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Sem 2 - Health Assessment > Assessment of Pain (Exam 1) > Flashcards

Assessment of Pain (Exam 1) Flashcards

1
Q

“The good physician treats the disease; the great physician treats the patient.”

A

Sir William Osler; 1900

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2
Q

Comprehensive Pain Interview explores context and meaning of pain; Addresses _____ not just _____

A

How (why); Complaint (what hurts)

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3
Q

All Pain has:

A

Cognitive, Sensory, and Emotional Influences + Behavioral Manifestations

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4
Q

Goals of Pain Interview

A

Build Trust, Gather Information, Facilitate Change

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5
Q

Why we strive for the goals for Pain Interview (previous card)

A

Understand Patient perspective; elicit pain history + diagnosis (Identify pain generator); Identify pt specific coping strategies; Identify pt functioning with pain; Identify comorbidities

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6
Q

Prior to gathering information with clinical-centered skills/questions, what should you do?

A

Use a patient-centered interview to build trust with patients.

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7
Q

Rule out Red Flags, which are

A

Bowel/Bladder Dysfunction
Saddle Anesthesia
Bilateral Leg Weakness
Severe, Sudden Onset Headache
Fever, Wt Loss, Night Sweats
Recent Injury
Hx of Cancer

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8
Q

Identify Patho-diagnostic patterns

A

Does specific activity elicit a different response than another.

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9
Q

Mnemonic to ask about pain

A

OPQRSTU
Onset - when did it start
Provocative/palliative - what makes it works
Quality/Character - what does it feel like
Region/Radiation - does it hurt anywhere else
Severity - how bad does it hurt
Timing/Treatment - how long does it hurt
U You/Impact - how does it effect daily life

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10
Q

Ask about Previous Tx + Outcomes

A

Medications (Effects, S/E, Dose, Duration of use)
Prior procedures (what type and good/bad outcomes)
Prior Sx (Indication and results)

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11
Q

Components of Psychosocial Assessment

A

Medical Comorbidities
(lung/sleep disorders, obesity, heart/liver/kidney disease)
Medication Hx
(don’t forget OTCs and Herbals!)
Psych Comorbidities
(Depr/Anx, ADHD, Subs Use, PTSD)
Coping Strategies
(Anxiety, Catastrophizing, Avoidance)
Functional Assessment
(Support Systems, Values, Function at home, work, & community)

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12
Q

What is Catastrophizing?

A

Negative Cascade of distressing thoughts and emotions about actual or anticipated pain.
(gave a scale in the notes section of ppts)

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13
Q

Why are interviews often confrontational?

A

Doubts and Frustrations by pts
Most pt will come in and expect to be “fixed”

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14
Q

Pay attention to what type of emotions when getting a pain history?

A

Atypical emotions of guilt, wishing to disengage, pity, revulsion, or other anti-social/borderline behaviors
Pay attention to the function of pts words rather than the content

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15
Q

Pts with chronic pain are often

A

Fearful, anxious, frustrated, angry, w/ poor emotion regulation

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16
Q

Why are interviews often confrontational?

A

Doubt and frustration from the patient

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17
Q

What should you do if you have a confrontation with a patient?

A

Suggest taking a break and seeking assitance from another team member

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18
Q

When should a clinician tune into their feelings and try to ascertain why they are present?

A

When a clinician has atypical emotions/inclinations (anger, wishing to disengage, etc.)

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19
Q

T/F Psychiatric conditions are associated with higher pain intensity and pain related disabilities.

A

True

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20
Q

T/F Poor sleep is associated with onset and worsening of chronic pain

A

True

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21
Q

What causes or worsens sleep-disordered breathing?

A

Opioid medications

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22
Q

What is associated with a history of substance use disorder?

A

Increased likelihood of prescription opioid misuse and abuse

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23
Q

Define countertransference

A

The reaction and feelings of a clinician toward their patient

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24
Q

What are the 8 components to a clinical exam?

A
  1. Inspection of general appearance
  2. Mental status
  3. Vital signs
  4. Posture and gait
  5. Palpation
  6. Range of motion (active/passive)
  7. Neurological examination
  8. Special tests
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25
Q

What is Trendelenburg gait?

