Module 1B: Student Differential Diagnosis Flashcards
What are some of the challenges of the acute care environment for patients?
Physical, psychological, emotional challenges
- change of routine
- lack of privacy/independence
- pain
- potential lifestyle change
- medical crisis
- critical illness/long-term illness
- lack of control
- confusion, fear, anger
What are some of the challenges of the acute care environment for the PT?
Physical, psychological, emotional challenges
- Pt refusal (too tired, bad mood)
- high turnover (working w/ lots of new Pts)
To minimize infection risk, you should always _______
Wash your hands
In most hospitals, a code red indicates a _______
Fire
In most hospitals, a code blue indicates a _______
Cardiac/respiratory arrest or a medical emergency
Needles should never be _______
reused, discarded in trash, or recapped*
Before leaving a Pt, make sure they have a _______ and the _______ are up
call light; top rails*
Leave assistive devices such as walkers in the Pt’s _______
reach
An _______ is one of the most common adverse events in acute care and accounts for increased lengths of stay, cost, morbidity, and mortality
infection
What are some factors that can increase a Pt’s chance of falling?
AKA What are some fall risks?
- Prior falls
- Age
- Polypharmacy (use of multi. drugs at same time)
- Use of diuretics or antihypertensive medications
- Bowel and bladder incontinence (lack of bowel/bladder control)
- Visual acuity (dim lights make it hard to see)
- Presence of lines and tubes (can get tangled)
- Med. conditions such as neuropathy
- Dementia, memory impairment, confusion
When are restraints used?
For Pts who are at risk of injuring themselves or others
Are all restraints physical restraints?
No, there are also chemical and environmental restraints such as sedating medication and bed rails
What are some Do’s of restraints?
- DO tie w/ a slip-knot
- DO tie to an immovable object
- DO rmr to re-tie after PT
- DO notify the team if you feel the Pt is excessively retrained, and vice-versa
What are some Don’ts of restraints?
- DON’T tie too tight
- DON’T leave restraint “tails” hanging during PT
Orders for restraints must be re-written every ___ hrs
24
What are some examples of restraints?
- ankle/wrist ties (P)
- vest ties (P)
- netted beds (E)
- medications (C)
- all bed rails in the raised position (E)
- gait belt (P)
What is orthostatic hypotension, as a cardiac effect of prolonged bed rest?
Sitting or lying down leads to LBP
Pt is constantly lying down during bed rest
What is thromboembolism, as a hematologic effect of prolonged bed rest?
Blood clot obstructs a blood vessel, causing blood to remain stuck in an area
No movement → may make it more diff. for blood to circulate
PT Imp: ankle/heel pumps may help blood flow w/ minimal mvmt
What is ventilation-perfusion mismatch, as a respiratory effect of prolonged bed rest?
Lung receives O2 w/o blood flow, or blood flow w/o O2
Occurs when an airway is obstructed
What is bowel motility, as a gastrointestinal (GI) effect of prolonged bed rest?
No physical movement → no bowel movement in the body
PT Imp: As soon as Pt gets up, they will need to go #2
What is muscle weakness, as a musculoskeletal effect of prolonged bed rest?
Loss of muscle strength/tone, possible atrophy
Pt needs movement to keep strength
PT Imp: Pt may be weaker than they look
What is risk of contracture, as a musculoskeletal effect of prolonged bed rest?
Joints get stiff w/o movement
Muscles don’t want to relax after being stretched in the same position for a long time
What is reduced pain threshold, as a neurologic effect of prolonged bed rest?
Pt becomes more sensitive to a stimulus that wasn’t painful before
PT Imp: be gentle, Pt is more sensitive to pain
What is pressure ulcer formation, as an integumentary effect of prolonged bed rest?
