Lecture 1A 1B and 1C Flashcards
“accessible, comprehensive, coordinated and continual care delivered by accountable providers of personal health services”
IOM definition of primary care
T or F: in 2015, all 50 US states, DC, and US have some direct access
true
How much direct access does Texas have?
10-15 days (depending on training)
!!! what is the 1st question that must be answered prior to any others when seeing a pt? what are the answer choices?
do you belong here??
YES- Tx
Yes & No- Refer and Tx
NO- Refer
Nine conditions not to miss
Depression
Suicide
Femoral head/neck fx
cauda equina syndrome
cervical myelopathy
abdominal aortic aneurysm
DVT
PE
atypical MI
risk factors of major depression :(
current/PMH
female- postpartum/pregnant
Hx of DM,MI, cancer, chem dependency
significant loss
family Hx
___% of PT formally screen for depression
18%
Risk factors for suicide
males - increased complete
females- increased attempt
Hx of psychiatric illness
Hx of progressive illness, attempts, family Hx
conditions assoc with femoral fx rates
osteoporosis
stress/fatigue
major trauma
medicines associated with compromised bone density
Corticosteroid, anti-convulsants, cytotoxic drugs, blood thinner, aluminum, throxine, caffeine, tobacco
risk factors with fatigue fx
female
high impact
change in training
nutritional def
leg length discrepancy
decreased muscle strength
clinical manifestation of fem neck/head fx
pain and localized tenderness- worse w/ WB
deformity- shortened limb
edema, ecchymosis
LOF
+ patellar-pubic percussion test
+ fulcrum test
risk factors for cauda equina syndrome
LBP, central disc herniation
congenital/acquired spinal stenosis
spinal fx
ankylosing spondylitis
TB, Potts
clinical manifestations of cauda equina
LB/LE pain
neurologic compromise
ataxia/poor balance
LE “heavy”
neurologic compromise of cauda equina
motor and sensory def
urinary, bowel. sexual dysfunction
! urinary retention most frequently noted !!
T or F: cauda equina syndrome onset of symptoms is quick
F: onset of symptoms can be quick OR gradual
risk factors for cervical myelopathy
- typically w/ C-spine spondylosis
- c-spine instability leading to compromise
- wide variation in natural HX -older over time, young folks due to trauma
What is the most common cause of non-traumatic paraparesis and quadriparesis?
cervical myelopathy
clinical manifestions of cervical myelopathy
S/S worsen in slow, step wise progression
neurologic compromise includes: impaired hand dexterity, gait/balance issues, paresthesis, neck stiffness, urinary retention, UE / LE weakness, UMN signs
aneurysm distal to the renal arteries
abdominal aortic aneurysm
risk of AAA rupture increases when diameter approaches
5-6 cm
risk factors for AAA
over 60 y/o
male
Hx of smoking, high cholesterol, CAD
family Hx
clinical manifestations of AAA
back, ab, hip, groin, buttock pain
non mech pain
insidious onset (slow or fast)
early satiety, weight loss, nausea
palpable mass, visible pulse
bruit +
if pt reports hot, searing, ripping, or tearing- STOP
T o F: most pt w AAA are asymptomatic
True
DVT risk factors
Hx, cancer, CHF, SLE
infection
chemo, Central Venous cath
surgery, trauma
immobility, paralysis
women during pregnancy/post
over 60
clinical manifestations of DVT
tightness, tenderness
edema
pitting edema
increased skin temp
__% of individuals w/ DVT are asymptomatic in early stages
50
DVT decision rule
> or = 2 points DVT likely
<2 points = DVT unlikely
-2 score only for when alternative dx
PE most associate with
DVT, air, fat, bone marrow embolism
proximal LE DVT compromise about what percent of PE?