A

The pelvis drops when lifting the leg opposite to the weak gluteus medius

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26
Q

What is steppage? (Aka: Slap-foot/Foot drop)

A

A common peroneal nerve palsy or L5 radiculopathy

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27
Q

Describe the grades for a motor exam

A

0 = No palpable contraction
1 = Palpable/observable contraction
2 = Full ROM w/ gravity eliminated
3 = Full ROM against only gravity
4 = Full ROM against resistance
5 = Normal

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28
Q

Describe the grades for reflexes

A

0 = absent
1 = diminished
2 = normal
3 = hyperactive
4 = hyperactive w/ clonus

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29
Q

T/F We should use diagnosing imaging when there are no red flag signs and we have a normal physical exam.

A

False; routine imaging reinforces sick behavior and WORSENS long-term outcomes

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30
Q

Do not image acute lower back pain ____

A

within the first six weeks UNLESS red flags are present

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31
Q

Do not image uncomplicated headaches unless ____

A

the neuro exam is abnormal, you’re unable to diagnose by history and exam, the headache is sudden/explosive, etc.

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32
Q

What specific information should you obtain to establish a specific pain patho-anatomic diagnosis?

A
  1. Acute vs. chronic vs. terminal
  2. Location
  3. Mechanism
  4. Etiology
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33
Q

How can we reduce suffering and impaired functioning and promote a sense of well-being with our patients?

A

We should seek to understand their unique history and communicate individualized treatment recommendations

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34
Q

When measuring pain intensity for patients with chronic pain, what scale is best for this?

A

Pain, Enjoyment, and General activity (PEG) is best as it is a short multidimensional assessment scale unlike the unidimensional verbal rating scale (VRS) and numeric rating scale (NRS) o

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35
Q

What screening tool do we use for patients who may have experienced PTSD?

A

The PC-PTSD screen; a positive answer indicates they may have PTSD and need further support

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36
Q

What does the STOP-BANG screening tool stand for?

A

Snoring
Tired
Observed apnea
High blood pressure

BMI
Age >50
Neck circumference >40 cm (16 in.)
Gender is male

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37
Q

How many yes’s on the STOP-BANG screening indicates presence and need to treat OSA?

A

At least 3 or more

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38
Q

A STOP-BANG score of ___ identifies patients with a high probability of moderate/severe OSA?

A

5-8

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39
Q

What do we use to assess the severity of fibromyalgia?

A

The widespread pain index (WPI) and the symptom severity (SS) score

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40
Q

What scores on the WPI and SS lead to a fibromyalgia diagnosis?

A

WPI >/= 7
SS >/= 5
(His notes also say “OR “WPI 3-6 and SS >/= 9)
WILL CLARIFY

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41
Q

What 3 conditions need to be met for preliminary diagnosis for fibromyalgia?

A
  1. WPI >/= 7 & SS >/= 5
    (His notes also say “OR “WPI 3-6 and SS >/= 9)
  2. Symptoms for at least 3 months
  3. Patient has no other disorder that would explain the pain
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42
Q

What is ORT used for? And what scores correlate to which risks?

A

Opioid risk assessment to screen patients prior to giving opioids
0-3: Low risk
4-7: moderate risk
>/= 8: high risk

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43
Q

what ORT scores represent a low risk

A

0-3

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44
Q

what ORT scores represent a high risk

A

> / 8

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45
Q

what 6 “A”s do we check to evaluate if the anesthesia plan worked on the patient

A

Activity
Analgesia
Aberrant drug related behaviour
Adverse effect
Affect
Adjuncts

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46
Q

which cervical vertebrae is the limit between upper and lower neck pain

A

C4

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47
Q

can neck pain cause arm pain

A

yes - arm pain or headache

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48
Q

is neck pain distribution myotomal or dermatomal

A

it is myotomal

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49
Q

state the meaning of this mnemonic for red flag conditions:
N SWIFT PICS

A

N - progressive neurological deficit
S - steroids
W - weightloss
I - immunosuppression
F- fever
T- trauma
P- porosis : osteoporosis
I - IV drug use
C- cancer
S- severity of pain

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50
Q

what are 2 major causes of chronic neck pain

A

facet pain
internal disc disruption

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51
Q

what 2 tests can be done to diagnose chronic neck pain

A

median branch block - facet pain
provocative discography - internal disc disruption

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52
Q

difference between radiating pain and referred pain

A

referred pain follows myotome distribution. neuro test is normal

radiating pain follows dermatome distribution. neuro test shows paresis , hyper-reflexia, hypoesthesia

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53
Q

what 4 methods are used to treat neck pain

A

exercise
CBD
radioablative frequency
surgery

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54
Q

Where can low back pain refer to?

