Exam 1 Flashcards
What is diagnosis most often based on?
cluster of clinical findings
What is the heuristic process based on?
clinical experience of clinician
What does heuristic process use to make a diagnosis?
clusters of s/s
What may the heuristic process not pick up on or ignore?
rare serious medical disorders
What is grouped and tested with heuristic process?
most probable hypothesis
Can ruled based diagnosis use pattern recognition only?
no
What do algorithms screen for?
non-systemic vs systemic disease
What disorders or diseases are investigated in hypothetic deductive process?
most and least probable
What reasoning process is fastest and which is slower?
hypothetic deductive process is fastest; heuristic process is slower
What does hypothetic deductive reasoning search for?
pathognomonic (hallmark) sign of disease/disorder
When does naturalistic or event driven reasoning occur?
when clinical decision is made without a reliable or valid diagnosis
What does the clinician do during naturalistic or event driven process?
switches decision making from eval of diagnostic possibilities to an eval of possible courses of action or therapeutic trials
Which model do experienced clinicians use?
heuristic
Which model do less experienced clinicians use?
hypothetic deductive approach
How much of the information is acquired from the interview? How much comes from the physical exam?
70-80%; 10%
What is the diagnostic hypothesis based on?
PMH, RF, & s/s
What is the diagnostic hypothesis confirmed /c?
physical exam, lab, & imaging tests
What is the purpose of ROS?
ID health probs that have been overlooked during the pt chief presenting hx
What is ROS used in conjunction /c?
detailed medical/surgical hx
What does ROS screen for?
- medical conditions yet to be diagnosed: responsible/not responsible for symptoms;
- existing clinically stable/unstable medical conditions
What does hypothetic deductive model rule out?
rare serious medical conditions
What is the most important part of the clinical eval?
the interview process
What are systemic syptoms?
involve multiple systems;
- hematologic (SCD)
- endocrine (hyperthyroid)
- immune (HIV)
- metabolic (paget’s)
- malignances /c metastasis
- adverse drug reaction
- neurological (GBS)
- CV (CHF)
- GU: renal failure
- Hepatic: cirrohsis
What are non-systemic systems?
<2 systems;
- GI (appendicitis)
- GU (kidney stones)
- Hepatic (abcess)
- biliary (gall bladder dis)
- CV (MI)
- pulmonary (bronchitis)
- non-mech MSK (bone infection, bone cancer)
Systemic reviews include what?
psych, endocrine, hematological, neurological, immune or metabolic, and adverse drug reaction
If a pt has consistent symptoms assoc /c local pn, ache or soreness; what is review based on?
hepatic & biliary, GI, GU, CV, pulmonary
What are constitutional symptoms?
fatigue, fever/chills, loss of weight 5-10% unexplained, nausea/vomitting, insomnia/irritability, syncope, general paresthesia/numbness/weakness, dyspnea, change in mental/cognitive abilities, bowel dysfunction, urination freq changes, and sexual dysfunction
If there is pn on C-spine, where is the ROS focused?
GI &GU
CV
pulmonary
If there is pn on T-spine, where is the ROS focused?
CV
GI
GU (T-L junction)
If there is pn on lumbar and SI joint, where is the ROS focused?
GI
GU
Perivascular
If there is pn on UE and LE, where is the ROS focused?
perivascular
What two things are less crucial for immediate management?
risk factor and PMH
WHat is important to confirm MS diagnosis?
pain/symptom behavior
What two things are important when choosing b/t medical referral and medical emeregency?
vital signs and current systemic/visceral s/s
What diseases may cause death or permanent loss if not managed quickly?
MI, cauda equina syndrome, SC compression
When referring for emergency, what is more important than RF and medical hx of disease?
present s/s of disease
When is medical hx useful when referring to emergency?
when pt has cluster of s/s matching medical hx; same goes for when risk factors matching s/s
What is considered abnormal vitals?
- cardiac or respiratory arrest/distress
- overdose and RR < 6
- HTN >160/100
- pale /c SBP at 70
- weak/dizzy, HR <30
- pt in distress
- tachycardia /c hypovolemia (Shock index >.9, HR divided by SBP; normal .5-.8)
When do you refer out without PT intervention?
