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Differential Diagnosis > Pain Types and Viscerogenic Pain Patterns > Flashcards

Pain Types and Viscerogenic Pain Patterns Flashcards

1
Q

What are the characteristics of VASCULAR pain?

A

Throbbing
Pounding
Pulsing
Beating

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2
Q

What are the characteristics of NEUROGENIC pain?

A 
Sharp
Crushing
Pinching
Burning
Hot 
Searing
Itchy
Stinging
Pulling
Jumping
Shooting
Electrical
Gnawing
Pricking
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3
Q

What are the characteristics of MUSCULOSKELETAL pain?

A 
Aching
Sore
Heavy
Hurting
Deep
Cramping
Dull
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4
Q

What are the characteristics of EMOTIONAL pain?

A 
Tiring
Miserable
Vicious
Agonizing
Nauseating
Frightful
Piercing
Dreadful
Punishing
Exhausting
Killing
Unbearable
Annoying
Cruel
Sickening
Torturing
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5
Q

What are the contents of the Verbal Descriptor Scale (VDS)?

A 
0 = No pain
1 = Slight pain
2 = Mild pain
3 = Moderate pain
4 = Severe pain
5 = Extreme pain
6 = Pain as bad as it can be
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6
Q

What are symptoms of pain characterized as in patients with cognitive impairments?

A

Verbal comments such as “ouch” or “stop”

Nonverbal vocalizations (moans, sighs, gasps)

Facial grimacing or frowning

Audible breathing independent of vaocalization (labored, short or long periods of hyperventilation)

Agitation or increased confusion

Unable to be consoled or distracted

Bracing or holding onto furniture

Decreased mobility

Lying very still, refusing to move

Clutching painful area

Resisting care provided by others, striking out, pushing others away

Sleep disturbance

Weight loss

Depression

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7
Q

What is the Nursing Assessment of Pain (PQRST)?

A

PROVOCATION and PALLIATION. What causes the pain and what makes it better or worse?

QUALITY of pain. What type of pain is present (aching, burning, sharp)?

REGION and RADIATION. Where is the pain located ? Does it radiate to other parts of the body?

SEVERITY on a scale of 1-10. Does the pain interfere with daily activities, mood, function?

TIMING. Did pain come on suddenly or gradually? Intermittent? How often? How long? Does it come at the same time?

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8
Q

What are the characteristics of SYSTEMIC pain pertaining to ONSET?

A

Recent, sudden

Does not present as observed for years without progression of symptoms

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9
Q

What are the characteristics of SYSTEMIC pain pertaining to DESCRIPTION?

A

Knife-like (stabbing from the inside out), boring, deep ache

Cutting, gnawing

Throbbing

Bone pain

Unilateral or bilateral

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10
Q

What are the characteristics of SYSTEMIC pain pertaining to INTENSITY?

A

Related to the degree of noxious stimuli; usually unrelated to presence of anxiety

Mild to severe

Dull to severe

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11
Q

What are the characteristics of SYSTEMIC pain pertaining to DURATION?

A

Constant, no change, awakens person at night

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12
Q

What are the characteristics of SYSTEMIC pain pertaining to PATTERN?

A

Although constant, may come in waves

Gradually progressive, cyclical

Night pain

  • Location: Chest and shoulder
  • Accompanied by shortness of breath, wheezing
  • Eating alters symptoms
  • Sitting up relieves symptoms (decreases venous return to the heart: possible pulmonary or cardiovascular etiology)

Symptoms unrelieved by rest or change in position

Migration arthralgias (pain/symptoms last for 1 week in 1 joint, then resolve and appear in another joint)

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13
Q

What are the characteristics of SYSTEMIC pain pertaining to AGGRAVATING FACTORS?

A

Cannot alter, provoke, alleviate, eliminate, or aggravate the symptoms

Organ dependent (examples):

  • Esophagus–eating or swallowing affects symptoms
  • Heart–cold, exertion, stress, heavy feeling affects symptoms
  • GI–peristalsis affects symptoms
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14
Q

What are the characteristics of SYSTEMIC pain pertaining to RELIEVING FACTORS?

