Final Book Questions

Question 1

Bleeding in the gastrointestinal (GI) tract can be manifested as:

Answer 1

Melena

Question 2

What is the significance of Kehr’s sign?

Answer 2

Gas, air, or blood in the abdominal cavity

Kehr’s sign (left shoulder pain) can occur as the result of blood (e.g., following trauma to the spleen, ruptured ectopic pregnancy) or air (laparoscopy) in the abdomen. Kehr’s sign following a laparoscopy will resolve within 24 to 48 hours as the gas bubble is absorbed or passed. The physician must be notified of shoulder pain associated with traumatic injury, nonsteroidal antiinflammatory drug (NSAID)-associated gastrointestinal bleeding, or possible ectopic pregnancy for possible medical evaluation (even if the clinical presentation is consistent with musculoskeletal dysfunction)

Question 3

What areas of the body can GI disorders refer pain to?

Answer 3

Sternum, shoulder, scapula, anterior neck, mid back, lower back, hip pelvis, sacrum. (All of the above)

Question 4

A 56-year-old client was referred to PT for pelvic floor rehab. His primary symptoms are obstructed defecation and puborectalis muscle spasm. He wakes nightly with left flank pain. The pattern is low thoracic, laterally, but superior to iliac crest. Sometimes he has buttock pain on the same side. He doesn’t have any daytime pain but is up for several hours at night. Advil and light activity do not help much. The pain is relieved or decreased with passing gas. He has very tight hamstrings and rectus femoris. Change in symptoms with gas or defecation is possible with:

Answer 4

Large intestine and colon dysfunction

Question 5

Name two of the most common medications taken by clients seen in a physical therapy practice likely to induce GI bleeding.

Answer 5

Antibiotics and antiinflammatories

Question 6

What is the significance of the psoas sign?

Answer 6

Infection of the peritoneum (e.g., peritonitis, appendicitis) can cause abscess formation of the psoas (or obturator) muscle, resulting in right lower quadrant (abdominal or pelvic) pain in association with specific movements of the right leg

Question 7

Which of the following are clues to the possible involvement of the GI system?

Answer 7

Abdominal pain at the same level as back pain, occurring either simultaneously or alternately

Question 8

A 65-year-old client is taking OxyContin for a “sore shoulder.” She also reports aching pain of the sacrum that radiates. The sacral pain can be caused by:

Answer 8

Pressure on sacral nerves from stored fecal content in the constipated client taking narcotics

Psoas abscess can affect the hip, buttock, groin, and parts distal but does not cause sacral pain; hemorrhoids and rectal fissures may cause rectal or anal pain, but not sacral pain; Crohn’s disease can be accompanied by sacroiliitis, but this client does not have a reported history of Crohn’s disease; narcotics are well known for constipation as a common adverse effect, especially in the older adult.

Question 9

Body temperature should be taken as part of vital sign assessment:

Answer 9

For every client evaluated
For any client who has musculoskeletal pain of unknown origin
For any client reporting the presence of constitutional symptoms, especially fever or night sweats

Question 10

Referred pain patterns associated with hepatic and biliary pathologic conditions produce
musculoskeletal symptoms in the:

Answer 10

Mid-back or upper back, scapular, and right shoulder areas

Question 11

What is the first most common sign associated with liver disease?

Answer 11

Jaundice is first noted as a yellowing of the sclerae of the eyes. The skin may take on a yellow hue as well, but this is not as easily observed as the change in the eye. This change in eye and skin color can also occur with pernicious anemia, a condition that may be accompanied by peripheral neuropathy as well.

Question 12

Clients with significant elevations in serum bilirubin levels caused by biliary obstruction will have which of the following associated signs?

Answer 12

Dark urine, clay- colored stools, jaundice, yellow tinged sclera

Question 13

Preventing falls and trauma to soft tissues would be of utmost importance in the client with liver failure. Which of the following laboratory parameters would give you the most information about potential tissue injury?