- symptoms that cant be reproduced /c MS procedures
- not getting better in 4 weeks
- symptoms at any jt AND suspicion of systemic condition
- symptoms on spine, shoulders, or hips concomitant /c NON systemic visceral probs
When can PT intervene and refer?
- jt pn and suspicion of metabolic bone disease or inflam arthritis WITH constitutional symptoms
- pt /c MS probs and additional dis/disorder that are NOT causing symptoms
What is the fitzpatrick scale?
numerical classification used for human skin color
What is type 1 skin?
always burns, never tans
What is type 2 skin?
usually burns, tans minimally
What is type 3 skin?
sometimes mild burns, tans uniformly
What is type 4 skin?
burns minimally, always tans well (light brown)
What is type 5 skin?
very rarely burns, tans easily (brown)
What is type 6 skin?
never burns, always tans
What races are most to least likely to acquire malignant melanoma?
Whites, hispanics, american indian/alaska native, asian, black
What is the most common skin cancer in the USA?
basal cell carcinoma
What is basal cell carcinoma?
slow growing surface epithelial tumor
Where does basal cell carcinoma originate?
undifferentiated basal cells in epidermis
Does basal cell carcinoma invade the blood or lymph vessels?
no; but causes local destruction
What are the most common causes of basal cell carcinoma?
prolonged and intermittent sun exposure
Is basal cell carcinoma malignant or benign?
benign
Explain the appearance of basal cell carcinoma
pearly or ivory, rolled edges, slightly elevated, small blood vessels on surface
If left untreated, what could basal cell carcinoma result in?
destruction of local tissues (bone or cartilage)
What is the second most common form of skin cancer in whites?
squamous cell carcinoma; may be in suti (confined) or invasive (infiltrates)
Where do most squamous cell carcinomas occur?
head and neck region; 80%
How can squamous cell carcinoma present?
flat red area, as an ulcer, cutaneous horn, indurated plaque, or nodule
What is the most dangerous form of skin cancer?
malignant melanoma
Which type of melanoma is the most common type?
superficial spreading melanoma; accounts for 75% of cutaneous melanomas
How does superficial spreading melanoma present?
brown or black, raised patch, irregular border, and variable pigmentation
Is it true that malignant melanoma is incurable?
No; 100% curable if detected early
Would it be accurate to say that malignant melanoma is associated more with duration of sunlight exposure?
no; more associated with intensity of sunlight exposure
What does ABCDE stand for?
A- asymetry B- border C- color D- diameter E- evolution/elevation
Regarding asymetry, what type is suspicious?
unequal or asymmetric
When is the border of skin lesion thought to be more cancerous?
if its irregular or indistinct
When is color suspicious?
when there is more than one
At what diameter is a skin lesion suspicious?
> 6 mm
Regarding elevation and evolution when should it become suspicious?
if the mole is elevated or raised; and if the progress is quick
What are the major features (3) for referral of skin screens?
change in size
change in color
change in shape
What are the minor features (4) for refferal of skin screens?
7 mm or more in any direction, inflammation, oozing, or bleeding
If the pt scores 3 or more points on the 7 point screening scale when should he/she see a dermatologist?
within 2 weeks
If the pt scores 1 or 2 points how long can he/she wait to see a dermatologist?
3 or 4 weeks
What are the stipulations for immediate referral of skin lesions?
any of the major and minor PLUS;
- abnormal vitals
- constitutional symptoms
- signs of metastases (lungs, brain, bone, lymph nodes, liver)
What are screening tools for psych and behavioral disorders?
- depression, anxiety, stress scales
- geriatric depression scale
- somatoform screening tool
- personality disorders screening tools
- Domestic violence scale
- FAB questionnaire
- Work APGAR
What gender is depression most common in?
females; 2:1
What are symptoms of depression?
- inability to feel pleasure (anhedonia)
- low self esteem/guilt/worry
- sleep probs
- appetite
- weight changes
- hopelessness
- suicidality
- fatigue
- cognitive impairments
- psychomotor retardation
What are the top 3 disorders assoc. /c depression?
