Deck 13 Flashcards

1
Q

68M presents to PT with c/o R shoulder/scapular pain and B hand tingling in digits 1-3. Currently managing pain with use of Acetaminophen without improvement. Shoulder pain does not vary with positioning or movement of his neck or arms which has made you as the therapist suspicious of a non-MSK origin of symptoms. Upon performing a thorough medical screen, the pt reveals his stool is light colored, almost white, and is having moderate abdominal pain. When taking a BP recording, you notice irregular flex/ext movements of the pt’s wrist. When asking the pt to actively hyperextend the wrist and hand with the arms in front, irregular flex/ext movements of the wrist and fingers also occur.

At this point, what sinister pathology is a likely dx and source of shoulder pain?

A. Pancreatitis
B. Hepatobiliary disease
C. Gastric ulcer
D. NSAID induced gastropathy

A

B. Hepatobiliary disease

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2
Q

68M presents to PT with c/o R shoulder/scapular pain and B hand tingling in digits 1-3. Currently managing pain with use of Acetaminophen without improvement. Shoulder pain does not vary with positioning or movement of his neck or arms which has made you as the therapist suspicious of a non-MSK origin of symptoms. Upon performing a thorough medical screen, the pt reveals his stool is light colored, almost white, and is having moderate abdominal pain. When taking a BP recording, you notice irregular flex/ext movements of the pt’s wrist. When asking the pt to actively hyperextend the wrist and hand with the arms in front, irregular flex/ext movements of the wrist and fingers also occur.

What observable sign is c/w irregular flex/ext movements of the wrist and fingers as described above?

A. Dysdiadochokinesia
B. Asterixis
C. Ataxia
D. Involuntary tremor

A

B. Asterixis

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3
Q

What is the most sensitive hx and/or physical exam data for ruling out cauda equina syndrome in a pt who presents with sudden, severe onset of LBP?

A. Urinary retention
B. Fecal incontinence
C. Saddle anesthesia
D. Sensory or motor deficits in the feet (L4, L5, S1 areas)

A

A. Urinary retention

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4
Q

55M presents via direct access 5 days s/p fall in shallow water while fishing. States he fell out of his boat and hit the R side of his head resulting in L lateral flex and axial compression. Denies any LOC, HA, vertigo, dizziness, paresthesias, dysarthria, dysphagia, or nausea. Pt states he was able to shake it off and return to sailing the following day. Pt reports persistent 3-7/10 pain on the NPRS in mid-lower cervical region. Reports mild reduction in cervical ROM compared to normal.

Based on the above info, your next action should be:

A. Proceed with full exam of his cervical spine
B. Measure cervical rotation ROM and then make decisions on need for imaging
C. Perform a sharp-purser exam to assess for upper cervical instability
D. Referral out for cervical spine imaging

A

D. Referral out for cervical spine imaging

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5
Q

25M professional ice hockey player presents for eval of acute groin pain that began 3 days ago during NHL competition. No hx of groin or abdominal injury prior to this incident. Pt describes MOI while he was turning L, skating in the 3rd period when an opposing player pushed him in the back His trunk extended, hip abducted and extended and he felt immediate pain in the groin region and was unable to continue playing the remainder of the game.

Today, pt experience lower abdominal/groin pain with most ADLs such as supine to sit txfr, walking, STS, coughing. Trunk ROM limited by pain. Also having sharp pain with PROM hip ext and resisted hip flex/hip add. Resisted double hip adduction painful and unchanged with pelvic stabilization belt.

What dx most clearly matches this pt presentation?

A. Sports hernia
B. Pubic symphysis instability
C. Adductor strain
D. Inguinal hernia

A

A. Sports hernia

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6
Q

25M professional ice hockey player presents for eval of acute groin pain that began 3 days ago during NHL competition. No hx of groin or abdominal injury prior to this incident. Pt describes MOI while he was turning L, skating in the 3rd period when an opposing player pushed him in the back His trunk extended, hip abducted and extended and he felt immediate pain in the groin region and was unable to continue playing the remainder of the game.

