Exam 1 Flashcards
red flags
Signs and symptoms consistent with a non-musculoskeletal origin or serious musculoskeletal health condition that requires referral to another clinician
yellow flags
Indicate need for more extensive examination or cautions/ contraindications to certain tests/ interventions
category one red flags
factors that require immediate medical attention
REFER
category 2 red flags
factors that require subjective questioning and precautionary examination and treatment procedures
LOOK FOR CLUSTERING
category 3 red flags
factors that require further physical testing and differentiation analysis
CONSIDER ADDITIONAL CONSULTATION
intuitive method of problem solving
forward thinking
interpret findings as you go
more efficient
early dx= likely a correct one
commonly 5-7 dx hypotheses generated
analytical method of problem solving
working memory
multiple hypotheses based on data gathered
reasoning types
probabilistic
causal
case-based
narrative
Tests with low - Likelihood Ratio (-LR) are good to
refute a diagnostic hypothesis
Tests with high + Likelihood Ratio (+LR) are good to
confirm a diagnostic hypothesis
elimination strategy
seeking data to reduce suspicion of unlikely hypotheses
RULE OUT
-LR
confirmation strategy
seeking data to support a highly likely hypotheses
RULE IN
+LR
discrimination strategy
seeking information to discriminate between likely hypotheses
ockham’s razor
the simplest solution may be the best
Dx Requires:
Coherency
Adequacy
Parsimonious Nature
expert practice is distinguished by:
Academic and work experience
Utilization of colleagues
Use of reflection**
View of primary role
Pattern of delegation of care to support staff
hyperalgesia
Increased pain from a stimulus that normally provokes pain
hyperesthesia
Increased sensitivity to stimulation, excluding the special senses
sensitization
Increased responsiveness of nociceptive neurons to their normal input, and/or recruitment of a response to normally subthreshold inputs
central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input
peripheral sensitization
Increased responsiveness and reduced threshold of nociceptive neurons in the periphery to the stimulation of their receptive fields
Waddell’s signs
TENDERNESS
Superficial- the client’s skin is tender to light pinch over a wide area of lumbar skin; unable to localize to one structure.
Nonanatomic- deep tenderness felt over a wide area, not localized to one structure; crosses multiple somatic boundaries.
Waddell’s signs
SIMULATION TEST
Axial loading- light vertical loading over client’s skull in the standing position reproduces lumbar (not cervical) spine pain.
Acetabular rotation- lumbosacral pain from upper trunk rotation, back pain reported when the pelvis and shoulders are passively rotated in the same plane as the client stands, considered a positive test if pain is reported within the first 30 degrees.
Waddell’s signs
DISTRACTION TESTS
Straight-leg-raise (SLR) discrepancy- marked improvement of SLR when client is distracted compared with formal testing; different response to SLR in supine (worse) compared with sitting (better) when both tests should have the same result in the presence of organic pathology.
Double leg raise- when both legs are raised after straight leg raising, the organic response would be a greater degree of double leg raising; clients with a nonorganic component demonstrate less double leg raise compared with the single leg raise.
Waddell’s signs
OVERREACTION
Disproportionate verbalization, facial expression, muscle tension, and tremor, collapsing, or sweating.
Client may exhibit any of the following behaviors during the physical
examination: guarding, bracing, rubbing, sighing, clenching teeth, or grimacing.
Waddell’s signs
REGIONAL DISTURBANCES
Weakness- cogwheeling or giving way of many muscle groups that cannot be explained on a neurologic basis.
Sensory disturbance- diminished sensation fitting a “stocking” rather than a dermatomal pattern.
5 pain sources
cutaneous
somatic
visceral
neuropathic
referred
CAGE questionnaire
C: Have you ever thought you should cut down on your drinking?
A: Have you ever been annoyed by criticism of your drinking?
G: Have you ever felt guilty about your drinking?
