Quiz 1/Exam 1 Flashcards
what happens to the subcutaneous layer as we age
As we age we lose the subcut layer, vascular supply is less and there is less nerve endings (skin thins – bc of less nerve endings and elderly person may not feel a wound)
Less protection from cold bc of subcut layer dim as we age
what % of our body is skin
15-20
functions of skin
Protection from injury or invasion
Insulation
Maintenance of homeostasis (sweating)
Assist in metabolism (Vit D production, aids in waste removal of urea and other waste products)
Attachment of muscles (ex. erector pili and frontalis)
Cutaneous sensation
a flat, circumscribed area that is a change in the color of skin, less than 1 cm in diameter
Examples: freckles, mole/moles (nevus/nevi), measles
macule
a flat macule that is greater than 1cm
patch
port wine stain is a
patch
an elevated mole or a wart is a
papule
an elevated, firm, area less than 1 cm in diameter
papule
an elevated, firm, rough lesion with a flat top surface greater than 1 cm in diameter
plaque
elevated, irregular-shaped area of cutaneous edema; solid, transient; variable diameter
Examples: insect bite, allergic reaction
wheal
elevated, firm, circumscribed lesion, deeper in dermis than papule; 1-2 cm
Example: lipoma
nodule
elevated, circumscribed, superficial, not into dermis, filled with serous fluid; less than 1 cm in diameter (varicella - chicken pox)
vessicle
vesicle greater than 1 cm in diameter (blister),
bulla
bursting of a bulla
erosion
elevated, superficial lesion; similar to a vesicle but filled with purulent fluid
Example: acne
pustule
elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material
cyst
Rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surface of the extremity
Example: chronic dermatitis (skin inflammation)
lichenefication (atopic dermatitis also is on flexor surfaces)
spider veins are aka
Telangiectasi
spider veins can be indicative of
liver disease
enlarging scar; grows beyond the boundaries of the wound, usually elevated; caused by excessive collagen formation
keloid
elevated, solid lesion; may be clearly demarcated; deeper in dermis; greater than 2 cm in diameter
tumor
nevi/nevus is associated with what term
macule
Cspine, Tspine, or shoulder px could be
cardio, pulmonary or GI condition
inconsistant px sx could be
Psychological, Endocrine, Neurologic, Rheumatic disorders, Adverse Drug Reactions
a pt who is having spine px and has a hx of Ca, what should you do
A pt who has px in spine when WB (and has hx of Ca)
refer, need to rule out Ca in the spine
age frame for Ca in spine or bone
Over 50, Ca is more likely to go to spine
30-50 they are more likely to have px/sx/Ca in long bones
what are main compentencies a primary care PT needs to be able to do
Know when to refer- know red flags, know how to rule in or rule out, know drug interactions, ability to read imaging
gallbladder px
right upper quadrant
where is visceral px for heart, lung, and diaphragm
o Heart- Cervical anterior, jaw, teeth, upper thorax, epigastric, L upper extremity, R shoulder and upper extremity
o Lungs and Bronchi- Ipsilateral thoracic spine, chest wall, cervical (when diaphragm involved)
o Diaphragm (central portion)- Cervical spine
in regards to cspine, which imaging has higher sensitivity and specificity
CT scan
skin plaques have a ___ top
flat (they are large papules)
most common skin Ca is
basal cell carcinoma (softer in appearance)
which type of skin Ca is hyperkeratotic - crusty
squamous cell
prognosis for melanoma is based on
depth
prognosis for what skin Ca’s are good
basal cell
squamous cell
are men or women more likely to have melanoma
men
melanoma travels where first
lymph and blood
distinguishing from malignant to benign lesions (what are char. of malignant)
- Malignancy: > 6 mm in size
- Multiple shades, varied pigmentation
- Irregular, blurred borders
- Asymmetric
- Often bleed or ulcerate
- Firm to hard consistency
- Slow or rapid rate of growth or change
where are basal and squamous cells typically located
back of hands, neck, face, ears
risk factors melanoma for men (# of moles)
17 or more moles increases risk for men they have 4.6 x risk for melanoma, 50% of melanoma dev in existing moles
risk factors melanoma for women (# of moles)
12 or more moles , risk is 5.2 x greater
overall risk factors for skin Ca
History ****** Age >50 Regular dermatologist absent M-mole changing M-male gender
itching is aka
pruritis
visceral px for lungs can be referred to
Lungs and Bronchi- Ipsilateral thoracic spine, chest wall, cervical (when diaphragm involved)