A

Organ dependent examples:

  • Gallbladder–leaning forward may reduce symptoms
  • Kidney–leaning to the affected side may reduce symptoms
  • Pancreas–sitting upright or leaning forward may reduce symptoms
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15
Q

What are the characteristics of SYSTEMIC pain pertaining to ASSOCIATED S&S?

A

Fever, chills

Sweats

Unusual vital signs

Warning signs of cancer

GI symptoms (nausea, vomiting, anorexia, unexplained weight loss, diarrhea, constipation)

Early satiety (feeling full after eating)

Bilateral symptoms (paresthesias, weakness, edema, nail bed changes, skin rash)

Painless weakness of muscles (more often proximal, but may occur distally)

Dyspnea (breathlessness at rest or after mild exertion)

Diaphoresis (excessive perspiration)

Headaches, dizziness, fainting

Visual disturbances

Skin lesions, rashes, or itching that the client may not associate with the musculoskeletal symptoms

Bowel/bladder symptoms

  • Hematuria (blood in the urine)
  • Nocturia
  • Urgency (sudden need to urinate)
  • Frequency
  • Melena (blood in the feces)
  • Fecal or urinary incontinence
  • Bowel smears
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16
Q

What are the characteristics of MUSCULOSKELETAL pain pertaining to ONSET?

A

May be sudden or gradual, depending on history

  • SUDDEN–usually associated with acute overload stress, traumatic event, repetitive motion; can occur as a side effect of some meds (statins)
  • GRADUAL–secondary to chronic overload of the affected part; may be present off and on for years
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17
Q

What are the characteristics of MUSCULOSKELETAL pain pertaining to DESCRIPTION?

A

Usually unilateral

May be stiff after prolonged rest, but pain level decreases

Achy, cramping pain

Local tenderness to pressure is present

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18
Q

What are the characteristics of MUSCULOSKELETAL pain pertaining to INTENSITY?

A

May be mild to severe

May depend on the person’s anxiety level–the level of pain may increase in a client fearful of a “serious” condition

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19
Q

What are the characteristics of MUSCULOSKELETAL pain pertaining to DURATION?

A

Can be modified by rest or change in position

May be constant but is more likely to be intermittent, depending on the activity or the position

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20
Q

What are the characteristics of MUSCULOSKELETAL pain pertaining to PATTERN?

A

Restriction of active/passive/accessory movements observed

One or more particular movements “catch” the patient and aggravate pain

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21
Q

What are the characteristics of MUSCULOSKELETAL pain pertaining to AGGRAVATING FACTORS?

A

Altered by movement; pain may become worse with movement or some myalgia decreases with movement

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22
Q

What are the characteristics of MUSCULOSKELETAL pain pertaining to RELIEVING FACTORS?

A

Symptoms reduced or relieved by rest or change in position

Muscle pain is relieved by short periods of rest without resulting stiffness, except in the case of fibromyalgia; stiffness may be present in older adults

Stretching

Heat, cold

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23
Q

What are the characteristics of MUSCULOSKELETAL pain pertaining to ASSOCIATED S&S?

A

Usually none, although stimulation of trigger points (TrPs) may cause sweating, nausea, blanching

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24
Q

What are all the possible SOURCES of pain?

A 
Cutaneous
Deep somatic
Visceral
Neuropathic
Referred
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25
Q

What are all the possible TYPES of pain?

A

Tension

Inflammatory

Ischemic

Myofascial pain

  • Muscle tension
  • Muscle spasm
  • Trigger points (TrPs)
  • Muscle deficiency (weakness and stiffness)
  • Muscle trauma

Joint pain

  • Drug induced
  • Chemical exposure
  • Inflammatory bowel disease
  • Septic arthritis
  • Reactive arthritis

Radicular pain

Arterial, pleural, tracheal

Gastrointestinal pain

Pain at rest

Night pain

Pain with activity

Chronic pain

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26
Q

What are all the possible CHARACTERISTICS/PATTERNS of pain?