Today, pt experience lower abdominal/groin pain with most ADLs such as supine to sit txfr, walking, STS, coughing. Trunk ROM limited by pain. Also having sharp pain with PROM hip ext and resisted hip flex/hip add. Resisted double hip adduction painful and unchanged with pelvic stabilization belt.

The above pt underwent laparoscopic hernia repair for his abdominal/groin pain and reported approximately 90% improvement in pain. Returns to clinic several months later for eval of his ongoing chronic groin pain, which is sensitive to palpation at the pubic tubercle and just lateral to this. PE reveals pain exclusively with resisted hip flex and resisted hip adduction when hip positioned to 90˚flex.

What dx most clearly matches this pt’s current presentation?

A. Psoas tendinopathy
B. RA tendinopathy
C. Pectineus tendinopathy
D. Adductor longus tendinopathy

A

C. Pectineus tendinopathy

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7
Q

65F presents to clinic with c/o medial elbow and hand pain. Your top ddx include ulnar neuropathy and C8-T1 radiculopathies. Which of the following muscles are likely to be weak in a pt with C8-T1 radic but intact in a pt with ulnar neuropathy at the elbow?

A. Medial lumbricals
B. Opponens pollicis
C. Dorsal interossei
D. Opponens digiti minimi

A

B. Opponens pollicis

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8
Q

42 yo obese woman presents to PT with severe acute LBP and RLE pain/numbness extending into the foot. During a quick functional screen, pt was able to heel walk, but struggled to maintain PF on the R side when asked to walk on her toes. Lumbar flexion increases both LBP and leg pain, extension increases both LBP and leg pain. When performing a side glide, the L side glides increase LBP/leg pain while R side glides reduce leg pain.

Based off the info above, you determine she meets the symptom modulation subgrouping of the TBC proposed by Alrwaily et al.

What tx subgrouping is best used to help guide treatment initially?

A. Manipulation
B. Specific exercise
C. Traction
D. Active rest

A

B. Specific exercise

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9
Q

42 yo obese woman presents to PT with severe acute LBP and RLE pain/numbness extending into the foot. During a quick functional screen, pt was able to heel walk, but struggled to maintain PF on the R side when asked to walk on her toes. Lumbar flexion increases both LBP and leg pain, extension increases both LBP and leg pain. When performing a side glide, the L side glides increase LBP/leg pain while R side glides reduce leg pain.

Based off the info above, you determine she meets the symptom modulation subgrouping of the TBC proposed by Alrwaily et al.

When performing sensory testing as a component of her neuro screen, where would you anticipate to find her “numbness” during sensory testing?

A. Medial malleolus
B. Web space between toes 1 and 2
C. Lateral border of 5th metatarsal
D. Posterior knee

A

C. Lateral border of 5th metatarsal

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10
Q

What 2 clinical findings would lead you to consider use of mechanical traction for a pt presenting with acute LBP and s/s of nerve root compression

A. Absence of a directional preference and (+) xSLR
B. Peripheralize with ext and leg pain more severe than LBP
C. Sx reduction with manual traction and leg pain > back pain
D. Peripheralization with extension and (+) xSLR

A

D. Peripheralization with extension and (+) xSLR

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11
Q

Light colored (almost white) stools indicate an inability of the liver or biliary system to excrete

A

bilirubin

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12
Q

Liver dysfunction results in increased

A

serum ammonia

urea

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13
Q

Nerve function can be impaired with liver dysfunction and is a potential cause of B ___

A

CTS

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14
Q

Any pt with sx of B CTS should be screened for

A

liver impairment

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15
Q

Asterixis aka

A

liver flap

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16
Q

What is asterixis?

A

pt extends arms, spreads finger, extends the wrist

abnormal flapping tremor at the wrist

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17
Q

In addition to testing for asterixis, may also be observed when?