the D in the ABCDEs of skin checks is for what specifically
diameter over 6 mm
What does the E stand for in the ABCDE’s of skin check
elevation or evolution
acne is a
pustule
a wart is a
papule
elevated, irregular-shaped area of cutaneous edema; solid, variable diameter
wheal
bulla can be due to
sunburn
heaped up, keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size
scale
chronic inflammation or chronic dermatitis
lichenification
scaly itchy rashes associated with family hx of hayfever or allergies
atopic dermatitis-exzema
what would you not use on pts with atopic dermatitis
alcohol wipes or gels/lotions
A chronic, relapsing, proliferative skin disorder with an unknown cause (possibly genetic and/or immunological), flare ups asst. with winter and no sunlight
psoriasis (immune disorder= genetic)
psoriasis is aggravated by stress or change in homeostasis
Assymetrical pxful joint with noticeable skin lesion = (often the DIP of fingers, toes, and SI jts)
psoriatic arthritis (usually unilateral)
how is psoriasis often DX
uric acid hematology
pustules that rupture easily and drain a straw-colored fluid that dries to a golden honey-colored crust.
impetigo
raynauds is usually 1st sign of
sclerederma (tightening -thickened skin causing contractures)
non msk (visceral px) descriptoin
Visceral pain is vague and not well localized and is usually described as pressure-like, deep squeezing, dull or diffuse.
vascular px description
heaviness
cramping
throbbing
numb
areas of referred pain for heart
Cervical anterior, jaw, teeth, upper thorax, epigastric, L upper extremity, R shoulder and upper extremity
of the 3 main types of skin cancer, list in order from superficial to deep the layers they go to
squamous - epi
basal cell-half way through dermis
melanoma - all way through dermis into blood and lymph
main blood/nerve location layer of skin
dermis (subcu has blood supply also epidermis has no blood supply on it’s own)
size of vessicles
less than 1cm
elevated, superficial, not into dermis, filled with serous fluid; less than 1 cm in diameter
vessicle
elevated, superficial, serous, small
skin issue that creates an elevated, hard, 1-2 cm deep bump
nodule
size of bullas
bullas are big
greater than 1cm
3 triage categories of pt condition
minimal
serious - (broken into urgent, immediate and delayed)
expectant
typically, if motion causes the px you can expect the issue to be related to
MSK
which type of triage is “requiring additional treatment before other needs or categories of patients attended to”
serious
medical trumps PT services
which type of triage is “can attend to other needs as well as treat primary condition (can attend to them later – maybe see PCP within a month or so)”
minimal
which type of triage is, “efforts are futile to tx”
expectant
PA’s have prescription authority but practice under
physicians
what are some key competencies she mentioned for a direct access PT to have
Know when to refer (diff dx) know red flags, know how to rule in or rule out know drug interactions ability to read imaging prevention care
if a pt has hx of Ca and px in spine that is difficult to determine a cause…you
refer out
px in upper right quadrant is
gallbladder
px in LOWER right quadrant is
appendix
what is sensitivity
if it has high sensitivity it means it is ruling out the condition (if the sensitive test was neg you rule out)
what is specificity
if it has high specificity it means you are ruling in the condition (if specific test is pos you rule in)
bone scans are highly sensitive, what does this mean
if the test is neg, it rules out the condition
if something has very low sensitivity it means
if the test is neg, it doesn’t do a very good job at ruling out the condition
if something has high specificity it means
if the test is pos, it does a good job at ruling IN the condition
if something has LOW specificity it means
if the test is pos, it DOESNT do a good job at ruling IN
what is likelyhood ratio
Combines sensitivity and specificity
Gives probability before and after test result
Positive LR = increase in odds for the condition to be present
Negative LR = decreases odds for the condition to be present
LR of 1 = test neither proves nor disproves the condition
glucose below ___ you don’t touch them
60
what is macrocytic anemia
it when their red blood cell distribution is high (they have very large RBC, but there isn’t enough of them)
often associated with alcoholism
BBS ratings that indicate high risk of falls
BBS scores of 31 to 45 correlated with significantly higher rates of falls.