Answer 13

Prolonged coagulation times

Question 14

Decreased level of consciousness, impaired function of peripheral nerves, and asterixis
(flapping tremor) would probably indicate an increase in the level of:

Answer 14

Serum ammonia

Question 15

An inpatient who has had a total hip replacement with a significant history of alcohol use/abuse has a positive test for asterixis. This may signify:

Answer 15

Hepatic encephalopathy

Question 16

A decrease in serum albumin is common with a pathologic condition of the liver because albumin is produced in the liver. The reduction in serum albumin results in some easily identifiable signs. Which of the following signs might alert the therapist to the condition of decreased albumin?

Answer 16

Peripheral edema and ascities

Question 17

Percussion of the costovertebral angle that results in the reproduction of symptoms:

Answer 17

Requires medical referral

Question 18

Renal pain is aggravated by:

Answer 18

NONE of the above

Spinal movement
Palpatory pressure over the costovertebral angle
Lying on the involved side

Question 19

Important functions of the kidney include all the following except:

a. Formation and excretion of urine
b. Acid-base and electrolyte balance
c. Stimulation of red blood cell production
d. Production of glucose

Answer 19

Production of glucose

Question 20

Who should be screened for possible renal/urologic involvement?

Answer 20

Anyone with back pain or shoulder pain of unknown origin, especially when accompanied by changes in urination, blood in the urine, or constitutional symptoms.

Question 21

What is...
Dyspareunia?
Dysuria?
Hematuria?
Urgency?

Answer 21

Dyspareunia—Difficult or painful sexual intercourse in women
Dysuria—Painful or difficult urination
Hematuria—Blood in the urine
Urgency—A sudden, compelling desire to urinate

Question 22

In a physical therapy practice, clients are most likely to present with signs and symptoms of metastases to:

Answer 22

Skeletal system, hepatic system, pulmonary system, central nervous system

Question 23

What is the significance of nerve root compression in relation to cancer?

Answer 23

In any individual, any neurologic sign may be the presentation of a silent lung tumor.

Question 24

Complete the following mnemonic:
C
A
U
T
I
O
N
S

Answer 24

• ​Changes in bowel or bladder habits
• ​A sore that does not heal within 6 weeks
• ​Unusual bleeding or discharge
• ​Thickening or lump in the breast or elsewhere
• ​Indigestion or difficulty in swallowing
• ​Obvious change in a wart or mole
• ​Nagging cough or hoarseness
• ​Supplemental signs and symptoms (rapid unintentional weight loss, changes in vital signs, frequent infections, night pain, pathologic fracture, proximal muscle weakness, change in deep tendon reflexes)

Question 25

Why is weight loss a significant red flag sign in a physical therapy practice?

Answer 25

Pain, movement dysfunction, and disability usually result in weight gain due to inactivity. When someone is experiencing back pain, for example, and reports a significant weight loss, this may be a red flag for systemic origin of the problem.

Question 26

When tumors produce signs and symptoms at a site distant from the tumor or its metastasized sites, these “remote effects” of malignancy are called:

Answer 26

Paraneoplastic syndrome

Question 27

A client who has recently completed chemotherapy requires immediate medical referral if he has which of the following symptoms?

Answer 27

Fever, chills, sweating

Question 28

A suspicious skin lesion requiring medical evaluation has:

Answer 28

Notched edges

Question 29

What is the significance of Beau’s lines in a client treated with chemotherapy for leukemia?

Answer 29

Impaired nail formation from death of cells

Question 30

A 16-year-old boy was hurt in a soccer game. He presents with exquisite right ankle pain on weight bearing but reports no pain at night. Upon further questioning, you find he is taking Ibuprofen at night before bed, which may be masking his pain. What other screening examination procedures are warranted?

Answer 30

Perform a heel strike test.
​Review response to treatment.
​Assess for signs of fracture (edema, exquisite tenderness to palpation, warmth over the painful site).

Question 31

When is it advised to take a work or military history?

