Assessment of Pain Flashcards
1
Q
Red Flag Rules
A
- Bowel/bladder dysfunction
- Saddle anesthesia (sphincter tone)
- Bilateral leg weakness (motor deficit)
- Severe sudden onset headache (ICH, stroke?)
- Fever, weight loss, night sweats (cancer)
- Recent injury
- History of cancer
2
Q
How will cancer affect your anesthesia plan?
A
think about pain medication
3
Q
OPQRSTU
A
Onset
Provocative/palliative
Quality or character
Region/radiation
Severity
Timing/treatment
U (you/impact)
4
Q
What causes interviews to be confrontational?
A
doubt and frustration
5
Q
Mindfulness
A
nonjudgmental awareness of the present moment
6
Q
Self-awareness
A
awareness of our own emotions, thoughts, and body
7
Q
Chronic pain often leads patients to feel these 5 things
A
fearful
anxious
frustrated
angry
poor ability to self-regulate their emotions
8
Q
What are the components of the clinical exam?
A
- Inspection/ general appearance
- Mental status
- Vital signs
- Posture and gait
- Palpation
- Range of motion (active and passive)
- Neurological exam
- Special Tests
9
Q
Where is neck pain located?
A
Anywhere between the base of the skull and the first thoracic process
10
Q
Where is upper and lower neck pain defined?
A
C4
11
Q
Cervicogenic headaches
A
Neck pain that causes headaches
12
Q
Red Flags- N SWIFT PICS
A
Neuro- progressive neurological deficit
Steroids (long term)
Weight loss (unexplained)
Immunosuppression
Fever (unexplained)
Trauma
Porosis (osteoporosis/osteopenia)
IVDU (IV drug use)
Cancer
Severity of pain
13
Q
What converts acute pain to chronic pain other than time?
A
PTSD, anxiety, multiple injuries
14
Q
At what point is pain considered chronic?
A
3 months
15
Q
What is considered low back pain?
A
Anywhere between the tip of the last thoracic spinous process to the tip of the sacro-coccygeal joints
16
Q
Surgical Trauma
A
When the surgeon causes pain and trauma
17
Q
What does all pain have?
A
cognitive, sensory, emotional influences and behavioral manifestations
18
Q
What does pain assessment focus on?
A
sensory, cognitive, emotional, behavioral and spiritual influences
19
Q
What is the goal of the pain assessment?
A
build trust, gather information, facilitate change
20
Q
Myopic Focus
A
only focusing on a specific set of problems present now
-ineffective when treating chronic pain
21
Q
Catastrophizing
A
negative cascade of distressing thoughts and emotions about actual or anticipated pain
22
Q
Pain Catastrophizing Scale examples
A
- I worry all the time about whether the pain will end
- It’s terrible and I think it’s never going to get any better
- It’s awful and it feels like it overwhelms me
- I become afraid the pain will get worse
- There’s nothing I can do to reduce the intensity of the pain
23
Q
What can worsen chronic pain?
A
Psychiatric conditions
poor sleep
24
Q
What can be caused or worsened by opioid medications?
A
Sleep disordered breathing
25
What increases likelihood of opioid misuse and abuse?
history of substance use disorder including tobacco
26
Countertransference
An emotional response in which the provider redirects their feelings, beliefs back onto the patient that can elicited by patients with chronic pain. It is only partially conscious, but always present
27
What is the goal of the physical exam?
to exclude red flags
28
Trendelenburg Gait
drop of pelvis when lifting opposite leg to the weak
29
Foot Drop Cause
unilateral is commonly caused by peroneal nerve palsy or L5 radiculopathy
30
Motor Grading
5=normal
4=full ROM against resistance
3=full ROM against gravity
2=Full ROM w/gravity eliminated
1=palpable/observable contraction
0=no palpable contraction
31
Myotomes
muscle group innervated by specific spinal nerve
32
DTR grading
0= absent
1= diminished
2= normal
3= hyperactive
4= hyperactive with clonus
33
Provocative findings
- straight leg raise
- Spurling's
- Tinel's
- Phalen's
34
When do you use diagnostic imaging?
red flag sign and a physical exam suggest red flag condition
35
When to image low back pain?
