Pathologies related to the Thorax Flashcards
What causes chicken pox and shingles?
varicella - zoster virus
What are risk factors for varicella?
Hx of chicken pox
increased risk around 50 years of age
Why has varicella declined in prevalence?
Vaccines :)
What is necessary for someone to develop shingles?
History of chicken pox
How is varicella transmitted?
Airborne or direct contact
Hold long should someone isolate with varicella?
Crusted lesions dry
Who is varicella highly contagious to?
Those who’ve not had chicken pox and 2-3 days prior to symptoms
If you’re exposed to varicella and you haven’t had chicken pox, what will you get?
Chicken pox, not shingles
How does the virus of varicella travel through the body?
From lymph through blood
What does varicella eventually target?
Nerve endings
Where can varicella persist in the body?
latent in dorsal root
Why are subsequent infections triggered with varicella - zoster virus?
Lowered immunity/ stress
What are PT implications of varicella?
- Pain and itching
- dewdrop on a rose petal vesicle on a red base that erupt
- shingles skin lesions and paresthesias occur in a dermatomal pattern
(typically T3-L3)
When is varicella - zoster virus an emergency referral?
When it is close to the eye
What kind of referral is varicella - zoster virus typically?
urgent referral
What is the risk of developing postherpetic neuralgia with varicella?
(pain more than 90 days after onset)
low
What is the incidence of spinal malignancy?
Multiple myeloma
- primary malignant tumor in bone marrow
- typically in older individuals
What is the most common tumor of the spine?
spinal metastases
Spinal metastases are the ___ most common serious spinal pathology
2nd
What are 30% of spinal metastases from?
Breast, lung, prostate, kidney, GI and thyroid tumors
What is the 3rd most common area of metastasis from?
Bone, behind lung and liver
What is the most common structure of bone involved with spinal malignancy?
Vertebral body, mostly in anterior portion leading to wedging
What is rarely involved with spinal malignancy?
Discs
What is the most common region of the spine for spinal malignancy?
Thoracic (70%)
Where are spinal malignancies rarely?
Cervical region
What percentage of spinal metastases create cord compression or myelopathy?
20%
What is a risk factor for spinal malignancy?
history of cancer
What is the pathogenesis of spinal malignancy?
Healthy bone replaced by tumor
What is the gold standard for imaging with spinal malignancies?
MRI
What are some clinical manifestations / S&S of spinal malignancy?
- Cancer S&S
- Spinal pain
- Unfamiliar and severe pain that may become progressive and constant
- possible myelopathy S&S
- Possible bony alterations including fxs and joint instability
- unable to lie flat due to pain
- likely mechanical pain for bone involvement
- Stress tests positive for bone involvement
What is the most common initial symptom of spinal malignancy?
spinal pain
What are the first type of S&S in 25% of spinal malignancy cases?
myelopathy S&S
What is the referral type of spinal malignancy?
urgent referral to MD unless cord S&S - then immobilize for emergency referral
What is thoracic spinal cord myelopathy?
Slow, gradual, and often progressive compression on cord
What is the incidence of thoracic spinal cord myelopathy?
Most common region of spine for myelopathy due to smaller ration of canal to cord than in other regions
What is thoracic spinal cord myelopathy most commonly due to?
Degenerative spinal changes
What percentage of the time is there a malignancy with thoracic spinal cord myelopathy?
20% of the time
What is the only validated red flag for malignancy with thoracic spinal cord myelopathy?
Hx of cancer
What can rarely happen with thoracic spinal cord myelopathy?
Rare central disc herniation
What is the pathogenesis for thoracic spinal cord myelopathy?
Slow, gradual, and often progressive compression causing ischemia
What are some clinical manifestations and S&S for thoracic spinal cord myelopathy?
-Level of injury determines specific S&S
- extreme spinal pain
- mechanical reproduction with thoracolumbar scan
- multi-segmental numbness and weakness/paralysis of extremities and trunk below level of injury leading to impaired balance
- spastic or retentive bowel and bladder
- hyperactive DTRs
- UMN tests positive
- Superficial reflexes - hypoactive
What is the referral type with thoracic spinal cord myelopathy?
- immobilize with emergency referral
What is the most common serious spinal pathology?
Non-traumatic spinal fractures
Where do 70% of non traumatic spinal fractures occur?
thoracic spine
What population predominately experiences non-traumatic spinal fractures?