Answer 31

Anyone presenting with joint pain of unknown cause accompanied by multiple other signs and symptoms

Question 32

A 70-year-old man came to outpatient physical therapy with a complaint of pain and weakness of his fingers and morning stiffness lasting about an hour. He presented with bilateral swelling of the metacarpophalangeal (MCP) joints of the index and ring fingers. He saw his family doctor 4 weeks ago and was given diclofenac, which has not changed his symptoms. Now he wants to try physical therapy. Since he last saw his physician, he has developed additional joint pain in the left knee and right shoulder. How can you tell if this is cancer, polyarthritis, or a paraneoplastic disorder?

Answer 32

You can’t. This requires a medical evaluation.

Question 33

A 49-year-old man was treated by you for bilateral synovitis of the proximal interphalangeal (PIP) joints in the second, third, and fourth fingers. His symptoms went away with treatment, and he was discharged. Six weeks later, he returned with the same symptoms. There was obvious soft tissue swelling with morning stiffness worse than before. He also reports problems with his bowels but isn’t able to tell you exactly what’s wrong. There are no other changes in his health. He is not taking any medications or over-the-counter drugs and does not want to see a doctor. Are there enough red flags to warrant medical evaluation before resumption of physical therapy intervention?

Answer 33

Yes; age, bilateral symptoms, progression of symptoms, report of GI distress

Question 34

A client with a past medical history of kidney transplantation (10 years ago) has been referred to you for a diagnosis of rheumatoid arthritis. His medications include tacrolimus, methotrexate, Fosamax, and Wellbutrin. During the examination, you notice a painless lump under the skin in the right upper anterior chest. There is a loss of hair over the area. What other symptoms should you look for as red flag signs and symptoms in a client with this history?

Answer 34

Fever, muscle weakness, weight loss

Question 35

The most common sites of referred pain from systemic diseases are:

Answer 35

Shoulder and back

Question 36

To screen for back pain caused by systemic disease:

Answer 36

​Perform special tests (e.g., Murphy’s percussion, Bicycle test)
​Correlate client history with clinical presentation and ask about associated signs and symptoms
Perform a Review of Systems

Question 37

4.​​Which statement is the most accurate?

A.​Arterial disease is characterized by intermittent claudication, pain relieved by elevating the extremity, and history of smoking.

B.​Arterial disease is characterized by loss of hair on the lower extremities, throbbing pain in the calf muscles that goes away by using heat and elevation.

C.​Arterial disease is characterized by painful throbbing of the feet at night that goes away by dangling the feet over the bed.

D.Arterial disease is characterized by loss of hair on the toes, intermittent claudication, and redness or warmth of the legs that is accompanied by a burning sensation.

Answer 37

C

Question 38

Pain associated with pleuropulmonary disorders can radiate to:

Answer 38

Anterior neck
​Upper trapezius muscle
​Ipsilateral shoulder
Thoracic spine

Question 39

Which of the following are clues to the possible involvement of the GI system?

Answer 39

Abdominal pain at the same level as back pain occurring either simultaneously or alternately

Question 40

Percussion of the costovertebral angle resulting in the reproduction of symptoms signifies:

Answer 40

Medical referral is advised

Question 41

A 53-year-old woman comes to physical therapy with a report of leg pain that begins in her buttocks and goes all the way down to her toes. If this pain is of a vascular origin she will most likely describe it as:

Answer 41

Throbbing, “tired”

Question 42

True or false; Twenty-five percent of the people with GI disease, such as Crohn’s disease (regional enteritis), irritable bowel syndrome, or bowel obstruction, have concomitant back or joint pain.

Answer 42

True

Question 43

True or false; Skin pain over T9 to T12 can occur with kidney disease as a result of multisegmental innervation. Visceral and cutaneous sensory fibers enter the spinal cord close to each other and converge on the same neurons. When visceral pain fibers are stimulated, cutaneous fibers are stimulated, too. Thus visceral pain can be perceived as skin pain.

Answer 43

True

Question 44

True or false; Autosplinting is the preferred mechanism of pain relief for back pain caused by kidney stones.