after the first 6 weeks unless red flags are present
36
Uncomplicated Headaches requiring imaging (red flags)
- neurologic exam abnormal
- unable to diagnose with history or exam
- sudden or explosive
- different from previous, especially over 50 y/o
-progressively worsening
-brought on by exertion
-accompanied by fever, seizure, vomiting, loss of coordination
-changes in vision, speech, alertness
-immunocompromised or known malignancy
37
First line pain intensity scale
VRS (verbal rating scale)
38
second line pain intensity scale
NRS (numeric raiting scale)
39
third line pain intensity scale
combined VRS and NRS
40
PEG Scale
Pain, enjoyment, and general activity scale that is multidimensional and can be used in the primary care setting
41
BPI scale
Brief pain inventory: multiple pain ratigns and intereference scale
42
PEG questions
1. What number describes your pain average over the last week?
2. What number describes how the pain has interfered with your enjoyment of life over the last week?
3. What number describes how pain has interfered with your general activity in the past week?
43
STOP-BANG screening
For sleep apnea
Snoring?
Tired?
Observed apnea?
P high blood pressure?
BMI >35?
Age>50?
Neck circumference>40cm (16 in)
Gender is male?
44
What score of STOP BANG has a high sensitivity for detecting OSA?
3 or more
45
What score of STOP BANG put patient of high probability of moderate/severe OSA
5-8
46
What 3 conditions are diagnostic criteria for fibromyalgia?
1) Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5 or
WPI 3 - 6 and SS scale score ≥9.
2) Symptoms have been present at a similar level for at least 3 months.
3) The patient does not have a disorder that would otherwise explain the pain.
47
Widespread Pain index
number of areas that patient has had pain over the last week
- shoulder (R/L)
-hip (R/L)
-upper arm(R/L)
-lower arm(R/L)
-upper leg(R/L)
-lower leg(R/L)
-jaw(R/L)
-chest
-abdomen
-lower back
-upper back
-neck
48
Synptom Severity (SS) score 0-12
- fatigue
-waking unrefreshed
- cognitive symptoms
- somatic symptoms
- rate each symptom separately (0-3)
-0: no problem, 1: slight, 2: moderate, 3: severe
- rate overall somatic symptoms (0-3)
49
ORT
opioid risk tool
- 0-3: low
- 4-7: moderate
- 8 or more: high
50
What domains is the ORT based on?
1) family history of substance abuse
2) personal history of substance abuse
3) Age
4) History of preadolescent sexual abuse
5) Psychological disorders
51
How to assess the effectiveness of your treatment to ANY PATIENT
4 (+2) A's
Check:
Activity: Has your activity increased following treatment?
Analgesia: Has your pain been somewhat relieved?
Aberrant behavior: Are your taking/seeking other drugs?
Adverse effects: Do you have constipation, drowsiness, low sexual desire?
Consider:
Affect: Are you sad, worried, or frustrated?
Adjunct: Are you doing other things like exercise, relaxation, and/or yoga to improve your health?
52
What bony structures are attached to the neck?
spine
scapula
Gleno-humeral joint
53
Most neck pain is what type of pain?
myofascial pain
54
Myofascial pain can be assessed by
- local tenderness
-single or multiple muscles
-trigger points
-firm or taut bands
- local twitch response
-muscle weakness
- muscle shortening
55
What red flags indicate tumor?
fever
night sweats
Hx of cancer
weight loss
56
What red flags indicate infection?
- fever
-recent surgery
- illicit drug use
- immunosuppression
- travel
-catheteritization
57
What red flags indicate fracture?
- trauma
- recent surgery
- manipulation
- corticosteroids
58
What red flags indicate aneurysm?
- CV
- cerebrovascular risk factors
59
What does pain of flexion of neck indicate?
disc injury/pain
60
What does pain of extension of neck indicate?
facet injury/pain
61
Referring pain
pain that follows myotomes and is muscular in nature...has a normal neurological exam
62
Radiating Pain
Pain that follows dermatomes and is nerve pain...has an abnormal neurological exam
63
Would you give a nerve block for radiating or referring pain?