Skin & soft tissue press against hard surfaces for a while → reduces blood supply to that area → forms bedsores/pressure sores
PT Imp: be careful around red areas of skin (skin check)
Critical Illness Polyneuropathy (CIP) is commonly seen in Pts w/…
sepsis, respiratory failure, or multisystem organ failure
What are symptoms (Sx) of Critical Illness Polyneuropathy (CIP)?
- distal extremity weakness
- muscle wasting
- sensory loss
- paresthesia
- decreased deep tendon reflexes (DTR)
The etiology of CIP is unknown but it’s possibly related to…
medication, elevated glucose levels, nutritional, or toxic factors
Critical Illness Myopathy (CIM) is also known as _______
Acute steroid myopathy
What are symptoms (Sx) of Critical Illness Myopathy (CIM)?
- diffuse quadriparesis (mostly aff. LG proximal muscles)
- respiratory muscle weakness
- decreased deep tendon reflexes (DTR)
- sensation remains intact
What is the etiology of CIM?
thought to be a result of high-dose corticosteroids and a neuromuscular (NM) blockade
What are the 4 factors of CIP & CIM pathogenesis (development)?
Microvascular alterations
Metabolic alterations
Electrical alterations
Bioenergetic failure
What are factors of microvascular alterations, leading to the development of CIP & CIM?
- vasodilation (blood vessels widen)
- inc. permeability
- endoneurial edema (exc. accumulation of fluid in interstitial connective tissue of a peripheral nerve)
- hypoxemia* (lack of O2 in blood)
- extravasation (leakage of blood, lymph, or fluid from a tube into tissue)
- cytokine production (T cell, macrophage)
What are factors of metabolic alterations, leading to the development of CIP & CIM?
- hyperglycemia* (high blood glucose)
- hormone imbalance
- hypoalbuminemia (low albumin prod. → fluid can’t remain in blood vessels)
- amino acid deficiency (lack of protein)
- activation of proteolytic pathways (break down proteins)
What are factors of electrical alterations, leading to the development of CIP & CIM?
- ion channel dysfunction
- cell depolarization
- cell inexcitability (can’t generate action potential)
- altered Ca2+ homeostasis
- changes in excitation-contraction coupling* (rhythm can be thrown off)
What are factors of bioenergetic failure, leading to the development of CIP & CIM?
- antioxidant depletion (lose protection against free radicals)
- reactive O2 species (ROS) increase
- mitochondrial dysfunction (can affect other diseases)
- apoptosis* (death of cell)
What is the difference b/t diagnosis (Dx) vs. prognosis (Px)?
Dx is the label/explanation given for relevant signs & symptoms
Px is how well a PT thinks a Pt will do based on age, motivation, etc.
What is Px used for?
Prepares Pt mentally (how well they’ll do, how long it’ll take, difficulty of PT)
Convinces insurance that PT will benefit the Pt (or not)
What is differential diagnosis?
Determination of which disease (out of 2 or more) a client is suffering from
Compare/contrast findings
Provides diff. options
What is the difference b/t signs vs. symptoms?
Signs are observed (skin color, edema, postural findings, atrophy, HR, BP, temp, O2 sats)
Symptoms are reported by the Pt (pain, discomfort, numbness, dizziness, tingling, fatigue, ringing in ears)
How should you structure an evaluation?
Chart Review if avail. (usually avail. in acute care)
Subjective interview
Objective examination
Assessment
Plan
What is included in a Medical Chart Review?
- corner stamp (age/birth date, name, attending MD, admit date, medical record #)
- advanced directives (DNR status is usually written written on outside of chart)
- physician’s report (Hx and physical, Dx, PMH, HPI)
- surgery notes (date, complications, restrictions, how well they think post-op will go)
- medications
- orders (orders for PT, restrictions like weight bearing/fluid/dietary)
- imaging (radiology)
- discharge planning (family support, living situation, insurance)
- lab results
- other disciplines (PT/OT/ST)
- nursing notes (admit eval, vitals, medication, daily routine/visitor, diet, bowel/bladder)
- progress notes
What does a “red” chart indicate?