A

Client describes:

  • Location/onset
  • Description
  • Frequency
  • Duration
  • Intensity

Therapist recognizes the pattern:

  • Vascular
  • Neurogenic
  • Musculoskeletal/spondylotic
  • Visceral
  • Emotional
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27
Q

What conditions cause CENTRAL neuropathic pain?

A

Multiple sclerosis (MS)

Headache (migraine)

Stroke

Traumatic brain injury (TBI)

Parkinson’s disease

Spinal cord injury (incomplete)

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28
Q

What conditions cause PERIPHERAL neuropathic pain?

A

Trigeminal neuralgia (Tic douloureux)

Poorly controlled diabetes mellitus (metabolic-induced)

Vincristine (drug-induced, used in cancer treatment)

Isoniazid (drug-induced, used to treat tuberculosis)

Amputation (trauma)

Crush injury/brachial avulsion (trauma)

Herpes zoster (shingles, postherpetic neuralgia)

Complex regional pain syndrome (causalgia)

Nerve compression syndromes (carpal tunnel syndrome, thoracic outlet syndrome)

Paraneoplastic neuropathy (cancer-induced)

Cancer (tumor infiltration/compression of nerve)

Liver or biliary impairment (liver cancer, cirrhosis, primary biliary cirrhosis)

Leprosy

Congenital neuropathy (porphyria)

Guillain-Barre syndrome

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29
Q

What are the risk factors for rhabdomyolysis as far as trauma?

A

Crush injury

Electrical shock

Severe burns

Extended mobility

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30
Q

What are the risk factors for Rhabdomyolysis?

A

Trauma

Extreme muscular activity

Toxic effects

Metabolic abnormalities

Medication-induced

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31
Q

What are examples of TRAUMA associated with Rhabdomyolysis?

A

Crush injury

Electrical shock

Severe burns

Extended mobility

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32
Q

What are the S&S of TRAUMATIC Rhabdomyolysis?

A

Profound muscle weakness

Pain

Swelling

Stiffness and cramping

Associated S&S

  • Reddish-brown urine (myoglobin)
  • Decreased urine output
  • Malaise
  • Fever
  • Sinus tachycardia
  • Nausea, vomiting
  • Agitation, confusion
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33
Q

What are examples of EXTREME MUSCULAR ACTIVITY associated with Rhabdomyolysis?

A

Strenuous exercise

Status epilepticus

Severe dystonia

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34
Q

What are examples of TOXIC EFFECTS associated with Rhabdomyolysis?

A 
Ethanol
Ethylene glycerol
Isopropanol
Methanol
Heroin
Barbiturates
Methadone
Cocaine
Tetanus
Ecstasy (street drug)
Carbon Monoxide 
Snake venom
Amphetamines
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35
Q

What are examples of METABOLIC ABNORMALITIES associated with Rhabdomyolysis?

A

Hypothyroidism

Hyperthyroidism

Diabetic ketoacidosis

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36
Q

What are examples of MEDICATION-INDUCED causes of Rhabdomyolysis?

A

Inadvertent IV infiltration (e.g. amphotericin B, azathioprine, cyclosporine)

Cholesterol-lowering statins (Zocor, Lipitor, Crestor)

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37
Q

What are the SYSTEMIC causes of joint pain?