A

when releasing the pressure in the arm cuff during BP readings

18
Q

Pectineus tendinopathy presents with greatest pain provocation during what resisted movements?

A

hip flex and hip adduction with the hip positioned in 90˚ flexion

19
Q

Opponens pollicis is innervated by what nerve?

A

recurrent thenar branch of the median nerve

20
Q

58M Uber driver with c/o chronic neck pain “for the better part of 2 decades.” Recently reports new onset of intense, constant, R sided scapular pain with burning/paresthesias into RUE. Reports turning his head to the R while merging in traffic leads to inc neck discomfort as well as more pronounced tingling into arm and hand. Additionally, he is unable to reach into the back seat while in the driver seat without reproduction of sx. 4/10 pain at best, 8/10 at worst. Sx worse in the morning and improve as the day goes on. Currently waking multiple times per night d/t difficulty finding a comfortable position. States forceful cough or sneeze “makes my arm feel like it’s going to explode.”

Cervical ROM: ext 20˚ inc arm pain | flex 4 finger widths, inc arm/scapular pain | LR 70˚ local neck pain | RR 50˚ inc neck pain down arm and into thumb

Neuro screen: reduced sensation over radial forearm, 1st/2nd digit
weak wrist extension/elbow flexion, all others WNL
DTR 1+ Biceps brachii, 1+ brachioradialis, 2+ triceps

Special tests:
Compression: inc sx | distraction reduces arm pain | (+) Spurling | (+) ULTTA
Jt mobility: inc burning sensation into involved UE with central and unilateral PA testing R C5-7

Based off the above info, what mechanism based pain classification is most responsible for the generation and/or maintenance of his sx?

A. Neuroplastic pain
B. Primary nociceptive pain
C. Central sensitization
D. Peripheral neuropathic pain

A

D. Peripheral neuropathic pain

21
Q

58M Uber driver with c/o chronic neck pain “for the better part of 2 decades.” Recently reports new onset of intense, constant, R sided scapular pain with burning/paresthesias into RUE. Reports turning his head to the R while merging in traffic leads to inc neck discomfort as well as more pronounced tingling into arm and hand. Additionally, he is unable to reach into the back seat while in the driver seat without reproduction of sx. 4/10 pain at best, 8/10 at worst. Sx worse in the morning and improve as the day goes on. Currently waking multiple times per night d/t difficulty finding a comfortable position. States forceful cough or sneeze “makes my arm feel like it’s going to explode.”

Cervical ROM: ext 20˚ inc arm pain | flex 4 finger widths, inc arm/scapular pain | LR 70˚ local neck pain | RR 50˚ inc neck pain down arm and into thumb

Neuro screen: reduced sensation over radial forearm, 1st/2nd digit
weak wrist extension/elbow flexion, all others WNL
DTR 1+ Biceps brachii, 1+ brachioradialis, 2+ triceps

Special tests:
Compression: inc sx | distraction reduces arm pain | (+) Spurling | (+) ULTTA
Jt mobility: inc burning sensation into involved UE with central and unilateral PA testing R C5-7

Based on the above info, what dx is most likely?

A. C6 radiculopathy
B. C8 radiculopathy
C. Thoracic outlet syndrome
D. Cervical discogenic referred pain

A

A. C6 radiculopathy

22
Q

58M Uber driver with c/o chronic neck pain “for the better part of 2 decades.” Recently reports new onset of intense, constant, R sided scapular pain with burning/paresthesias into RUE. Reports turning his head to the R while merging in traffic leads to inc neck discomfort as well as more pronounced tingling into arm and hand. Additionally, he is unable to reach into the back seat while in the driver seat without reproduction of sx. 4/10 pain at best, 8/10 at worst. Sx worse in the morning and improve as the day goes on. Currently waking multiple times per night d/t difficulty finding a comfortable position. States forceful cough or sneeze “makes my arm feel like it’s going to explode.”