- stroke
- MI
- PD
If depressive consequences are not treated, do you think PT intervention will be as effective?
no, outcome will be worse
What is the best treatment for depression?
medication combined /c therapy
What gender is more likely to suffer from anxiety?
females; 2x more likely
What are the physical signs of anxiety?
high BP, increased HR, increased sweating, tremors
What is fear and panic more associated /c?
anxiety
What are the types of anxiety disorders?
- PTSD
- phobias (simple and social)
- OCD
- panic disorder
- medically induced
- substance induced
What are symptoms of anxiety?
fear, sleep probs, uncontrollable thoughts, intrusive thoughts, flashbacks, avoidant behavior, ritualistic/compulsive behavior, mood changes
What is the most common treatment for anxiety?
benzodiazepines
What does DASS screen for?
depression, anxiety, stress
If a pt scores > 7 in any of the DASS sub-scales, what must be done?
pt must be referred out
What are somatoform disorders?
pt expresses emotional problems through physical symptoms; no mechanical s/s noted
Patients with somatoform disorders will typically do what?
call in sick, “whine”, try to make PT feel incompetent
What are the six types of somatoform disorders?
- somatization
- undifferentiated hypochondriac
- somatoform pain disorder
- body dysmorphic disorder (amputee)
- conversion disorder (rare)
What are somatic pain disorders?
pt worries about pain constantly, this may delay appropriate care to psych disorders
What is a dysmorphic disorder?
preoccupied /c a body part due to specific reason (burnt, scar, amputation, bone deformity)
When screening for somatoform disorders, how many positive findings on the questionnaire result in referral to a psychologist?
3 or 4
How many personality disorders are there?
12
Personality disorder grouping
- eccentric (no chronic pn or exaggeration of symptoms)
- Dramatic (symptoms exaggerated)
- anxious (excuses, “persistant pain”)
- self defeating (dont keep appointments, DC)
What gender attempts suicide more?
females; 3x more
What gender completes suicide more?
males; 4x more
What are s/s of skin disease?
- pruritis (itching)
- urticaria (hives)
- rash
- blisters (vesicle or bulla)
- xeroderma (excessive dry skin)
What should you inspect for during a skin exam?
color, texture, turgor (elasticity), moisture, lesions, hair distribution, and warmth
What could pallor mean when examining the skin?
iron def. anemia
Yellow skin coloring could mean what?
jaundice, carotenemia, or hemolysis
Red skin coloring could mean what?
erythroderma
What is assoc. /c acute rheumatologic disease?
lupus erythematosus
What is assoc. /c chronic rheumatologic disease?
discoid lesions
What is systemic sclerosis?
diffuse CT disease that causes fibrosis of skin, jts, blood vessels, and internal organs
What is the first manifestation of systemic sclerosis?
raynaud phenomenon
What is the common areas pt /c lyme disease will present /c pain?
knee or shoulder most common
What does herpes zoster (shingles) mimic?
radiculopathy in t spine
Iron deficiency anemia is caused by what?
- blood loss (only RBC’s)
- increased iron demand
Anemia caused by inflammatory response is caused by what?
- chronic infection/disease
- cancer
- RA
- Lupus
Aplastic anemia results in what?
low RBC, WBC, and platelet count
What are typical symptoms of aplastic anemia?
fatigue and bruising
What causes renal insufficiency?
not having enough erythropoieten
What causes megaloblastic anemia?
lack of B12 or folate
What are s/s of mild/slow anemia?
fatigue, SOB, palpitations
What are s/s of severe/rapid anemia?
- Hgb < 7.5 gm/dL
- at rest: SOB, palpitations, faint upon rising, pale (conjunctivae, mucous membranes, and nail beds), chest pn
What is anemia based on?
blood tests (RBC shape/size, CBC, WBC, PT, PTT)
Findings for megaloblastic anemia?
- GI (smooth, red tender tongue; diarrhea)
- B12 (numbness in extremeties, unsteady gait, motor weakness, decreased vibration/position sense, dimentia)
What is the first sign /c aplastic anemia?