A

To lower extremity both above and below the knee

54
Q

What areas are considered low back pain?

A

tip of the last thoracic spinous process to the tip of the sacro -coccygeal joints

55
Q

What areas are affected in Cauda Equina Injury/ Syndrome?

A

L2-Sacrum (lumbosacral nerve roots)

56
Q

What is cauda equina injury classified as?

A

Rule out red flag diagnosis

57
Q

If left untreated, what can cauda equina injury lead to

A

Paralysis

58
Q

Signs of cauda equina syndrome

A

Saddle anesthesia (usually asymmetric)
Loss of bowel and bladder function

59
Q

How do we cause cauda equina syndrome and why is it difficult to assess?

A

Epidural hematoma (difficult to assess as pt is already numb from epidural so symptoms consistent with intended effects)
*** Need ASAP imaging.
** Can also be from trauma or cancer as mentioned in class.

60
Q

Low back pain classification

A

Pain present for less than 3 months

61
Q

Prognosis and recovery with acute low back pain

A

Favorable prognosis and 80% likely for rapid recovery. Though common & severe at first, is self-limiting.

62
Q

Chronic low back pain risk factors

A

Stress (work stress mentioned)
Previous injuries
Litigation

63
Q

RED FLAG positive preferred tests

A

C-reactive protein (CRP)
Erythrocyte sedimentation rate (ESR)
Full blood count
Immuno-electrophoretogram (IEPG)
MRI
Prostate-specific antigen (PSA)

64
Q

Preferred tests for:
Fracture
Stress fracture
Infection
Pathological fracture
Tumor
Aortic Aneurysm

A

Fracture - Xray
Stress fracture - Bone scan or MRI, X-ray
Infection - Xray, MRI
Pathological fracture -
1) ESR, FBC, CRP
2) MRI, PSA
3) IEPG, serum protein electrophoresis
Tumor - ESR, CRP, MRI
Aortic Aneurysm - Ultrasound [AA pain feels like tear/ stabbing in back]

65
Q

Osteopenia [bone loss] affects who

A

should be suspected in all patients >50 yo.
** If seen in the back, suspect it is everywhere.

66
Q

When to use advanced imaging?

A

When there is suspicion for a red flag condition and not seen or not seen well on x-ray alone.

67
Q

Back pain management

A

General/ easy activity (Bed rest NOT recommended
Acupuncture (lateral inhibition)
Stretch & spray
Heat packs

NSAIDS and muscle relaxants are NOT really effective
Opioids NOT indicated
–> the risks of chronic opiois therapy outweighs the benefits

68
Q

What comprises the shoulder and pectoral girdle?

A

Scapula
Clavicle
Humerus

69
Q

What makes the gleno-humeral (between glenoid of scapula & proximal humerus) joint complicated?

A

Multi-axis movement

70
Q

What stabilizes the shoulder and pectoral girdle?

A

Rotator cuff
*** Any muscle injury to rotator cuff will compromise shoulder movement.

Ask pt to rotate shoulder and if cannot then it’s a rotator cuff injury. Know that with this, surrounding muscles are usually also injured

71
Q

Specific muscles to know in shoulder and pectoral girdle area

A

Upper Trapezius
Rhomboids
Scalene
Levator Scapulae
Sternocleidomastoid
Splenius and longus capitis
Pectoralis major

71
Q

Note these pain behaviors during physical exam:

A

Grimace
Groan
Guarding
Over reaction
Inconsistencies
Give-way weakness
Shaking

72
Q

Where/ what is shoulder pain referred FROM?

A

neck
heart
gallbladder

(e.g. cervicogenic headache, myocardial infarction or cholecystitis)

73
Q

What else can present as shoulder pain?

A

Cervical facet pain

74
Q

Shoulder exam consists of:

A

inspection, palpation, range of motion and pain on certain tests

75
Q

What’s the Apley scratch Test?

A

pain when reaching to opposite scapula

76
Q

What is Neer’s test?