There are new orders that the nsg staff needs immediately
Keep the chart close to the charge nurse
What does a “yellow” chart indicate?
Orders have been read once but still needs to be noted by a 2nd nurse
May be able to take the chart, but ask first
If not flagged, you may take the chart to the charting area
Can you copy chart materials without permission?
Never, due to HIPAA guidelines
PT can’t even release chart materials to Pts directly, they must go through a process
What is in the History (Hx) portion of SOAP notes?
- date of surgery
- social info
- MD diagnosis
- prior Dx illness/conditions
- restrictions (weight-bearing)
What is in the Subjective portion of SOAP notes?
During eval:
- Pt profile (age, occupation, hobbies, gender, ethnicity)
- Pt comments/concerns
- Pt goals**
- body chart (localize Sx, pain, numbness, tingling, referred/radiating pain)
- Hx of present illness (sudden/gradual)
- past Hx
- Tx that worked (medication, past Tx)
- 24 hr behavior (pain in AM/PM, constant/changing)
- pain level
During Tx:
- pain level before/after Tx
- ex. difficulty level
What is in the Objective portion of SOAP notes?
During eval:
- Vital signs (BP, O2)
During Tx:
- names of ex. performed
- reps/duration of ex. performed
- resistance levels of ex.
- assist. level needed
- modalities/Tx used
What is in the Assessment portion of SOAP notes?
During eval:
- Pt’s major problem (ex: LB pain, radicular neuropathy)
- Differential diagnoses
During Tx:
- Pt progress/status
- Pt goals
What is in the Plan portion of SOAP notes?
During eval:
- tests, procedures, consultations (if needed)
- Pt education, pharmacology (if needed)
- plans for follow-up visit
During Tx:
- duration of Tx (3 d/wk, 12 wks)
- type of Tx needed (traction, cryoTx, modalities)
What are some PROs of asking open-ended questions?
Allows Pt to control and direct interview
Likely to uncover imp. info
What are some examples of open-ended questions?
Tell me why you are here.
What makes your pain worse?
How did you sleep last night?
What are some CONs of asking closed-ended questions?
Pt responses may be limited
Can be impersonal
Limits info you get from Pt
What are some examples of closed-ended questions?
Is the pain worse in the AM or PM?
Are you under any stress?
Did you sleep well last night?
First, how do you interpret a Pt’s Hx?
- identify info not likely contributing to the problem
- identify 1st/2nd problems
- identify info that’s inconsistent w/ the presenting complaint
- generate a “working hypothesis” (general idea of what you think may be the problem)
- determine whether PT will help or if it’s outside your scope of practice (referral)
After interpreting a Pt’s Hx, what do you do?
Make a plan
Rule in/out your hypothesis of Pt’s problem
Only test what you need to
What are the 6 vital signs?
Blood pressure
Temperature
Pulse (HR)
Respiration
Pain
Gait speed
What are “Red flags”?
Signs/Sx that should make you consider referring the Pt back to their physician
What type of red flag is this problem?
Anginal (chest) pain not relieved in 10-20 min
Emergency Department
What type of red flag is this problem?
Pt w/ angina who has nausea, vomiting, or profuse sweating
Emergency Department
What type of red flag is this problem?
Diabetic (or any) Pt who is confused, lethargic, or has changes in mental alertness and function
Emergency Department
What type of red flag is this problem?
Onset of incontinence or saddle anesthesia
Incontinence: loss of bowel/bladder control
Saddle anesthesia: sudden numbness in groin/thigh area
Emergency Department
What type of red flag is this problem?
Anaphylactic shock Sx (hives, asthma, tachycardia, hypotension, anxiety, nausea, vomiting)
Emergency Department
What type of red flag is this problem?
Heart palpitations
Emergency Department
What type of red flag is this problem?
Difficulty swallowing/urination
Emergency Department
What type of red flag is this problem?
Unexplained exc. perspiration
Emergency Department
When is a red flag a maybe emergency/maybe referral?