E: Do you ever have an eye-opener (a drink or two) in the morning?
strategies for refinement
Insight/ awareness
Metacognition
Consider alternatives
Simulation
Decrease reliance on memory
Cognitive forcing strategies
Minimize time pressures
Accountability
Feedback
no fault errors
most people would not have gotten it correct
tough situation
system errors
technical failures (poor reading or visualization or glitch in technology)
organizational failures (PT overbooked, overstressed)
cognitive errors
what we can address and refine
aggregate bias
predisposition to thinking population is special compared to others for that general presentation
anchoring
make a decision too early without thinking through the rest of the results
commission and omission biases
commission– force something in (if I don’t do anything, the patient will get worse)
omission– stay away (I better not do anything or I will make the patient worse)
confirmation bias
if you develop a hypothesis during a differential, you will pay attention to everything that supports the dx and ignore the rest
seeks to confirm suspicion
outcome bias
predisposed to a certain condition because you know there is a better prognosis // tendency to think pt will have a better outcome
(tight pec minor as opposed to cervical rib for thoracic outlet syndrome)
overconfidence bias
extraordinary belief in yourself
premature closure
do not finish eliminating or just confirm one thing
common in new clinicians
search satisfying
as soon as you find something consistent with one dx, you zone into that and not consider other possibilities
emotional based practice
emotionally attached to a procedure or dx that you do not use contrary procedures
base-rate neglect
ignores how common or uncommon something is
playing the odds
leaning towards the more common things because they are more likely
faulty causation
putting too many links in a chain
trying to assign a cause and effect relationship where there might not be one
ascertainment bias
stereotyping populations or demographics
(older people and OA)
availability bias
not considering clinical patterns and jumping to something at the top of your mind
representativeness restraint
script is almost there, may be too broad// overrepresentation
3 key CV risk factors:
hypertension, high cholesterol, smoking
Palpitations
Presence of irregular heartbeat
Common descriptors: bump, pound, jump, flop, flutter, racing sensation of the heart
Palpations lasting for hours with pain, shortness of breath, fainting or severe lightheadedness require medical evaluation
Medical referral if observed with a family Hx of unexplained sudden death
Dyspnea
Breathlessness or SOB
Could also be secondary to pulmonary pathology, fever, certain meds, allergies, poor physical conditioning, obesity
Severity corresponds with severity of disease progression
Medical referral if patient:
Cannot climb a single flight of stairs without feeling moderately to severely winded
Reports waking at night or observes SOB when lying down (either obesity or more serious concern)
Cardiac Syncope
fainting due to reduced O2 delivery to brain
Observed with arrhythmias, orthostatic hypotension, poor ventricular function, coronary artery disease, vertebral artery insufficiency
Syncope without warning of lightheadedness, dizziness, or nausea requires referral
Fatigue
If provoked by minimal exertion, may have a cardiac origin
Associated SxS common: dyspnea, chest pain, palpitations, headache
Monitor closely if fatigue exceeds normal expectations during or after exercise
Cough
Possible cause: Left ventricular dysfunction from mitral valve dysfunction when aggravated by exercise, metabolic stress, supine position, or paroxysmal nocturnal dyspnea
Hacking cough with significant frothy, bloody sputum
Cyanosis
Bluish discoloration of lips and nailbeds due to inadequate blood-oxygen levels
Edema
> /= 3 lb. weight gain or gradual, continuous gain over several days with swelling in ankles, abdomen and hands is a red flag for HF
Even more so with presence of SOB, fatigue and dizziness
Possible associated SxS: jugular vein distension & cyanosis
Claudication
leg pain that occurs with PVD
Pitting edema & leg pain commonly accompany with vascular disease
Immediate MD consult if abrupt onset of ischemic rest pain or sudden worsening of intermittent claudication requires immediate referral
side effects of statins
Unexplained fever, nausea, vomiting
s/sx of liver impairment
Dark urine
Asterixis (liver flap)