symbiosis vs pathogenic infection
symbiosis is good (microflora in gut)
pathogenic is bad - like strep
differentiate Ca sx and infection sx in regards to lymph nodes
in Ca pts, they get swollen but don’t hurt
in an infection they are swollen and pxful
Confusion
Tachycardia
Hypotension
where do these infection sx come in to play
typically immunosuppressed or elderly pts
chain of infection transmission
existing pathogen reservoir (anything) portal of exit transmission type host portal of entry
bacteriocidal vs bacteriostatic
Bacteriocidal: will kill invading organisms (everything dies)
Bacteriostatic: will inhibit bacterial growth without killing organisms (ex: soaps)
chemotherapeautic aka
antibiotic
leading cause of infective endocarditis
staph
most common pathogen causing infection of any age
strep
what is pseudomonas
common infection in hospitals, nursing homes
leads to pneumonia or sepsis in immunocompromised
Clostridial Myonecrosis is aka
gangrene
needs anaerobic env to thrive
Sudden sharp pleuritic pain aggravated by movement Hacking & productive cough Rust- or green-colored sputum Decreased chest excursion Cyanosis Headache Fatigue, fever & chills Generalized aches Myalgia of the thighs and calf muscles
all sx of
pneumonia
sx of walking pneumonia
more than 2 weeks
low grade fever
long courses of antibiotic
immunocompromised pt
smelly, loose stools
all sx of
cdiff
how to prevent spread of cdiff
only soap and water
hand sanitizer does not prevent
types of herpes
HSV-1 & 2: Simplex causes lesions on mouth and genitals
HSV-3: Zoster is associated with chickenpox and shingles
HSV-4: Mononucleosis (“kissing disease”)
HSV-5: Cytomegalovirus
2 manifestations of varicella zoster
primary is chicken pox
secondary is shingles
what precautions do you use for someone with chickenpox
airborne and contact
Spread by coughing and sneezing-airborn- (highly contagious), by direct contact, and by aerosolization of virus from skin lesions
what precautions do you use for someone with shingles
contact only
if you have shingles and you pass on the virus to someone who has not had chicken pox will they get shingles or cp
chicken pox
pt has a joint replacement surgery, but px is not getting any better since it was done, but rather it is getting worse….what might you think of
infection in the joint
refer out
strange neuro sx with a target like rash could be
lymes disease
precautions for tb, measles and chicken pox
airborne
Productive cough > 3 wks Weight loss Fever Night sweats Fatigue Malaise Anorexia Rales in the lungs
these are all sx of
TB
In CNS
It will manifest like neural tension stress
They will have swollen pxful lymph nodes, fever, and malaise. Stiff neck
bacterial meningitis
staph can be prevented by
handwashing or sanitizing
staph is spread by
contact (skin to skin)
staph is tx by
antibiotics
staph appears as a supprative wound, this means
pus
strep appears both ___ and ___
supprative and non supprative
Most common type of eczema
atopic dermatitis
presents with scaling and itchy rashes
Atopic dermatitis is Most common
in infants and usually clears by age 36, but is chronic in adults
risk factors for atopic dermatitis include
○ Family or personal history of allergies, asthma or hay fever
irritants for atopic dermatitis
cold weather
dry skin
certain foods and products
wool
where does atopic dermatitis often present
flexor surfaces or face
psoriatic arthritis often presents where
affecting the fingers, toes, and sacroiliac joints
skin turnover is decreased from the normal 26-30 days to 3-4 days with increased T cell lymphocytes, so immature skin cells are building on top of eachother
dermis and epidermis are thick with hyperproliferation
psoriasis
where does psoriasis usually show up
primarily on the scalp, the chest, the elbows, the knees, the groin, skin folds, lower back, and buttocks.