If the Sx is not normal for the Pt, but depends on if the situation could lead to the Sx or not
ex: dizziness if dehydrated, faintness if tired, high HR if Pt had intense ex.
- constant/intense pain
- dizziness/faintness
- problems w/ vision
- temporary/no relief w/ rest/change in position
- Sx that present bilaterally (edema, numbness, weakness)
- abdominal edema (ascites) - sign of liver disease
What type of red flag is this problem?
Blood in urine
Refer back to MD
What type of red flag is this problem?
Fever, nausea, vomiting, night pain, night sweats, pain w/ urination
Refer back to MD
What type of red flag is this problem?
Unusual menstrual Hx
Refer back to MD
What type of red flag is this problem?
Cyclical patterns of Sx (good → bad → good → bad)
Refer back to MD
What type of red flag is this problem?
Unexplained weight loss/gain
Refer back to MD
What type of red flag is this problem?
Disproportionate pain relief w/ aspirin (CA Pts)
Refer back to MD
What type of red flag is this problem?
Clubbing (hands)
Refer back to MD
Sign of chronic O2 deprivation
ex: COPD
What type of red flag is this problem?
Peripheral edema
Refer back to MD
Sign of heart failure
What type of red flag is this problem?
Pain described as knifelike, boring (drilling), deep visceral (organ) pain
Refer back to MD
What type of red flag is this problem?
Pain doesn’t fit the neuromuscular (NM) pattern
Refer back to MD
What are the goals of a PT assessment?
Integrate subjective and objective exams
If your findings make sense after a PT assessment, what do you do?
Plan your Tx
If your findings don’t make sense after a PT assessment, what do you do?
Further review the S and O
Confer w/ a colleague
Refer Pt for a medical consultation
If a Pt responded to Tx for a musculoskeletal problem after intervention, your intervention could’ve either…
Been effective, or Pt just got better despite the intervention
If a Pt didn’t respond to Tx for a musculoskeletal problem after intervention, your intervention could’ve either…
Have been the wrong intervention, or the problem wasn’t amenable to intervention
If a Pt doesn’t have a musculoskeletal problem, PT will…
be inappropriate
so, PT should refer Pt elsewhere
Tx may only temporarily work or worsen the problem
If a Pt has a combination of musculoskeletal and non-musculoskeletal problems, PT…
may be appropriate and some Sx may improve
but, PT should still refer Pt elsewhere for Sx that PT doesn’t improve
What is deep somatic pain caused by?
Name examples
Injury/disease to bone, muscle, tendon, ligament etc.
ex: arthritis, bone fracture
How can deep somatic pain be described by Pts?
Dull or achy, can be sharp
Not always well-localized
Is deep somatic pain usually well-localized?
It’s not always well-localized
~ if pain is deep, it’s hard to pinpoint
What is superficial somatic pain caused by?
Name examples
Injury/disease of skin
ex: sprained ankle, bee sting
How can superficial somatic pain be described by Pts?
Sharp, burning, throbbing
Is superficial somatic pain usually well-localized?
It’s often well-localized
~pain on skin is easy to pinpoint
What is visceral pain caused by?
Name examples
Injury/disease of 1 or more organs (heart, liver, pancreas, GI)
Receptors are partic. sensitive to stretching, hypoxia (lack of O2 in tissues), or visceral inflammation
ex: angina, bowel distension (tummy bloating/swelling), pancreatitis, menstrual cramps
How can visceral pain be described by Pts?
Dull, aching, throbbing, pressured sensation
Is visceral pain usually well-localized?
It’s often poorly localized
Incl. referred pain
~ pain in organs is hard to pinpoint
Visceral pain may be assoc. w/ autonomic Sx such as…
sweating, nausea, BP/HR changes
What is neuropathic pain caused by?