A

Allergic reactions (meds such as antibiotics)

Side effect of medications such as statins, prolonged use of corticosteroids, aromase inhibitors

Delayed reaction to chemicals or environmental factors

Sexually transmitted infections (STIs) such as HIV, syphilis, chlamydia, gonorrhea)

Infectious arthritis

Infective endocarditis

Recent dental surgery

Lyme disease

Rheumatoid arthritis

Other autoimmune disorders (systemic lupus erythematosus, mixed connective tissue disease, scleroderma, polymyositis)

Leukemia

Tuberculosis

Acute rheumatic fever
Chronic liver disease (hepatic osteodyst. affecting wrists & ankles; hepatitis causing arthralgias)

Inflammatory bowel disease (Crohn’s disease or regional enteritis)

Anxiety or depression (Major depressive disorder)

Fibromyalgia

Artificial sweeteners

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38
Q

What is included in the CLINICAL PRESENTATION of SYSTEMIC joint pain?

A

Awakens at night

Deep aching, throbbing

Reduced by pressure

Constant or waves/spasm

Cyclical, progressive symptoms

39
Q

What is included in the PAST MEDICAL HISTORY of SYSTEMIC joint pain?

A

Recent history of infection

History of bone fracture, joint replacement, or arthroscopy

History of human bite

Sore throat, headache with fever in the last 3 weeks or family/household member with recently diagnosed strep throat

Skin rash (infection, medications)

Recent medications (last 6 weeks); any drug, but especially statins (cholesterol lowering), antibiotics, aromatase inhibitors, chemotherapy

Hormone associated (Post-menopausal status, low estrogen levels)

History of injection drug use/abuse

History of allergic reactions

History of GI symptoms

Recent history of enteric or venereal infection or new sexual contact (Reiter’s)

Presence of extensor surface nodules

40
Q

What is included in the ASSOCIATED S&S of SYSTEMIC joint pain?

A

Jaundice

Migratory arthralgias

Skin rash/lesions

Nodules (extensor surfaces)

Fatigue

Weight loss

Low grade fever

Suspicious or aberrant lymph nodes

Presence of GI symptoms

Cyclical, progressive symptoms

Proximal muscle weakness

41
Q

What is included in the CLINICAL PRESENTATION of MUSCULOSKELETAL joint pain?

A

Decreases with rest

Sharp

Reduced by change in position

Reduced or eliminated when stressful action is stopped

Restriction of active and passive ROM

Restriction of accessory motions

1 or more movements “catch,” reproducing or aggravating pain/symptoms

42
Q

What is included in the PAST MEDICAL HISTORY of MUSCULOSKELETAL join pain?

A

Repetitive motion

Arthritis

Static postures (prolonged)

Trauma (including domestic violence)

43
Q

What is included in the ASSOCIATED S&S of MUSCULOSKELETAL joint pain?

A

Usually none

Check for trigger points

TrPs may be accompanied by some minimal ANS phenomenon (e.g. nausea, sweating)

44
Q

What are the screening questions to ask for joint pain?

A

Please describe the pattern of pain/symptoms from when you wake up in the morning to when you go to sleep at night?

Do you have any symptoms of any kind anywhere else in your body? (You may have to explain these symptoms don’t have to relate to the joint pain; if the client has no other symptoms, offer a short list including constitutional symptoms, heart palpitations, unusual fatigue, nail or skin changes, sores or lesions anywhere but especially in the month or on the genitals, and so forth)?

Have you ever had cancer of any kind, leukemia, Crohn’s disease, sexually transmitted infection, fibromyalgia, joint replacement or arthroscopic surgery of any kind?

Have you recently (last 6 weeks) had any fractures, bites (human/animal), antibiotics or other medications, infections, skin rashes or other skin changes?

Do you drink diet soda or use aspartame?

45
Q

What are some other quick survey questions for joint pain?

A

What kind of work do you do?

Do you think your health problems are related to your work?

Are your symptoms better or worse when you’re at home or at work? (Do others at work have similar problems?)

Have you been exposed to dusts, fumes, chemicals, radiation, or loud noise?

Do you live near a hazardous waste site or any industrial facilities that give off chemical odors or fumes?

Do you live in a home built more than 40 years ago? Have you done any renovations or remodeling?

Do you use pesticides in your home, in your garden, or on your pets?