psoriasis is chronic, how is it tx
Treatment includes: Topical preparations – corticosteroids, synthetic vitamin D, vitamin A analogs (retinol), ointments (petroleum jelly, etc), oatmeal baths, emollients, and open wet dressings to prevent pruritis, tar preparations (for their anti-mitotic effects) UV light (or sunlight) Anti-metabolic medication Immunosuppressants
PT implications for herpes
not heat or US
impetigo is caused by __ or ___
strep or staph
found on exposed areas (face, extremeties, neck)
tx for impetigo
Treatment usually involves systemic or topical antibiotics and gentle debridement of crusts with warm water soaks.
phases, not stages, of wound healing
Phase 1: Hemostasis - immediate
Phase 2: Inflammatory - should last 3- 7 days (NORMAL)
Phase 3: Proliferation- granulation (wound bed)
Phase 4: Remodeling
during remodeling, if there is an imbalance in collagen synthesis and lysis at the cellular level (whether it be overproduction of collagen, too much or too little mvmt, lack of blood flow) what can occur
dehisience
without the balance then keloids or holes occur
why don’t PTA’s do wound care
you have to re-assess every time you tx
SWHT
sussman wound healing tool (assessment for wounds)
PUSH
pressure ulcer scale of healing
4 main components of an OE for wounds
Measurement
Classification
Peri-wound
Wound Bed Assessment
when measuring a wound, what is L and W
L 12-6 (head to foot)
W 3-9 side to side
ways to STAGE/classify tissue loss for NON PRESSURE ULCER wounds
partial or full thickness
what is partial thickness
loss of epidermis and down into but not through the dermis
what is full thickness
all way through dermis to subq, muscle may be exposed
capillary refill Longer than 2-3 seconds can indicate
arterial occlusion
ABI under ___ indicates arterial disease
.9
1 is normal
never compress if .7 or lower
what is hypergranulation
the tissue overfills the boundaries of the wound
what is slough
necrotic, non healthy tissue that should be granulated
when doing wound bed assessment you look at % escar, % yellow necrotic, what do these mean
escar-black
yellow necrotic - any non tendon yellow
characteristics of arterial wounds
Toes, Dorsal aspect of foot
Lateral malleolus
Tibia
Thin dry skin, absence of hair, shiny, smooth, cool to touch
Pulses: Absent or diminished
if px decreases with dependent/dangled legs it’s prob a(n) ____ wound
arterial (px increases when blood drained from LE -elevated)
if px increases withdependent/dangled legs it’s prob a(n) ___ wound
venous
dry
“punched out” smooth edges – punched with a circle stamper
erythematous halo – red halo surrounding wound
black/gray necrotic tissue
type of wound
arterial
locations of venous wounds
MEDIAL
medial malleoli
characteristics of venous wounds
WET
Eschar or slough, yellow fibrous
Moderate to heavy exudate
Irregular wound edges
Surrounding skin is dry and scaly
Pulses present
what is usually present with venous wounds
Hemosiderin staining – dark stain around the wound – hemoglobin stains the skin
4 main contributing factors for decubs
- Pressure
- Shear
- Friction
- Moisture
risk factors for decubs
Advanced Age: ability of soft tissue to distribute mechanical load is impaired Nutrition Smoking Low blood pressure Poor oxygen perfusion
explain stages of decubs
1 - skin intact but red (does not blanch)
2- (partial thickness loss) shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
3 - (full thickness loss) Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
4- bone exposed
unstagable - full thickness in which the base is totally covered by necrosis
explain neuropathic pressure ulcers
they lack sensation so WB areas are taking on pressure without the pt knowing