Name examples
Injury/disease of the PNS/CNS
May have assoc. evidence of nerve damage (sensory impairment and/or weakness)
ex: neuropathy, phantom pain, irritated nerve root
How can neuropathic pain be described by Pts?
Burning, shooting, tingling, electric shock
Incl. radiating pain
What is viscerosomatic pain?
Organ pain is felt in the muscle (referred pain)
ex: Acute appendicitis → abdominal muscle rigidity & pain
MI → pain in L arm
What is somatovisceral pain?
Muscle pain is felt in the organ (referred pain)
ex: palpating a trigger point → nausea/vomiting/pain
What is somatoemotional pain?
Occurs when emotional/psychological distress causes physical pain, and vice-versa
ex: Pt w/ worker’s comp has back pain → feels uncertain about returning to work
What is referred pain?
Pain that is felt at a site diff. from its origin
ex: CAD → pain in L arm
Common w/ visceral pain (viscerosomatic, somatovisceral)
Can also be from trigger points (somatovisceral)
Why does referred pain occur?
Sensory nerves from diff. parts of the body share common pathways in the spinal cord
Acute nerve root irritation tends to be _______, _______, and _______
burning; shooting; constant
Chronic nerve root pain tends to be _______ or _______, and causes _______ _______
annoying; nagging
radiating pain
What is radiating pain?
Pain that is felt at the origin site and spreads to a different site, depending on the corresponding spinal nerve root(s)
ex: radicular pain from a herniated disc
What are the 3 patterns of radiating pain?
Dermatome (area of skin supplied by 1 spinal nerve root)
Scleratome (area of bone supplied by 1 spinal nerve root)
Myotome (area of muscle supplied by 1 spinal nerve root)
Muscle pain worsens with…
contraction/stretch of the muscle, and use of muscle, bone, tendon, bursa
Muscle pain can be caused by _______
ischemia, the lack of blood flow and O2
_______ brings relief to muscle pain
Rest
If a Pt awakens at night due to joint pain, what could be the cause?
Bone disease or neoplasm (new and abn. growth of tissue; sign of CA)
What is claudication?
Muscle pain caused by lack of blood flow/O2 during exercise, typ. walking
Crampy calf pain while walking can be explained by _______, and often indicates _______ _______ _______
claudication; peripheral artery disease (PAD)
Cardiac pain increase when there is an _______ demand on the heart
Name some examples of demands
increased
ex: exertion, cold weather, emotional distress
Cardiac pain typ. _______ w/ rest
decreases
As symptoms progress, pain may be…
present w/o an increase in activity
What is arterial pain caused by?
Inflammation of an artery
ex: migraine headaches
Arterial pain increases with increased _______ _______ _______
systolic blood pressure, b/c it increases pressure on an artery
Typ. described as “throbbing”
ex: bend over, fever
Pleural pain in the thoracic cavity correlates with _______ movements
respiratory
Pleural pain is typ. worse at the _______ _______ _______
end of inspiration
Pain at rest may be due to _______ from vascular disease, or _______
ischemia (lack of O2); neoplasm (new & abn. growth of tissue)
If pain is worse at night, wakes Pt up from sleep, and Pt can’t go back to sleep, what is the possible cause?
Neoplasm (new & abn. growth of tissue)
What are the 5 Ps of pain at rest?
Pain (disproportionate)
Pallor (loss of color)
Pulselessness
Paresthesia (numbness)
Paralysis
If the 5 Ps of pain at rest are present, what do you do?
Go to ER
Think acute arterial occlusion (sudden blockage of a peripheral artery → interrupts blood flow)
What are the cardinal cancer warning signs?
(CAUTION)
C hanges in bowel/bladder (sudden incontinence)
A sore that doesn’t heal
U nusual bleeding/discharge
T hickening or lump in breast/elsewhere
I nexplicable pain
O bvious change in wart/mole
N agging cough/hoarseness
Also proximal muscle weakness, change in deep tendon reflexes (DTR), persistent bone pain (esp. at PM)