A

pain with shoulder flexion

77
Q

What is Hawkin’s test?

A

Pain with internal rotation

78
Q

What’s the O’Brians’ Test?

A

Pain with rotation and abduction

79
Q

What do the Apley, Neer, Hawkin’s, Drop arm, Lift off and O’Brian tests all test for?

A

Rotator cuff injury

80
Q

What’s the Speed’s and Yerguson’s test?

A

tests with elbow flexion

81
Q

What does the Speed’s and Yerguson’s tests detect?

A

Biceps tendonitis

82
Q

Common shoulder pain impingements

A
  1. Rotator cuff impingement or tear
  2. Gleno-humeral / sub-acromial bursitis [inflammation treated with rest]
  3. Gleno-humeral instability
  4. Bicep tendonitis

Utilize MRI if rehab fails and/or weakness and loss of function progress.

Respond to intra-articular injections and
rehabilitation.

83
Q

What are shoulder conditions classified as & who treats them?

A

Musculoskeletal conditions treated by physiatrists and orthopedic surgeons

** These injuries are typically from overuse (activity) or wear & tear with age

84
Q

Shoulder Pain in elderly arise from what conditions?

A

Osteoarthritis (Mostly)
Adhesive Capsulitis (less frequently)
But pay attention to Red Flags! (could be mets, infection,etc)

85
Q

Imaging has ______ utility in shoulder pain.

A

Limited
Consider only if rehabilitation fails or increased loss of fxn.

86
Q

What is imaging of choice for shoulder pain (if indicated)?

A

MRI

Often even with asymptomatic will see rotator cuff tears, arthropathy, and structural abnormalities (not the source of pain usually).
Over imaging causes unnecessary interventions

87
Q

What is usually required to correct shoulder instabilities (rotator cuff tears)?

A

Arthroscopic Surgery

88
Q

In general, symptom management provides ______ to _____ relief.

A

Minimal to modest

89
Q

What are not particularly effective in treating shoulder pain?

A

NSAIDs and Muscle Relaxants
Opioids are often not indicated as well.

90
Q

Hip Pain increases with ____, Especially in individuals ______.

A

Age
Over 60 (up to 15% of pts in this age range)

91
Q

Mechanical Hip Pain consists of:

A

Musculoskeletal in origin; typically localized and aggravated by load (wt on the hip)
May or may not exist at rest.

92
Q

Referred Hip Pain consists of:

A

Poorly localized; may or may not increase with load
May exist even at rest

93
Q

Hip pain can be referred to/from the:

A

Lower Back, Thigh, Buttocks, or Groin

94
Q

Differentiate hip pain in 2 categories

A

Intra-articular vs. extra-articular

95
Q

What is extra-articular hip pain?

A

Pain generated from lumbar spine or knee

96
Q

Myofascial pain of what muscle causes hip pain?

A

Piriformis muscle (Piriformis syndrome or Greater Trochanter Syndrome)

97
Q

What sensation do hip pain sufferers experience? What does it feel like?

A

Snapping Hip Syndrome. Feels like they “dislocated their hip”

98
Q

What is snapping hip syndrome?

A

When the ligament passes tightly over a bony prominence and causes sharp “dislocation” pain.

Can’t actually dislocate as sacrum is immovable.

99
Q

Knee pain increases in what population?

A

women over the age of 60

100
Q

Where can knee pain refer to?

A

thigh, lower back, and leg

101
Q

What type of pain can patients experience and will it increase with mechanical loading?

A

referred pain (cramping, poorly localized) and may not increase with mechanical loading

102
Q

Knee pain accounts for _____ ER visits and _____ PCP visits annually

A
  • 1 million
  • 1.9 million
103
Q

Symptomatic knee OA by age and gender per 100:

A
  • > 60 = 12.1 (10.0 F, 13.6 M)
  • > 45 = 16.7 (18.7 F, 13.5 M)
  • > 26 = 4.9 (4.9 F, 4.6 M)
104
Q

3 compartments of the knee

A
  1. tibiofemoral
  2. patellofemoral
  3. proximal tibiofibular
105
Q

which knee compartment joint is less often the site of problems?

A

proximal tibiofibular

106
Q

What is the meniscus and what its roles?