70%
risk factors of PE
Hx PE/DVT, surgery
THR, TKR
immobility
lower limb fx
late stage pregnancy
clinical manifestations of PE
dyspnea
tachypnea
pleuritic chest pain
persistent cough
apprehension, anxiety
tachycardia/ palpitations
___ of deaths related to PE are potentially preventable
> 50%
clinical decision rule for PE: Wells Criteria
<2 points = low
2-6 = moderate
>6 = high
~ __% of women experience chest pain w MI
50%
T or F: cardiac death is the 2nd leading COD in women of all ages
F,
cardiac death is the LEADING COD in women of all ages
risk factors of atypical MI
smoking, high cholesterol, HTN, DM, obesity, sedentary
age > 55 for women
age > 45 for men
fam Hx
ethnicity
clinical manifestations of atypical MI
SOB, fatigue, nausea
dizziness, diaphoresis, anxiety, sleep disturbance
chest pain (w/ or w/o UE pain)
upper ab, epigastric, jaw, neck tooth pain
pain w/ w/o exertion
what is the first step if you assume an MI
Take vital signs!!!
What is reliability vs validity?
Reliability- consistently gives the same score
Validity- Measures what it’s suppose to measure
What is “Responsiveness” in a study?
Ability to detect change over time
Sensitivity is good for ruling a condition __________
OUT
Specificity is good for ruling a condition ______
IN
“Given that the individual has the condiiton, the probability that the test will be +”
Is this sensitivity or specificity?
Sensitivity
Specifity definition
Given that the individual does NOT have a condition, this is the probability that the test will be negative
How do you calculate sensitivity
True positive / (True Positive + False Negative)
How do you calculate Specificity
True negative / (False positive + True negative)
A study that easily picks up symptoms but has a lot of false positives has high __________
Sensitivity
Sensitivity is good for __________ (screening/diagnositc)
Screening
Specifity is good for (Screening/Diagnostic)
Diagnostic
How do you calculate positive predictive value
True positive / ( True positive + False positive)
What is this definition:
Given a (+) test result, the probability that the individual DOES have the condition
positive predictive value
How do you calculate negative predictive value?
True negative / (true negative + false negative)
What is this definition:
Given a (-) test result, the probability that the individual DOES NOT have the condition
Negative predicitive value
Conditions with very low prevelance will have a
______ positive predictive value
______ negative predicitve value
Lower positive predictive value (lower amount of true positives)
Higher negative predictive value (higher amount of true negatives)
How do you calculate positive likelihood ratio?
Sensitivity / (1-specificity)
How do you calculate negative likelihood ratio
1-sensitivity / specifity
Definition of Positive likelihood ratio
Given the result of + test, the increase in the odds favoring the condition
Negative likelihood ratio definition
Given the result of - test, the decrease in the odds favoring the condition
What is considered a large positive likelihood ratio?
What is considered a good negative likelihood ratio?
10
0.10
What is considered a bad positive likelihood ratio?
What is considered a bad negative likelihood ratio?
1-2
0.5-1
If the negative LR is 0.75, is a negative result to this test reliable?
Not helpful, too high
What is considered the most powerful tool for quantifying importance of a particular test?
Likelihood ratios
T or F, very few tests have a good positive likelihood ratio and negative likelihood ratio
T
Minimal detectable change
Amount of change needed to exceed the measurement of error of the test
What is the MCID (minimal clinical importance difference)?
Smallest difference detected that represents important improvement for individuals with the condition
Increased reliability of test leads to ___________ Minimal detectable change
Lower
What should be higher:
Minimal Clincial Important Difference
or
Minimal Detectable Change
MCID
What are 5 parts of patient history that can help identify mechanical pain
Severity
Irritability
Nature
Stage
Stability
Severity
describes clinician’s assessment of intensity of pt’s symptoms as they relate to a functional activity
Irritability
describes clinician’s assessment of ease w/ which symptoms can be provoked or stirred up
Nature of symptoms
- Hypotheses of structures, syndrome/classification or pathoanatomic structures or syndromes responsible for producing pt’s pain
- Anything about the problem or condition that may warrant caution w/ physical exam
- Character of presenting pt or problem (i.e. psychological, personality, ethnicity, SES factors
Stage of symptoms
Describes clinician’s assessment of stage in which pt is presenting (acute, sub-acute, chronic, acute on
chronic); may be obtained from past & present hx
Stability of symptoms
describes progression of pt’s symptoms over time (i.e. getting better, worse or staying the same)
When collective subjective data you should start with _____ questions and follow up with ______ ended questions
Open Ended
Closed ended
T or F: You should let the patient tell their story, but make sure you get the info your need to direct your exam
True
Unexplained weightloss of over 10lbs in 3 months is an example of a
red flag
T or F: Being over 50 years old is an example of a red flag
T, due to increased risk of cancer, infection, AAA
B
Resting/night pain is an example of a…..