- bleeding is often first sign
What are the 2 classifications of hemolytic anemia?
sickle cell anemia and thalassemias
What causes hemolytic anemia?
increased rate of RBD destruction
What causes sickle cell anemia?
synthesis of structurally abnormal hemoglobin
What causes thalassemia?
decreased synthesis of structurally normal hemoglobin
Which form of sickle cell anemia is “best”?
heterozygous form; 60% of Hgb is normal
Which form of sickle cell anemia will result in an enlarged spleen and why?
homozygotes; due to excessive recycling of RBC and WBC
What are symptoms of mild/minor thalassemia (heterozygotes)?
mild anemia or asymptomatic
What are symptoms of major or beta (homozygotes) thalassemia?
- mod-severe fatigue & weakness
- short life span
What is normal Hgb count in men? Women?
13-17 mg/dL; 12-16 mg/dL
What is polycythemia the result of?
increased Hgb and HCT count
What is primary polycythemia?
disorder of bone marrow causing excessive proliferation of RBC; viscosity increases
What is secondary polycythemia caused by?
increased erythropoietin
What are physical findings for polycythemia?
large spleen, fulness and redness of face, high BP
What is nadir? What is the pt at risk for?
lowest point white blood count reaches; at risk for acquiring infection
Name some symptoms of platelet disorders.
multiple petechia (skin or gums), severe bruising, jt swelling, and hematomas
What are the two types of hemophilia?
hereditary and acquired
What would the clinical presentation of platelet disorders look like?
bleeding in superficial sites (skin, mucous membranes, gums, menstrual, GI)
Describe the clinical presentation of clotting factor deficiencies
deep tissue bleeding (bleeding into mm, jt, and body cavities)
For hemophilia to be diagnosed, what is considered to be normal and abnormal?
PT will be normal; PTT will be abnormal
When hemophilia and MS problems are present, what is going to be the most common finding?
hemarthrosis
Which tissue is the second most common site for bleeding /c hemophilia and MS problems?
muscle; capsular pattern will be present
With mild hemophilia, what will the pt present with?
fatigue and jt bleeding
With severe hemophilia, what will the pt present like?
vital signs will be affected
What are CARDINAL symptoms of cardiac disease?
- chest, neck, arm pn/discomfort
- palpitations
- dyspnea
- paroxysmal nocturnal dyspnea
- syncope
- fatigue
- cough
- cyanosis
What are most common symptoms of CV conditions?
edema and leg pain
Where are symptoms of angina presented in women? Men?
women: more central
men: neck & arm
What is angina in females associated with?
microvascular disease
What is angina in males associated /c?
CAD
What are the 3 types of angina?
stable (classic/effort), unstable (crescendo), and variant (prinzmetal)
What is angina described as?
pressure, squeezing, or tightness in chest
What may occur /c angina?
SOB, weakness, light-headedness, and sweating
What is the most notable symptom of MI?
sudden sensation of pressure (crushing)
Where could MI pain radiate?
arms, throat, neck, and back
What symptoms accompany MI?
pain (30 min - hours), pallor, SOB, profuse sweating
What is orthopnea?
breathlessness during recumbency
How is orthopnea relieved?
sitting upright
What causes cardiac syncope?
reduced oxygen to brain
What causes vasovagal syncope?
strong parasympathetic response leading to vasodilation
What are statins used for?
lowering cholesterol in pt /c CAD
What is the most common myotoxic event assoc. /c statins?
myalgia
What is rhabdomyolysis?
assoc. /c impaired renal and liver function
What are side effects of statins?
- myalgia
- mm aches/pn
- unexplained fever
- nausea
- vomiting and dark urine
- rhabdomyolysis
- symptomatic myopathy
What is symptomatic myopathy?
mm soreness, pn, weakness, dyspnea
What is myositis?
elevated CK level
S/S of liver impairment?
- dark urine
- asterixis (liver flap)
- bilateral CTS
- palmar erythema (liver palms)
- spider angiomas
- nail bed changes
- ascites