What is your source of drinking water?

Chronology of jobs? (type of industry, type of jobs, years worked)

How new is the building you now work in?

Exposure survey (protective equipment used, exposure to dust, radiation, chemicals, biologic hazards, physical hazards)

46
Q

What are the risk factors for infectious arthritis?

A

A history of:

  • Previous surgery, especially arthroscopy for joint repair or replacement
  • Human bite, tick bite, fracture, central line placement
  • Direct, penetrating trauma
  • Infection of any kind
  • RA, Lupus, scleroderma, mixed connective tissue disease
  • Diabetes
  • Sarcoidosis
  • Sexually active, young adult
  • Injection drug user
  • Chronic joint damage (RA, gout)
  • Previous infection of joint prosthesis
  • Recent immunization
  • Increased age
  • Indwelling catheter (especially when prosthetic joint present)
  • Malnutrition, skin breakdown
  • Immunosuppression or immunocompromised
47
Q

What are the clinical signs and symptoms of INFECTIOUS ARTHRITIS?

A

Fever (low-grade or high), chills, malaise

Recurrent sore throat

Lymphadenopathy

Persistent joint pain

Single painful swollen joint

Multiple joint involvement (often migratory)

Pain on weight-bearing

Back pain (infective endocarditis)

Skin lesions (characteristic of the specific underlying infection)

Conjunctivitis, uveitis

Other MSK sx depending on specific underlying infection:
- Myalgias
- Tenosynovitis (especially wrist
and ankle extensor tendon sheaths)

Elevated C-reactive protein and sedimentation rate

48
Q

What are some screening questions for night pain?

A

Tell me about the pattern of your symptoms at night (open-ended)

Can you lie on that side? For how long? (does it wake you up when you roll onto that side?)

How are you feeling in general when you wake up? (Do you have any other symptoms when the pain wakes you up? Give the client time to answer before prompting with choices such as coughing, wheezing, SOB, nausea, need to go to the bathroom, night sweats)

Always ask the client reporting night pain of any kind (not just bone pain) the following screening questions:

  • What makes it better, worse?
  • What happens to your pain when you sit up? (Upright posture reduces venous return to the heart; decreased pain when sitting up may indicate cardiopulmonary cause)
  • How does taking aspirin affect your pain/symptoms? (Disproportionate pain relief can occur using aspirin in the presence of bone cancer)
  • How does eating or drinking affecting your pain/symptoms
  • Does taking an antacid such as Tums change your pain/symptoms? (Check vital signs)
49
Q

What are the AGS Recommendations for chronic pain assessment in the geriatric population?

A

All older clients should be assessed for signs of chronic pain

Use alternate words for pain when screening older clients (burning, discomfort, aching, sore, heavy, tight)

Contact caregiver for pain assessment in adults with cognitive or language impairments

Clients with cognitive or language impairments should be observed for non-verbal pain behaviors, recent changes in function, and vocalizations to suggest pain (irritability, agitation, withdrawal, gait changes, tone changes, nonverbal but vocal utterances such as groaning, crying, or moaning)

Follow AGS guidelines for comprehensive pain assessment including:
- Medical history
- Medication history, including current and previously used prescription and OTC drugs, as well as any nutraceuticals (natural products, “remedies”)
- Physical examination
- Review pertinent lab results and diagnostic tests (look for clues to the sequence of events leading to present pain complaint)
- Assess characteristics of pain (frequency, intensity, duration, pattern, description, aggravating and relieving factors); use a standard pain scale such as the visual analog scale
Observe neuromuscular (NMS) system for:
- Neurologic impairments
- Weakness
- Hyperalgesia; hyperpathia (exaggerated response to pain stimulus)
- Allodynia (skin pain to noxious stimulus)
- Numbness, paresthesia
- Tenderness, trigger points
- Inflammation
- Deformity
Pain that affects function or quality of life should be included in the medical problem list

50
Q

What are ROM changes with systemic disease?