Answer 44

False

Question 45

True or false; Back pain from pancreatic disease occurs when the body of the pancreas is enlarged, inflamed, obstructed, or otherwise impinging on the diaphragm.

Answer 45

True

Question 46

Pelvic pain that is made worse after 5 to 10 minutes of physical activity or exertion but goes away with rest or cessation of the activity describes:

Answer 46

Vascular pattern of ischemia

Question 47

Pain that is relieved by placing a pillow or support under the hips and buttocks describes:

Answer 47

Response to vascular congestion

Question 48

A positive Blumberg’s sign indicates:

Answer 48

Pelvic infection

Question 49

A 33-year-old pharmaceutical sales representative reports pain over the mid-sacrum radiating to the right PSIS. Overpressure on the sacrum does not reproduce symptoms. This signifies:

Answer 49

​A lack of objective findings

Question 50

A 67-year-old man was seen by a physical therapist for low back pain rated 7 out of 10 on the visual analogue scale. He was evaluated, and a diagnosis was made by the physical therapist. The client attained immediate relief of symptoms, but after 3 weeks of therapy, the symptoms returned. What is the next step from a screening perspective?

Answer 50

The client should be screened for systemic disease even if you have already included screening during the initial evaluation.

Question 51

McBurney’s point for appendicitis is located:

Answer 51

Approximately one-half the distance from the ASIS toward the umbilicus, usually on the right side

Question 52

Which one of the following is a yellow (caution) flag?

Answer 52

Sacral pain is relieved when the client passes gas or has a bowel movement.

Question 53

Cancer as a cause of sacral or pelvic pain is usually characterized by:

Answer 53

A previous history of reproductive cancer
​Constant pain
​Blood in the urine or stools
​Constitutional symptoms

Question 54

Reproduced or increased abdominal or pelvic pain when the iliopsoas muscle test is performed suggests:

Answer 54

Inflammation or abscess of the muscle from an inflamed appendix or peritoneum

Question 55

A 75-year-old woman with a known history of osteoporosis has pain over the sacrum radiating to the right PSIS and right buttock. How do you rule out an insufficiency fracture?

Answer 55

Diagnostic imaging is the only way to know for sure.

Question 56

The screening model used to help identify viscerogenic or systemic origins of hip, groin, and lower extremity pain and symptoms is made up of:

Answer 56

Past medical history, risk factors, clinical presentation, and associated signs and symptoms

Question 57

Hip and groin pain can be referred from:

Answer 57

​Low back
​Abdomen
​Retroperitoneum

Question 58

Screening for cancer may be necessary in anyone with hip pain who:

Answer 58

​Is younger than 20 or older than 50

Question 59

Pain on weight bearing may be a sign of hip fracture, even when x-rays are negative. Follow-up clinical tests may include:

Answer 59

Squat test, hop test, translational/rotational tests

Question 60

Abscess of the hip flexor muscles from intraabdominal infection or inflammation can cause hip and/or groin pain. Clinical tests to differentiate the cause of hip pain resulting from psoas abscess include:

Answer 60

Iliopsoas and obturator tests

Question 61

Anyone with hip pain of unknown cause must be asked about:

Answer 61

​Previous history of cancer or Crohn’s disease
​Recent infection
Presence of skin rash

Question 62

Vascular diseases that may cause referred hip pain include:

Answer 62

Aortic aneurysm

Question 63

True hip pain is characterized by:

Answer 63

Groin or deep buttock pain with active or passive range of motion

Question 64

Hip pain associated with primary or metastasized cancer is characterized by:

Answer 64

​Bone pain on weight bearing; may not be able to stand on that leg
​Night pain that is relieved by aspirin
Positive heel strike test with palpable local tenderness

Question 65

Chest pain can be caused by trigger points of the:

Answer 65

Sternocleidomastoid

Question 66

During examination of a 42-year-old woman’s right axilla, you palpate a lump. Which characteristics most suggest the lump may be malignant?