Bilateral carpal tunnel syndrome
Palmar erythema (liver palms)
Spider angioma
Changes in nail beds, skin color
Ascites
MSK commonly mimics
Angina
MI
Pericarditis
Dissecting aortic aneurysm
atherosclerosis
hardening of arteries
thrombus
when a clot forms on plaque that is built up on artery walls
spasm
sudden constriction of coronary artery
symptoms of coronary artery disease are commonly not observed until the artery ____
artery narrows by 75%
angina
acute pain in the chest
imbalance between cardiac workload and O2 supply to heart muscle tissue
Chronic stable angina
Occurs at a predictable level of physical or emotional stress
Responds quickly to rest or nitroglycerin
No pain at rest & location/ duration/ intensity/ frequency of chest pain consistent over time
Unstable angina
Abrupt change in the intensity & frequency of symptoms or decreased threshold of stimulus
Most common trigger: bursting of a cholesterol-filled plaque in lining of coronary artery
Clot forms & partially blocks blood flow
Duration > the usual 1 to 5 minutes (may last for up to 20-30 minutes)
Pain or discomfort unrelieved by rest or nitroglycerin = risk for MI
Immediate MD assessment necessary
resting angina
Chest pain that occurs at rest in the supine position
nocturnal angina
Can wake a person from sleep with the same sensation experienced during exertion
atypical angina
Abnormal SxS with physical or emotional exertion (toothache or earache)
Subsides with rest or nitroglycerin
angina s/sx
Gripping, vise-like feeling of pain or pressure behind the sternum
Pain that may radiate to the neck, jaw, back, shoulder, or arms (most often the left arm in men)
Toothache
Burning indigestion
Dyspnea; exercise intolerance
Nausea
Belching
heartburn s/sx
Frequent use of antacids to relieve symptoms
Heartburn wakes the client up at night
Acidic or bitter taste in the mouth
Burning sensation in the chest
Discomfort after eating spicy foods
Abdominal bloating and gas
Dysphagia
signs of cardiac arrest
Sudden loss of responsiveness (no response to gentle shaking)
No normal breathing (patient doesn’t take a normal breath when observed for several seconds)
No signs of circulation
No movement or coughing
myocardial infarction S/sx
Prolonged or severe substernal chest pain or squeezing pressure
Pain radiating down one or both arms and/or up to the throat, neck, back, jaw, shoulders, or arms
Nausea or indigestion
Angina >/= 30 min
Angina unrelieved by rest, nitroglycerin, or antacids
Pain of infarct unrelieved by rest or position change
Nausea
Sudden dimness or loss of vision or speech
Pallor
Diaphoresis
SOB
Weakness, numbness, and feelings of faintness
pericarditis
inflammation of the pericardium
if fluid accumulates in the pericardial sac, it may prevent the heart from expanding
pericarditis s/sx
Substernal pain
Dysphagia
Pain relieved by:
Leaning forward or sitting upright
Holding the breath
Pain aggravated by:
Movement associated with deep breathing
Trunk movements
Lying down
Fever, chills, weakness
Cough
Lower extremity edema
right ventricular failure s/sx
Increased fatigue
Dependent edema (usually beginning in the ankles)
Pitting edema
Edema in the sacral area or the back of the thighs
Right upper quadrant pain
Cyanosis of nail beds
left ventricular failure s/sx
Fatigue and dyspnea after mild physical exertion or exercise
Persistent spasmodic cough, especially when lying down, when fluid moves from the extremities to the lungs
Paroxysmal nocturnal dyspnea
Orthopnea
Tachycardia
Fatigue and muscle weakness
Edema and weight gain
Irritability/restlessness
Decreased renal function or frequent urination at night
diastolic heart failure s/sx
Fatigue and dyspnea after mild physical exertion or exercise
Orthopnea
Edema and weight gain
Jugular vein distention
risk factors of aneurysm
Hx smoking
Known congenital heart disease
Sx to repair/ replace aortic valve before age of 70 years
Recent infection
Atherosclerosis
Predisposing genetic conditions
Active older adults
ruptured aneurysm s/sx
Sudden, severe chest pain with a tearing sensation
Pain may extend to the neck, shoulders, between the scapulae, low back, or abdomen
Pain is not relieved by a change in position
Pain may be described as “tearing” or “ripping”
Pulsating abdominal mass
Other signs: cold, pulseless lower extremities, BP changes (more than 10 mm Hg difference in diastolic BP between arms; systolic BP less than 100 mm Hg)
Pulse rate more than 100 bpm
Ecchymoses in the flank and perianal area
Light-headedness and nausea