A

EARLY SCREENING:
Full and pain-free ROM

LATER SCREENING: Biomechanical response to pain results in changes associated with splinting or guarding

51
Q

What are the PHYSICAL symptoms of anxiety and panic?

A

Increased sighing respirations

Increased BP

Tachycardia

Muscle tension

Dizziness

Lump in throat

Shortness of breath

Clammy hands

Dry mouth

Diarrhea

Nausea

Profuse sweating

Restlessness, pacing, irritability, trouble concentrating

Chest pain

Headache

Low back pain

Myalgia (muscle pain, tension, tenderness)

Arthralgia

Abdominal (stomach) distress
Irritable bowel syndrome (IBS)

52
Q

What are the BEHAVIORAL symptoms of anxiety and panic?

A

Hyper-alertness

Irritability

Uncertainty

Apprehension

Difficulty with memory or concentration

Sleep disturbance

53
Q

What are the COGNITIVE symptoms of anxiety and panic?

A

Fear of losing mind

Fear of losing control

54
Q

What are the PSYCHOLOGIC symptoms of anxiety and panic?

A

Phobias

Obsessive-compulsive disorder (OCD)

55
Q

What CARDIOVASCULAR conditions are commonly associated with depression?

A

Atherosclerosis

HTN

MI

Angioplasty/bypass surgery

56
Q

What CNS conditions are commonly associated with depression?

A

Parkinson’s disease

Huntington’s disease

Cerebral arteriosclerosis

Stroke

Alzheimer’s disease

Temporal lobe epilepsy

Post-concussion injury

Multiple Sclerosis

Miscellaneous focal lesions

57
Q

What ENDOCRINE/METABOLIC conditions are commonly associated with depression?

A

Hyperthyroidism

Hypothyroidism

Addison’s disease

Cushing’s disease

Hypoglycemia

Hyperglycemia

Hyperparathyroidism

Hyponatremia

Diabetes

Pregnancy (postpartum)

58
Q

What VIRAL conditions are commonly associated with depression?

A

AIDS

Hepatitis

Pneumonia

Influenza

59
Q

What NUTRITIONAL conditions are commonly associated with depression?

A

Folic acid deficiency

Vitamin B6 deficiency

Vitamin B12 deficiency

60
Q

What IMMUNE conditions are commonly associated with depression?

A

Fibromyalgia

Chronic fatigue syndrome

Lupus

Sjogren’s syndrome

RA

Immunosuppresssion (Corticosteroid treatment)

61
Q

What CANCER conditions are commonly associated with depression?

A

Pancreatic

Bronchogenic

Renal

Ovarian

62
Q

What MISCELLANEOUS conditions are commonly associated with depression?

A

Pancreatitis

Sarcoidosis

Syphilis

Porphyria

Corticosteroid treatment

63
Q

What drugs are commonly associated with depression?

A

Anxiety medications (Valium, Xanax)

Illegal drugs (cocaine, crack)

Antihypertensive drugs (beta blockers, anti-adrenergics)

Cardiovascular medications (digitoxin, digoxin)

Antineoplastic agents (vinblastine)

Opiate analgesics (morphine, Demerol, Darvon)

Anticonvulsants (Dilantin, phenobarbital)

Corticosteroids (prednisone, cortisone, dexamethasone)

NSAIDs

Alcohol

Hormone replacement therapy and oral contraceptives

64
Q

What are the GENERAL effects depression causes?

A

Persistent fatigue

Insomnia, sleep disturbance

**Clinical signs and symptoms

65
Q

What are the CARDIOVASCULAR effects depression causes?

A

Chest pain

  • Associated with MI
  • Can be atypical chest pain not associated with CAD
66
Q

What are the GI effects depression causes?

A

IBS

Esophageal dysmotility

Nonulcer dyspepsia

Functional abdominal pain (heartburn)

67
Q

What are the NEUROLOGIC effects depression causes?

