General Approach Flashcards
What should you never fail to do?
exam the area of patient complaint
what can happen if a diagnostic error is made?
many times, it is inconsequential
others can result in substantial harm
ROWS
rule out worst case senarios
differential dx
process that involves the use of clinical signs and symptoms, physical exam, a knowledge of pathology and mechanisms of injury, provocative and motion tests, palpation, labratory and diagnostic imaging
common conditions of bone
tumors (primary or metastatic) osteochondrosis/apophysitis fracture osteopenia/osteoporosis osteomyelitis congenital anomalies and variants
common conditions of soft tissue and musccle
strain or rupture trigger points atrophy myositis ossificans muscular dystrophy rhabdomyositis
tendinitis
inflammation
tendonosis
intra-tendon degeneration
paratendonitis
inflammed paratendon
common ligament conditions
sprain or rupture
common bursa conditions
bursitis
common fascial conditions
myofascitis
common joint conditions
arthritis
subluxation/fixation
joint mice
dislocation/subluxation
what should you rule out with acute traumatic pain?
fracture
dislocation
instability
neutral, vasculara injury
what should you rule out with nontraumatic pain?
tumors
inflammatory arthridities
infections
visceral referral
how do you clarify the type of complaint?
is there trauma?
is there a history of overuse?
is the onset insidious?
what should you ask if the injury was traumatic?
what was the mechanism of injury
what should you ask if the injury is overuse?
what is the repetitive motion and what is the positional status of the patient
what should you ask if the injury is insidious?
is there fever, lymphadenopathy, multiple areas affected, local signs of inflammation, deformity, associated weakness, numbness, tingining, neurologic dysfunction?
18 questions
when did it start? gradual or sudden? anything cause or contribute to it? ever had this before? point to area of complaint? does it radiate/travel? symptoms in other parts of the body? how would you rate the pain? is it costant, come and go? getting better, worse, staying the same anything that makes it better? anything that makes it worse? any change in bodily functions? affected daily activities? tried store bought or at home remedies? seen anyone else for this? anything else you want me to know?
evaluation
always examine area of complaint visualization palpation AROM, PROM, resisted ROM orthopedic and neurologic exam radiographs specialized imaging labs manage, co-manage, emergent referal
orthopedic exams are to?
reproduce complaints
reveal laxity
demonstrate weakness
demonstrate restriction
what questions should you ask if you want to do radiographs?
are there red flags
is patient high or low risk?
combine history, clinical presentation
if someone has had pain for more than 6 weeks, what are the ddx?
tumor, infection, rheumatologic disorder
if someone is less than 18, what are the ddx of low back pain?
congenital defect, tumor, infection, spondylolysis, spondylolisthesis
if someone is above 50, what are the ddx of LBP?
tumor, intra abdominal process, infection
if there is major trauma, or minor trauma in elderly, what is usually the cause?
fracture
recent genitourinary or gastrointestingal procedure usually indicates?
infection
night pain usually indicates what DDX?
tumor, infection
unremitting pain, even when supine indicates what ddx?
tumor, infection, AAA, nephrolithiasis
pain worsened by coughing, sitting or valsalva maneuver indicades what ddx?
herniated disc
pain related below knee indicates what?
herniated disc, NR compression below L3
incontinence, saddle anesthesia, severe or rapidly progressive neurologic deficit indicates what ddx?
cauda equina syndrome, spineal cord compression
red flags
significant trauma suspicion of cancer, infection chronic corticosteroid use drug or alcohol abuse history of surgery to involved area neurotumor deficits scoliosis labratory abnormalities medicolegal requirements (not best reaon) unresponsive to conservative care for >1 month
when should you generally refer/refer or comanage?
refer- fractures/dislocations, infections, tumors (orthopedic management)
refer/comanage- RA, CT disorders
if problem is instability w/o ligament rupture?
stabilize the joint through appropriate exercise program using brace if necessary
if problem is weakness?
strengthen associated muscles
those who want to return to ADLs, dowhat?
functionally retrain
what do you do for articular dysfucntion?
manipulation/mobilization
WIRS pain
weakness instability restricted movement surface complaints pain
weakness
may be due to pain inhibition, muscle strain or neurologic interruption
instability
maybe due to damaged ligaments, muscles or inherent looseness
restricted motion
due to pain, muscle spasm, soft tissue contracture, joint mice, fracture or soft tissue swelling/effusion
surface complaints
skin lesions, cuts/abrasions, swelling, patient subjective sense of numbness of paresthesia
pain is..
non specific and cause usually will be revealed by combinging a history of trauma, overuse, or insidious onset with associated complains and exam findings
nociceptive pain
caused by stimulation of peripheral nerve fibers
neuropathic pain
damage or disease affecting nervous system
psychogenic pain
mental, emotional, behavioral factors
phantom pain
type of neuropathic pain
scleratogenous sources
nondermatomal pattern, with no hard neurological findings, refers primarily to facet and disc generated pain
referred pain
historical screening is helpful in revealing a visceral complain, referral zones
bone pain
deep pain, commonly worse at night, trauma may require xrays, overuse suggestie of stress fracture and may require xrays and maybe specialized imaging as needed
nociceptive pain represents the normal response to..?
noxious insult or injury of tissues such as skin, muscles, visceral organs, joints, tendons or bones
examples of nociceptive pain
somatic
visceral
somatic nociceptive pain
musculoskeletal (joint of myofascial), cutaneous, well localized
visceral nociceptive pain
hollow organs and smooth muscle, usually referred
neuropathic pain is initiated by?
primary lesion or disease in the somatosensory nervous system
sensory abnormalities for neuropathic pain
deficits perceived as numbness to hypersensitivity and to paresthesias
examples of neuropathic pain
diabetic neuropathy postherpetic neuralgia spinal cord injury pain phantom limp pain post stroke central pain
what should you consider if the msuculoskeletal pain doesn’t have an obvious mechanical or taumatic cause?
search for myofascial disorders, arthridites, phychological factors, CT disorders, cancer, infection
sharp pain on motion
joint
contant pain
joint or nerve
burning/hot pain
nerve
sharp no motion
nerve
stabing
nerve
tingling/numbness
nerve
cramping/knot/spasm
muscle
dull ache
muscle
deep burning, dull pain
bone/ligament
pinpoint pain over paraspinal tissue
MTRP
crawling sensation
myofascial pain
throbbing
vascular
well localized
peripheral
diffuse
central
what structures can you directly palpate to test?
ligaments (stress), tendons (stretch), muscles (contraction)
how do you test nerves?
tapping, compression, muscle testing, deep tendon reflexes, sensory testing
decreased ROM can be caused by?
subluxation muscle spasm/strain ligament sprain arthritic conditions obesity
how can you tell between contracile and non-contractile tissue?
PROM
AROM
contractile tissue
painful with stretch or mid range contraction
AROM not painful, painful PROM non contractile tissue involved
pain on AROM
muscle or ligament
pain on PROM
ligament, bursa, capsule
bone pain
deep and worse at niht
