trauma including fx, dislocation or surgery
Pain does not respond to typical analgesics
Severe aching, stinging, cutting or boring pain that is not typical of injury
Hypersensitivity
Area swollen (pitting edema), warm & erythematous
Complex regional pain syndrome (formerly reflex sympathetic dystrophy)