Red Flag
What is saddle anesthesia
Absence of sensation in the 2nd-5th sacral nerve roots
RED FLAG
Bowel and bladder dysfunction is an example of a
potential red flag
Differential diagnosis is based on pt’s health history and subjective interview,
Differential diagnosis is ________________ what is going on with the patient
What is most likely going on
When creating differential diagnosis you should have a top ____ in mind after the subjective interview
Top 3
T or F: Referred pan can be mechanical OR non-mechanical
T
Pain that fluctuates over a 24 hour period is likely:
Pain that does not fluctuate over 24 hours or with positive/activity is likely:
Mechanical
Non-Mechanical
Pain with inconsistent location, insidious onset, and with a dull ache not located near MSK structures is likely
nonmechanical
Pain that comes on after eating or urinating is likely
nonmechanical
Throbbing pounding and pulsating pain is likely from _____ disorders
Vascular
Pain that is sharp, lancinating, shocking, and burning is likely from ____ disorders
Neurological
Pain that is aching, squeezing, gnawing, burning, cramping is likely from _____ disorders
Visceral
Low back region pain with Hx of cancer, weight loss, failure of conservative treatment, and over 50?
Potential tumor
Back pain w/ history of recent infection, IV drug abuse, immunosupressive disorder
Possible back-related infection
(spinal osteomyelitis)
Low back pain w/ history of spinal stenosis and history of DDD, saddle anesthesia, urinary problems, progressive weakness?
Potential cauda equina
Back pain w/ Hx of trauma, long term corticosteroid use, and over 70?
Edema in area w/ tenderness at palpation
Potential spinal fracture
What are the signs of an abdominal aneurysm
Back/groin pain
PVD/CAD and risk factors
Over 50
Symptoms unrelated to movement
Abnormal width of aortic/iliac artry pulses
Presence of bruit in central epigastric area upon auscultation
Medical screening questionare for LBP
Recent fall or trauma/MVA?
Osteoporosis?
Cancer?
Pain at rest?
Fever?
Weight loss?
antibiotics/infection?
Hip pain w/ bowel disturbances, weight loss, hx of cancer, pain unchanged by position?
Colon cancer
Hip pain in older women (70+)
Hx of fall
Constant severe pain
Shortened and ER LE
Fx of femoral neck
Pelvis/hip pain in 5-8 year old boys, antalgic gait, pain complaints aggrevated w/ hip movement especially IR and ABD
Legg-Calve-Perthes disease
Hip/pelvis pain w/ Hx of corticosteroid
Hx of osteonecrosis/trauma
Gradual onset of pain that worsens w/ weightbearing
Osteonecrosis of femoral head
Pelvis/Hip pain in overweight adolescent
HX of recent growth spurt
Aching in groin that gets worse with weight bearing
Leg held in ER
Hip ROM limited into IR
Slipped capital femoral epiphysis
Pelvis/Hip screening questions
Recent fall?
Osteoporosis?
Blood circulation problems in hip?
Corticosteroids?
Pain in different positions?
Hx of cancer in yourself or family?
Knee/leg/ankle/foot pain w/
60+ Y/O
Hx of Diabetes
Hx of ischemic heart disease
Smoking hx
sedentary lifestyle
prolonged vascular filling time
cool to touch extremity
Peripheral Arterial Occlusive Disease
Knee/leg/anke/foot pain w/
Recent surgery/cancer/pregnancy/trauma
Calf pain/edema/tenderness/warmth
Weight bearing makes it worse
Potential DVT
Knee/leg/anke/foot pain w/
Hx of blunt trauma, crush injury, or unaccustomed exercise
Severe persistent pain that intensifies with stretch to muscles
potential compartment syndrome
Knee/leg/anke/foot pain w/
Hx of infection, surgery, or immunosuppresant disorder
Constant throbbing, warmth, swelling
elevated body temperature
possible septic arthritis
Knee/leg/anke/foot pain w/
Hx of recent skin ulceration or abrasion
venous insufficiency
Coronary heart failure
pain/swelling/warmth
Advancing irregular margin of redness
Fever/chills/weakness
Cellulitis
Knee/leg/anke/foot pain
screening questions
Recent Fever?