Radiating
64
What therapy provides the best long term outcome?
exercise and cognitive behavior therapy
65
Where can back pain refer to?
the lower extremity above and below the knee
66
What bony structures are attached to the back?
spine
iliac crests
hip joint
67
Cauda Equina
Red flag...happens L2-sacrum normally by trauma
68
Cauda Equina symptoms
saddle anesthesia
loss of bowel/bladder
69
What is the common complaint with an abdominal aortic aneurysm?
"feels like my back is tearing"
"something is stabbing me in the back"
70
What is generally the first line imaging?
X-ray
71
True or False: if osteopenia is in the back, it is everywhere
True: think of it like CV disease
72
How does Acupuncture provide pain relief?
lateral inhibition
73
What should be prescribed for back pain?
gentle activity
74
What are the shoulder and pectoral girdle composed of?
scapula, clavicle, humerus
75
How are the shoulder and pectoral girdle stabilized?
rotator cuff
76
Where can shoulder pain be referred from?
neck, heart, gallbladder
77
Apprehension test
detects labral tear, direct pressure on humeral head
78
What tests are used for rotator cuff injury?
Apley
Neer
Hawkins
Drop arm
Lift off
O'Brian
all involve shoulder movement
79
What tests are used for bicep tendontitis?
Speed
Yerguson
both involve elbow flexion
80
Most common shoulder pain condition in eldery
osteoarthritis
81
Shoulder red flags
metastases
infection
systemic disease
82
What injections can be given in the shoulder?
peptides
stem cells
PRP
83
What is imaging of choice for shoulders when indicated?
MRI
84
What is hip pain hard to differentiate from?
pelvis or sacrum
85
Where can hip pain be referred from?
low back, thigh, buttocks, groin
86
Snapping Hip Syndrome
when the ligament passes tightly over a boy prominence
-helps differentiate between hip and femur
- patients will complain their hip is dislocated without the trauma
87
If a patient has hip pain will they normally be sitting or standing?
sitting
88
If a patient is having sacral pain, will they normally be sitting or standing?
standing
89
Which quadricep crosses both the hip and knee and what does this mean?
rectus femoris
- can cause hip AND knee pain
90
Avascular necrosis
when the femoral head vascular supply isn't adequate
- can cause need for early hip replacement
91
How many planes of direction does the hip have and what are they?
- Flexion and extension
-External and internal rotation
- Abduction and adduction
92
Favor Test
have patient sit and cross leg... put pressure on the knee which opens the SI joint
- if there is pain...SI joint pain
93
How to tell is pain is originating from hip
flexion movement of hip...sacrum is stable so it won't hurt with movement
94
Why are steroid injections not favorable for joint injections?
can cause avascular necrosis
95
Slipped Capital Femoral epiphysis (SCFE)
a fracture of the growth plate and is a pathology of adolescence, usually causes hip and groin pain, often can cause thigh and knee pain.
96
Legg-Clave-Perthes Disease (LCP)
a childhood hip disorder initiated by a disruption of blood flow to the femoral head causing avascular necrosis.
97
What is the biggest predisposing factor in hip osteoarthritis and who is it more commonly seen in?
age
women
98
What offer best long term results for hips?
exercise and patient activation
99
Where can knee pain refer to?
thigh, lower back, leg
100
How do you tell if knee pain is referred form another location?
it typically doesn't increase with mechanical loading
101
Symptoms for knee effusion
enlarged or lacks full flexion
102
positive moviegoe's sign
when the patient experiences their pain when sitting for a prolonged period of time with knees flexed at 90 degrees
103
What is an emergency associated with knee hyper extension?
popliteal artery tear
104
Ottawa Rules
Imaging rules for knee pain
- Age > 55
- Tenderness at the head of the fibula
- Isolated tenderness of the patella
- Inability to flex knee to 90 degrees
- Inability to walk 4 weight bearing steps
- Plain radiography is an appropriate first line
- If unrevealing MRI is useful for the detection of ongoing knee instability
105
Meniscal tear
common in osteoarthritis after twisting the knee with a fixed foot. It can lead to knee ‘locking’, effusion, and pain with loading activity.
106
Bursitis
most commonly at the pre-patellar once it becomes infected and may require aspiration.