A

Paresthesias

Dizziness

Difficulty concentrating and making decisions; problems with memory

68
Q

What are the MUSCULOSKELETAL effects depression causes?

A

Weakness

Fibromyalgia

Myofascial pain syndrome

Chronic back pain

69
Q

What are the IMMUNE effects depression causes?

A

Multiple allergies

Chemical hypersensitivity

Autoimmune disorders

Recurrent or resistent infections

70
Q

What are the DYSREGULATION effects depression causes?

A

Automatic instability:

  • Temperature intolerance
  • BP changes

Hormonal dysregulation

Migraine and tension headaches

71
Q

What are the OTHER effects depression causes?

A

SOB associated with asthma/not clearly explained at times

Anxiety or panic disorder

72
Q

What are the S&S of depression?

A

Persistent sadness, low mood, feelings of emptiness

Frequent or unexplained crying spells

A sense of hopelessness

Feelings of guilt or worthlessness

Problems sleeping

Loss of interest or pleasure in ordinary activities/loss of libido

Fatigue or decrease in energy

Appetite loss (or over-eating)

Difficulty in concentrating, remembering, and making decisions

Irritability

Persistent joint pain

Headache

Chronic back pain

Bilateral neurologic symptoms of unknown cause (numbness, dizziness, weakness)

Thoughts of death or suicide

Pacing and fidgeting

Chest pain and palpitations

73
Q

What are the S&S of panic disorder?

A

Racing or pounding heartbeat

Chest pains and/or palpitations

Dizziness, light-headedness, nausea

Headaches

Difficulty breathing

Bilateral numbness or tingling in nose, cheeks, lips, fingers, toes

Sweats or chills

Hand wringing

Dream-like sensations or perceptual distortions

Sense of terror

Extreme fear of losing control

Fear of dying

74
Q

What tools can you use for emotional overlay?

A

McGill Pain Questionnaire (MPQ)

Symptom magnification and illness behavior

Waddell’s non-organic signs

75
Q

What are the SIGNS of Waddell’s non-organic TENDERNESS?

A

SUPERFICIALLY– client’s skin tender to light pinch over a wide area of lumbar skin, unable to localize to one structure

NON-ANATOMIC– deep tenderness felt over a wide area, not localized to one structure; crosses multiple somatic boundaries

76
Q

What are the SIGNS of Waddell’s non-organic SIMULATION TESTS?

A

AXIAL LOADING– light vertical loading over client’s skull in standing position reproduces lumbar spine pain

ACETABULAR ROTATION– lumbosacral pain from upper trunk rotation, back pain reported when pelvis and shoulder are passively rotated in the same plane as the patient is standing, consider it a positive test if pain aries in first 30 degrees

77
Q

What are the SIGNS of Waddell’s non-organic DISTRACTION TESTS?

A

STRAIGHT LEG RAISE DISCREPANCY– marked improvement of SLR when client is distracted as compared with formal testing; different response to SLR in supine (worse) compared with seated (better) when both tests should have the same result in the presence of organic pathology

DOUBLE LEG RAISE– when both legs are raised after SLR, organic response would be of a greater degree; patients with nonorganic component demonstrate less double leg raise as compared with SLR

78
Q

What are the SIGNS of Waddell’s non-organic REGIONAL DISTURBANCES?

A

WEAKNESS– cog-wheeling or giving way of many muscle groups that cannot be explained on a neurologic basis

SENSORY– diminished sensation fitting a “stocking” rather than a dermatomal pattern

79
Q

What are the SIGNS of Waddell’s non-organic OVERREACTION?

A

Disproportionate verbalization, facial expression, muscle tension, tremor, collapsing, or sweating

Patient may exhibit any of the following behaviors during the physical examination:

  • Guarding
  • Bracing
  • Rubbing
  • Sighing
  • Clenching teeth
  • Grimacing
80
Q

What are Waddell’s non-anatomic or behavioral description of symptoms?