Older biological females with osteoporosis
What levels are non-traumatic spinal fractures most common at?
T8 and L4 levels
** kyphotic posture increases pressure on vertebral bodies
What is the etiology of non traumatic spinal fractures?
Malignancy
Osteoporosis
What are risk factors for non-traumatic spinal fractures?
Prior osteoporotic or low impact spinal fx
more than 3 months of corticosteroid use
biological female
- late onset menarche, early onset menopause
older age
- women older than 65, men older than 75
What is a low evidence risk factor for non traumatic spinal fractures?
hx of cancer
What is the pathogenesis of non-traumatic spinal fractures?
Weakening and eventual failing of bone due to disease
What are high evidence clinical manifestations / S&S of non traumatic spinal fractures?
thoracic pain with history of malignancy and/or osteoporosis
What are low evidence S&S of non traumatic spinal fractures?
- Unfamiliar and severe pain and possibly worsening
- likely mechanical pain for bone involvement
- sudden change in spinal posture/ shape such as increased kyphosis
- rare neurological S&S in LEs including coordination and bowel/bladder dysfunction
What type of referral are non-traumatic spinal fractures?
urgent referral unless cord S&S than immobilize with emergency referral
What is the first choice for imaging with non-traumatic spinal fractures?
x ray
When would we use an MRI with non-traumatic spinal fractures?
multiple fxs on x-ray
determine age of fx
What is a spinal infection?
Infectious disease of spinal structures
What is the incidence of spinal infection?
- Uncommon in wealthier countries, resurgence with longevity and IV drug use
- skeletal tuberculosis aka Potts disease more common in thoracic spine
What is the etiology of spinal infections?
Primarily from mycobacterium TB,
staph and brucella also involved at times
What are low evidence risk factors for spinal infection?
- Immunosuppression
- surgery, of spine and repeated procedures
- IV drug use
- social deprivation
- Hx of TB or other recent infection
How long does it take for a spinal infection to develop after initial air droplet infection enters lungs?
2-3 YEARS
how does a spinal infection spread within the body?
Through lymph and blood
Where does the infection begin and progress to with spinal infections?
Begins in lung (pulmonary TB), progresses to vertebral body (osteomyelitis), and eventually to the disc (discitis) and adjacent vertebrae (skeletal TB)
What happens as the abscess grows with spinal infections?
Nerve root irritation
Vertebral body collapse/fx
and cord compression
all may develop
What will we see on x ray with spinal infections?
body destruction
TB abscess
loss of height
sclerotic end plates
diminished disc space
What are EARLY clinical manifestations and S&S of skeletal TB?
Arthritic like back pain stiffness is most common
What are low evidence clinical manifestations and S&S of skeletal TB?
- Localized and progressive pain that limits motion
- likely mechanical pain for vertebral body and possibly disc involvement
- stress tests positive for vertebral body and possibly disc involvement
- infections S&S
- Unexplained weight loss of more than 5-10% over a 3-6 month period
- Possible tenderness with palpation, percussion and or vibration at SPs
What S&S can we see with skeletal TB if untreated?
Neuro S&S influence LE coordination, bowel and bladder function
Increased thoracic kyphosis
What kind of referral is skeletal TB?
Urgent referral unless cord S&S
What is angina?
Chest pain
What are the two types of angina?
Stable and unstable
What is stable angina?
Occurs with stress, physical activity and/or emotion
What is unstable angina?
Occurs at rest
Is angina a disease?
No
What is angina a symptom of?
Underlying problem such as a coronary artery disease (CAD)
What is a myocardial infarction?
heart attack
What is angina and myocardial infarction most common in?
Males 65 years and older
What are risk factors for angina and myocardial infarction?
Smoking
Metabolic syndrome
- high cholesterol
- HTN
- Diabetes
- Obesity
- high triglycerides
Psychosocial disorders
SAD
What is the etiology of angina and myocardial infarction?
CAD
What is the general theme with risk factors for angina and myocardial infarction?
any condition that limits blood supply to or increases demand of the heart
What is the pathophysiology for angina and myocardial infarction?
Ischemia or limited circulation with imbalance between supply and demand for the heart with possible complete occlusion and myocardial tissue death
What are typical clinical manifestations and S&S of angina and myocardial infarction?