A
  • fibrocartilagenous
  • deepens the socket that the femoral condyles roll in to
  • stability
  • cushion
107
Q

which muscle works to extend the knee and flex the hip?

A

rectus femoris (one quad muscle that crosses the knee and hip)

108
Q

which muscle works to extend the knee and flex the hip?

A

rectus femoris (one quad muscle that crosses the knee and hip)

109
Q

how do the hamstrings work?

A

extend the hip and flex the knee

110
Q

what is the main function of the gastrocnemius?

A
  • strong plantar flexor of ankle
  • also helps flex the knee
111
Q

When assessing knee pain, look for these 7 things:

A

Grimace
Groan
Guarding
Over reaction
Inconsistencies
Give-way weakness
Shaking

112
Q

How do you assess for knee pain? (3)

A
  1. palpate knee and surrounding structures (slight flexion)
  2. assess for effusion (if swollen and lacks full extension –> may need to be drained)
  3. McMurray test (nonspecific) or Thessalay test
113
Q

Define patellofemoral pain

A
  • usually from overuse
  • under 45 yo
  • more in women than men
  • not surgical
  • aggravated by squatting, climbing, sitting, running, lifting
114
Q

Define osteoarthritis

A
  • knee pain and 3/6 of the following:
    1. > 50 yo, 2. morning stiffness < 30 minutes , 3. knee crepitus, 4. bony tenderness, 5. bony enlargement, 6. no palpable warmth
  • PT and NSAIDS = first line tx
115
Q

3 types of trauma in knees:

A
  1. meniscal tears = common with OA and twist injury w/ fixed foot; “locking”, effusion, and pain w/ activity; tx = PT/rest/ice/NSAIDS
  2. bursitis = common w/ pre-patellar before infection (may need draining)
  3. ligamentous injuries =common w/ trauma, tx = brace, crutches, RICE, PT; can also see popliteal vascular tears (limb threatening from knee hyperextension)
116
Q

Ottawa Rules for imaging (knee)

A
  1. > 55 yo
  2. tenderness at head of fibula
  3. isolated tenderness of patella
  4. inability to flex knee at 90
  5. inability to walk 4 weight bearing steps
  6. plain radiography (1st step)
  7. MRI (if XR = nothing)
117
Q

knee pain treatments (5)

A
  1. exercise therapy and weight loss
  2. active PT > passive PT (OA)
  3. image guided steroid injections (can increase joint degradation)
  4. knee sx (OA/trauma)
  5. disco-supplementation, prolotherapy, acupuncture
118
Q

tx for hip pain (5)

A
  1. exercise therapy
  2. active PT (OA)
  3. image guided steroid injection (trochanteric bursitis)
  4. hip replacement (OA/trauma)
  5. disco-supplementation, prolotherapy, acupuncture
119
Q

two diseases that occur in peds (congenital hip)

A
  1. slipped capital femoral epiphysis (SCFE) = growth plate fx
  2. Legg-Clave-Perthes disease (LCP) = disruption of blood flow leading to avascular necrosis

can also have avascular necrosis (idiopathic)

120
Q

What is common in the elderly hip

A

OA

121
Q

what is a trendelenberg sign

A
  • hip drop during gait due to weakness of hip abductors
122
Q

Describe a patrick’s test

A
  • detect a hip labral injury or SI joint problem
123
Q

which test will detect a hip flexion contraction

A

Thomas test

124
Q

what does FABER stand for and what does it test

A
  • Flexion ABduction External Rotation
  • SI joint
125
Q

where is blood supply most vulnerable in the hip and what can happen:

A
  • femoral neck
  • avascular necroses (seen in etoh, corticosteroids, systemic dx like lupus/RA)
126
Q

Hip pain vs SI joint positioning

A
  • hip = want to sit down
  • SI joint = don’t want to sit down/can’t
127
Q

snapping hip syndrome

A

ligament passes over bony prominence (“dislocated” feeling)

128
Q

hip pain increases at what age

A

60 yo

129
Q

The ball and socket joint consists of what?

A
130
Q

2 types of hip pain that can be aggravated/increases by loading

A
  • mechanical
  • referred (poorly localized)
131
Q

where can hip pain refer to?

A
  • lateral aspect of proximal thigh
  • buttock
  • groin
  • low back

Sem 2 - Health Assessment (35 decks)

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