A

Pain at the tip of the tailbone

Whole leg pain from groin down to below knee in a stocking pattern (intermittent)

Whole leg numbness or whole leg “going dead” (intermittent)

Whole leg giving-way or collapsing (intermittent, patient still maintains upright position)

Constant pain for years on end without relief

Unable to tolerate any treatment, reaction or side-effects to any intervention

Emergency admission to hospital for back pain without precipitating traumatic event

81
Q

What are the S&S of conversion disorder?

A

Sudden, acute onset

Lack of concern about the symptoms

Unexplainable motor or sensory function impairment

MOTOR:

  • Impaired coordination or balance and/or bizarre gait pattern
  • Paralysis or localized weakness
  • Loss of voice, difficulty swallowing, sensing a lump in throat
  • Urinary retention

SENSORY:

  • Altered touch or pain sensation (paresthesia or dysesthesia)
  • Visual changes (double vision, blindness, black spots)
  • Hearing loss (mild to profound deafness)
  • Hallucinations
  • Seizures or convulsions
  • Absence of significant lab findings
  • Electrodiagnostic testing within normal limits
  • Deep tendon reflexes within normal limits
82
Q

What are the screening questions for psychogenic source of symptoms?

A

Do you have trouble sleeping at night?

Do you have trouble focusing during the day?

Do you worry about finances, work, or life in general?

Do you feel a sense of dread or worry without cause?

Do you ever feel happy?

Do you have a fear of being in groups of people? Fear of flying? Fear of public speaking?

Do you have a racing heart, unexplained dizziness, or unexpected tingling in you face or fingers?

Do you wake up in the morning with your jaw clenched or feeling sore muscles and joints?

Are you irritable or jumpy most of the time?

83
Q

What is the best follow-up question for someone who tells you that the pain is constant?

A

Do you have that pain right now?

84
Q

A 52-year-old woman with shoulder pain tells you that she has pain at night that awakens her. After asking a series of follow-up questions, you are able to determine that she had trouble falling asleep because her pain increases when she goes to bed. Once she falls asleep, she wakes up as soon as she rolls onto that side. What is the most likely explanation for this behavior?

A

The minimal distractions heighten a person’s awareness of musculoskeletal discomfort

85
Q

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

A

The left shoulder (Kehr’s sign)

86
Q

True of false?

Associated S&S are a major red flag for pain of a systemic or visceral origin compared to musculoskeletal pain.

A

True

Table 3-2

87
Q

Words used to describe neurogenic pain often include:

A

Crushing

Shooting

Pricking

88
Q

Pain (especially intense bone pain) that is disproportionately relieved by aspirin can be a symptom of:

A

Neoplasm

89
Q

Joint pain can be a reactive, delayed, or allergic response to:

A

Medications

Chemicals

Infections

Artificial Sweeteners

90
Q

Bone pain associated with neoplasm is characterized by:

A

Increase with weight-bearing

91
Q

True or false?

Pain of a viscerogenic nature is not relieved by a change in position.

A

False

Some can be

92
Q

True or false?

Referred pain from the viscera can occur alone but is usually preceded by visceral pain when an organ is involved.

A

True

93
Q

A 48-year-old man presented with low back pain of unknown cause. He works as a carpenter and says he is very active, has work-related mishaps (accidents and falls), and engages in repetitive motions of all kinds using his arms, back, and legs. The pain is intense when he has it, but it seems to come and go. He is not sure if eating makes his pain better or worse. He has lost his appetite because of the pain. After conducting and examination including a screening exam, the clinical presentation does not match the expected pattern for a musculoskeletal or neuromuscular problem. You refer him to a physician for medical testing. You find out later that he had pancreatitis.

What is the most likely explanation for this pain pattern?

A

Obstruction, irritation, or inflammation of the body of the pancreas distends the pancreas, thus applying pressure on the central respiratory diaphragm

Differential Diagnosis (5 decks)

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