Antibiotics?
Surgery/injections?
Cut/wounds?
Immunosupressant disorder, heart disorder, or cancer?
Recent long trip?
Bed ridden?
Thoracic/rib pain w/
Hx of CAD/HTN/ elevated cholesterol
Men 40+, Women 50+
Chest pain
Pallor/dyspenia/nausea
Potential Myocardial infarction
Thoracic/rib pain w/
Hx of autoimmune disorder
myocardial infection
sharp/stabbing pain that refers to lateral neck or shoulder
pain is position dependent
Pericarditis
Stable angina pectoralis is most common in people ______
65+
men
Thoracic/Rib pain W/
Hx of DVT, Immobility, Trauma, Cancer
Pt is experiencing Tachypnea, Dyspenia, Or Tachycardia w/ Chest pain
Potential Pulmonary Ebolism
Thoracic/Rib pain W/
Hx of recent respiratory disorder/infection/pneumonia, tumor
Severe/sharp pain w/ inspiration
Dyspenia and decreased chest wall excursion
Possible Pleurisy
Thoracic/Rib pain W/
Recent bout of coughing/strenous exercise or trauma
Chest pain w/ inspiration/ difficulty ventilating
Decreased breathsounds
Hyperresonance on percussion
Possible Pneumothorax
Thoracic/Rib pain W/
Hx of infection
Pleuritic pain
Fever/ Chills/Nausea
Possible pneumonia
Thoracic/Rib pain W/
Middle aged women
Elevated WBC count
Colicky pain in R upper abdominal quadrant/ R scapular pain
Symptoms worse with ingestion of fatty food
Cholecystitis
Thoracic/Rib pain W/
Dull/Gnawing pain or burning in epigastrium midback region
symptoms reliefed w/ food
hx of infection
hx of stress
constipation/vomiting
coffee ground emesis
Possible peptic ulcer
pyelonephritis
nephrolithiasis
Spinal Fx
Questions to ask for thoracic/rib pain
Hx of heart problems?
Nitroglycerin use?
Diabetes?
HTN?
Smoking?
Position dependent pain?
Surgery?
Bedridden?
Difficulty breathing,sneezing,coughing?
Recent infection?
Meningitis
Additional rib/thoracic questions
Recent trauma to chest/MVA?
Coughing up sputum?
Symptoms relieved w/ eating?
Fatty foods increase symptoms?
UTI?
Kidney Stone?
Severe back/flank pain?
1 brain tumor
subarachnoid hemorrage
Questions for screening head/face/tmj pain
Depressed immune system?
Recent intestinal infection, mumps, or herpes?
Contact w/ pigeon droppings?
Living in close quarters w/ lot of people like military or dormatory?
Recent trauma?
High fever
Nausea/vomiting
light sensitivity?
Inability to concentrate?
C Spine and shoulder pain presenting w/
Cervical ligamentous instability w/ possible cord compromise
C Spine and shoulder pain presenting w/
Cervical and shoulder girdle peripheral entrapment
Cervical spine/shoulder pain w/
Pancoast’s tumor (superior sulcus lung tumor)
Medical screening questions for shoulder/ C spine
Direct blow?
Excessive use?
Traction injury?
FOOSH?
Difficulty lifting arm?
Pin needle sensation?
Do you experience pain that doesn’t improve w/ rest?
elbow/wrist/hand pain w/
Radial head fx
elbow/wrist/hand pain w/
Distal radius/colle’s fracture
Elbow/Wrist/Hand pain w/
Scaphoid fracture
Elbow/Wrist/Hand pain w/
Lunate Fx or dislocation