Pain
- sudden onset of chest pain, pressure, tightness, and / or heaviness
- additional pain into the jaw or left arm
- referred pain could be anywhere with C4 to T4 dermatomal pattern
SOB
Sweating
Nausea
Fatigue
Syncope
What are some atypical clinical manifestations with females only with myocardial infarction?
Intrascapular and right arm pain
50% don’t have angina
people with ________ have less pain with neuropathy
diabetes
What is the most common S&S in older adults with myocardial infarction?
SOB due to impaired ANS response and central pain processing
What are PT implications of stable angina?
if less than 20 mins then urgent referral
if more than 20 minutes emergency referral
What are PT implications with Unstable angina?
Emergency referral
What is a pulmonary embolism?
A blockage of the pulmonary artery
What are pulmonary embolisms associated with?
High morbidity and high mortality
How many pulmonary embolisms go undiagnosed? Why?
around half
Non-specific signs and symptoms
What percentage of patients with an untreated pulmonary embolism die?
1/3
What percentage of patients with a a diagnosed pulmonary embolism die?
Only 8%
What sex and age are pulmonary embolisms more common in ?
Biological females over the age of 50
What are risk factors for a pulmonary embolism?
- Prior PE or DVT
- Immobility
- Hx of abdominal or pelvic surgery / malignancy
- LE Joint replacement
- Late-stage pregnancy
- LE fractures
What is the etiology of a pulmonary embolism?
Most often a DVT or clot, especially in the LE
What other factors can cause a blockage with a PE?
Fat (fx/jt. replacements), air bubbles (injections), amniotic fluid (pregnancy), clumps of parasites or tumors
How does a PE happen?
Obstruction travels through the right side of the heart and becomes lodged in the smaller pulmonary artery feeding the lungs
What is the result of a pulmonary embolism?
Pulmonary infarction which impairs gas exchange and leads to damage
What condition is called the “great masquerader”? why?
Pulmonary embolism
Silent, non specific S&S
What is the most common sign of a pulmonary embolism?
Pleuritic chest pain - sharp sudden and stabbing chest pain probably exacerbated by:
- deep inspiration
- coughing
- mechanical stress by fascial attachments between lungs, ribs, and vertebra
What may be the only non specific symptom with a PE?
SOB, wheezing, and/or rapid breathing
What are some other potential signs and symptoms of a pulmonary embolism?
Cough, possibly bloody
painful breathing
fainting
tachycardia and palpitations
What are the PT implications of a pulmonary embolism?
Timely detection critical for survival, utilize CDR and emergency referral if indicated
What makes up the upper GI system?
Esophagus
stomach
duodenum
What are the PT implications for the upper GI system?
Must differentiate from cardiopulm issues
thoughtful positioning with interventions (Keep upright)
What is gastroesophageal reflux disease?
Consequence from backflow of stomach contents into esophagus
What is one of the most common digestive disorders, especially in older people?
GERD
How many US adults will experience GERD S&S?
2/3
What is the etiology of GERD?
Foods
obesity
smoking
hiatal hernia
medications
What is the pathogenesis of GERD?
Dysfunctional valve between stomach and esophagus allowing backflow of stomach contents -> increased acidity and acid volume
What is esophagitis?
Inflammation or injury to esophagus
What is the most common clinical manifestation of gastroesophageal reflux disease?
Heartburn or chest pain/tightness esp after meals when reclining or lying
Where can GERD pain refer to?
The neck
What are other S&S of GERD?
Dysphagia
odynophalgia (painful swallowing)
belching
nausea
What is scheuermann disease?
Anterior vertebral body wedging of adjacent thoracic vertebrae in adolescents
What is the most common cause of adolescent hyperhykyphosis?
Scheuermann disease (kyphoscoliosis)
What population does sheuermann’s disease happen in most often?
males
What is the etiology of sheuermann’s disease?
Possibly inherited
possible collagen abnormality
modic changes following acute IDD
What is the pathogenesis of scheuermann disease?
Abnormal vertebral end plate mineralization and ossification during growth leading to:
- anterior vertebral body wedging
- schmorl’s nodes (disc herniates into the vertebral body)
What are PT implications for Scheuermann disease?
Proceed with caution considering potential progressions with bone and/or neurological tissue
What are some clinical manifestations / S&S of Scheuermann disease?
Excessive and rigid thoracic kyphosis
Thoracic pain
Better with rest
Possible counter hyperlordosis in cervical/lumbar regions