Cervical ROM: ext 20˚ inc arm pain | flex 4 finger widths, inc arm/scapular pain | LR 70˚ local neck pain | RR 50˚ inc neck pain down arm and into thumb

Neuro screen: reduced sensation over radial forearm, 1st/2nd digit
weak wrist extension/elbow flexion, all others WNL
DTR 1+ Biceps brachii, 1+ brachioradialis, 2+ triceps

Special tests:
Compression: inc sx | distraction reduces arm pain | (+) Spurling | (+) ULTTA
Jt mobility: inc burning sensation into involved UE with central and unilateral PA testing R C5-7

What initial intervention has the most potential for success in managing this pt’s condition?

A. Mechanical cervical traction
B. Neurodynamic exercises
C. Thoracic and cervical manipulation
D. Repeated cervical spine dorsal glides/retractions

A

A. Mechanical cervical traction

23
Q

44F presents with 5 yr hx of intermittent paresthesias and pain in her RUE. Recalls onset beginning while studying for finals during grad school years ago. Describes as weakness, numbness, and pain located in “my whole arm” from the brachial area to dorsal forearm, wrist, and hand. Over the past 5 yrs, symptoms have waxed and waned depending on UE use. Recently started a new job requiring extensive typing at her desk and has noticed considerable inc in pain, weakness, and numbness associated with stress, typing, and mousing. Sx improve with rest but can take up to 20 mins to calm down when severe. No reproduction with cough or sneeze.

Based off the subjective exam alone, what hypothesis is most consistent with these findings?

A. C8-T1 radiculopathy
B. Parsonage turner syndrome
C. TOS
D. T4 syndrome

A

C. TOS

24
Q

44F presents with 5 yr hx of intermittent paresthesias and pain in her RUE. Recalls onset beginning while studying for finals during grad school years ago. Describes as weakness, numbness, and pain located in “my whole arm” from the brachial area to dorsal forearm, wrist, and hand. Over the past 5 yrs, symptoms have waxed and waned depending on UE use. Recently started a new job requiring extensive typing at her desk and has noticed considerable inc in pain, weakness, and numbness associated with stress, typing, and mousing. Sx improve with rest but can take up to 20 mins to calm down when severe. No reproduction with cough or sneeze.

Which is NOT a typical location of entrapment for TOS?

A. Interscalene triangle
B. Costoclavicular space
C. Thoracocoacopectoral space
D. Spiral groove of the humerus

A

D. Spiral groove of the humerus

25
Q

44F presents with 5 yr hx of intermittent paresthesias and pain in her RUE. Recalls onset beginning while studying for finals during grad school years ago. Describes as weakness, numbness, and pain located in “my whole arm” from the brachial area to dorsal forearm, wrist, and hand. Over the past 5 yrs, symptoms have waxed and waned depending on UE use. Recently started a new job requiring extensive typing at her desk and has noticed considerable inc in pain, weakness, and numbness associated with stress, typing, and mousing. Sx improve with rest but can take up to 20 mins to calm down when severe. No reproduction with cough or sneeze.

Which TOS special test is designed to examine neural tissue compromise through the thoracocoracopectoral gate?

A. Adson’s
B. Supraclavicular pressure test
C. Costoclavicular maneuver
D. Wright test

A

D. Wright test

26
Q

20 yo colegiate gymnast with c/o R anterolateral thigh burning, tingling, and numbness. Sx aggravated with prolonged standing, walking, and gymnastic routines on uneven bars. Upon further exam you clear lumbar spine and find no motor weakness of LEs. What is your leading hypothesis at this time?

A. ITBS
B. Meralgia paresthetica
C. Obturator nerve entrapment
D. Femoral nerve entrapment

A

B. Meralgia paresthetica

27
Q

48F downhill skier had a fall on the slopes resulting in hyperextension and radial deviation of thumb against her ski pole handle. UCL stress testing reveals pain and mild laxity over thumb joint. Plain films and MRI revealed GII sprain and absence of a stener lesion.