Answer 66

Hard, immovable, nontender

Question 67

A client complains of throbbing pain at the base of the anterior neck that radiates into the chest and interscapular areas and increases with exertion. What should you do first?

Answer 67

Monitor vital signs and palpate pulses.

Question 68

A 55-year-old grocery store manager reports becoming extremely weak and breathless whenever stocking groceries on overhead shelves. What is the possible significance of this complaint?

Answer 68

Myocardial ischemia

Question 69

Chest pain of a pleuritic nature can be distinguished by:

Answer 69

Exacerbated by deep breathing

Question 70

You are evaluating a 30-year-old woman with left chest pain that starts just below the clavicle and extends down to the nipple line. The majority of test results point to thoracic outlet syndrome. Her blood pressure is 120/78 mm Hg on the right (sitting) and 125/100 on the left (sitting). She is in apparent good health with no history of surgeries or significant health problems. What plan of action would you recommend?

Answer 70

Document your findings, and contact the physician by phone or by fax while initiating treatment

Question 71

A 60-year-old woman with a history of left breast cancer (10 years postmastectomy) presents with pain in her midback. The pain is described as “sharp” and radiates around her chest to the sternum. She gets some relief from her pain by lying down. Her vital signs are normal, and there are no palpable or aberrant lymph nodes. She denies any changes in breast tissue on the right or the scar and soft tissue on the left. You do not have adequate training to perform a clinical breast examination, but the client agrees to visual inspection, which reveals nothing unusual. All other findings are within normal limits; you are unable to provoke or aggravate her symptoms. Neurologic screening examination is within normal limits. The client denies any history of trauma. What plan of action would you recommend?

Answer 71

Refer her to a physician before initiating treatment.

Question 72

9.​​You are working with a client in his home who had a total hip replacement 2 weeks ago. He describes chest pain with increased activity. Knowing what could cause this symptom will help guide you in asking appropriate screening questions. Can this be a symptom of:

Answer 72

​Asthma
​Angina
Pleuritis or pleurisy

Question 73

Cardiac pain in women does not always follow classic patterns. Watch for this group of symptoms in women at risk:

Answer 73

Unusual fatigue, shortness of breath, weakness, or sleep disturbance.

Question 74

Which of the following would be useful information when evaluating a 57-year-old woman with shoulder pain?

Answer 74

​Influence of antacids on symptoms
​History of chronic NSAID use
​Effect of food on symptoms

Question 75

Referred pain patterns associated with impairment of the spleen can produce musculoskeletal symptoms in:

Answer 75

The left shoulder

Kehr’s

Question 76

Referred pain patterns associated with hepatic and biliary pathology can produce musculoskeletal symptoms in:

Answer 76

The mid or upper back, scapular, and right shoulder areas

Question 77

The most common sites of referred pain from systemic diseases are:

Answer 77

Shoulder and back

Question 78

A 28-year-old mechanic reports bilateral shoulder pain (right more than left) whenever he has to work on a car on a lift overhead. It goes away as soon as he puts his arms down. Sometimes, he has numbness and tingling in his right elbow going down the inside of his forearm to his thumb. The most likely explanation for this pattern of symptoms is:

Answer 78

Thoracic outlet syndrome

Question 79

A client reports shoulder and upper trapezius pain on the right that increases with deep breathing. How can you tell if this results from a pulmonary or a musculoskeletal cause?

Answer 79

Symptoms get worse when lying supine but better when right sidelying when it is pulmonary

Question 80

Organ systems that can cause simultaneous bilateral shoulder pain include:

Answer 80

Heart

Question 81

A 23-year-old woman was a walk-in to your clinic with sudden onset of left shoulder pain. She denies any history of trauma and has only a past history of a ruptured appendix three years ago. She is not having any abdominal pain or pain anywhere else in her body. How do you know if she is at risk for ectopic pregnancy?

Answer 81

She is sexually active, and her period is late.

Question 82

The most significant red flag for shoulder pain secondary to cancer is:

Answer 82

Previous history of breast or lung cancer