What is the correct POC going forward?

A. 2-4 weeks in thumb spica cast followed by progressive strengthening
B. 4-6 weeks in thumb spica cast with tip pinch grip strengthening
C. Surgical intervention for UCL repair
D. Optional spica cast with tip pinch grip strengthening 1st 4 weeks

A

A. 2-4 weeks in thumb spica cast followed by progressive strengthening

28
Q

Seeing a pt 2 weeks s/p R shoulder dislocation. Experienced traumatic dislocation while playing football when throwing a pass and was tackled, forcing the shoulder into excessive abd/ER in a 90/90 position. Shoulder reduced in hospital 2 hrs later by ED physician. Pt continues to have diffuse shoulder pain, weakness, lateral shoulder numbness, and sensations of instability with various movements.

Observation: FHP, deltoid atrophy
AROM: 70˚ flex | 60˚ abd | ER 60˚ with pain
Strength: 2/5 flex | 2/5 R | 3/5 ER painful | 4/5 IR painful
Sensation: sharp/dull and light touch dec in lateral shoulder
Palpation: ttp throughout RTC musculature
Special tests: (+) Sulcus | (+) Apprehension | (+) relocation

What complication of his shoulder dislocation explains the above PE findings?

A. Suprascapular nerve injury
B. Dorsal scapular nerve injury
C. Axillary nerve injury
D. Brachial plexus traction injury

A

C. Axillary nerve injury

29
Q

A therapist hypothesizes an elevated 1st rib may be contributing to a pt’s distal UE complaints and wants to perform a special test to support the hypothesis. With the pt seated, examiner passively rotates the head away from the affected side and gently flexes the neck to end range moving the ear toward the chest. Pt has equal motion with normal endfeel when performing test bilaterally. What can we conclude at this point?

A. r/o presence of elevated first rib d/t highly sensitive test
B. rule in presence of elevated first rib as this is a specific test
C. Nothing can be concluded as the sensitivity of this test is poor
D. Nothing can be concluded as the specificity of this test is poor

A

A. r/o presence of elevated first rib d/t highly sensitive test

30
Q

Peripheral neuropathic pain refers to pain attributable to a lesion or dysfunction where?

A
  • peripheral nerve
  • DRG
  • dorsal root
31
Q

Peripheral neuropathic pain refers to pain attributable to a lesion or dysfunction in a peripheral nerve, DRG, or dorsal root arising from

A
  • trauma
  • compression
  • inflammation
  • ischemia
32
Q

variables that indicate a pt may respond to cervical traction

A
age > 55
(+) abduction test
(+) ULTTA
sx peripheralization with lower cervical PA testing
(+) distraction test
33
Q

Thoracocoracopectoral space aka

A

retropectoralis minor space

34
Q

Common sites of brachial plexus entrapment in pts with TOS?

A
  • retropectoralis minor space
  • interscalene triangle
  • costoclavicular space
35
Q

These tests for TOS specifically address compromise to the plexus through the scalene triangle?

A
  • supraclavicular pressure test

- Adson’s test

36
Q

The costoclavicular maneuver evaluates provocation produced by

A

costoclavicular space narrowing

37
Q

These tests appear to display the greatest sensitivity for neurogenic and vascular TOS

A
  • Wright’s test

- elevated arm stress test

38
Q

Grade II UCL sprains are recommended to be placed in a thumb spica splint x how long?

A

2-4 weeks

39
Q

Grade II UCL sprains are recommended to be placed in a thumb spica splint x 2-4 weeks with the IP joint…

A

free

40
Q

Grade II UCL sprains are recommended to be placed in a thumb spica splint x 2-4 weeks with the IP joint free, followed by progressive strengthening while avoiding tip pinch grip x __ weeks

A

8

41
Q

The cervical rotation lateral flexion test is highly (sensitive/specific)

A

sensitive (1.0)