callous forms around edges of wound
foot deformities can occur (hammer toe, claw toe, charcot foot)
pts should be turned at least ___
q 2 hrs
Sloughing of skin
Phagocytosis of bacteria
Destruction of pathogens by acid secretions
Digestive enzymes in the gastrointestinal tract
Sneezing or coughing
these are examples of ___ immunity
innate
occur every time same way (no memory)
which type of immunity is the 1st line of defense
innate
2 types of acquired immunity
active
passive
both develop after invasion by a foreign agent
what is active acquired immunity
you had direct contact with the antigen and you create antibodies and they have memory of that antigen
what is passive acquired immunity
mom to baby (temporary)
or injection of antibodies via innoculation
List the specific leukocytes responsible aquired immunity
2 TYPES OF LYMPHOCYTES
Tcells- Cell-mediated response
Recognizes one antigen
Attacks the antigen directly
Produces: Memory cells, T-cytotoxic (killer) cells,T-helper cells, T-suppressor cells, Lymphokine-producing cells
Bcells-Humoral response
Recognizes one antigen
Produces and secretes ANTIBODIES that attack antigen
Produces memory cells for future responses
effect of aging on immunity
decreased acidity in GI tract shallower breathing =junk stays in lungs less acidity in urine = UTIs thymus gets smaller decreased responsiveness of Tcell decreased antibody responsiveness increased antibody responsiveness to self-cells= autoimmune
poor diet = malformation of WBC
where T cells go to mature
thymus
issue with BP and chronic fatigue syndrome or (SEID)
they have ortho HTN and their BPs dont respond to exercise
what scale to use with SEID
RPE
tx for SEID
don’t let them do a lot of bed rest
work on gradual endurance/graded exercise and fatigue management
Low to moderate level of intensity (RPE 9-12/20),
3-5 times a week with 5 minute sessions progressing to 40-60 minutes
an antigen is anything that
TRIGGERS IMMUNE RESPONSE
TYPE OF WBCS ASSOCIATED WITH INNATE IMMUNITY
Granulocytes: Basophils, Eosinophils, Neutrophils
Monocytes:Macrophages
apoptosis ____ with age
decreases (ability to self destruct if unable to complete it’s normal job)
but EXERCISE increases healthy apoptosis
other aging responses in regards to immunity
they don’t run fevers as much to fight off infections
number of lymphocytes does not change, but the configuration of lymphocytes and their reaction to infection does.
duration of antibody response is shorter
after age 70, are more likely to produce autoantibodies, which attack parts of the body itself instead of infections.
exercise and immunity
strenuous ex =bad
moderate ex =good (decreases stress)
in general, what does AIDS do to immunity
attaches itself to the T4/CDF cells (the ones that call other cells to initiate the immune response and destroys them)
destructs Tcells
changes Bcells
sx of HIV
-Arthralgia ‐ Myalgia ‐ Night sweats ‐ Gastrointestinal problems ‐ Aseptic meningitis ‐ Oral or genital ulcers
stages of HIV
if CD4 cells are still over 500 it’s asymptomatic
200-500 early sx (infections can make them sick here)
under 200 late sx (more advanced illness) = AIDS no longer HIV
pts with HIV are at high risk for what illnesses
pneumonia thrush TB kaposi sarcoma wasting syndrome lipodystrophy
explain wasting syndrome
2 or more loose stools per day
fevers for 30 days
10% loss of body wt
explain tx focus for HIV
medical -antiretroviral drugs (which have many side effects)
increase CD4 count
exercise guidelines for HIV
No exercise testing during acute infections
Frequency: 3-4 times a week at 40-60% of VO2
Moderate level of resistance training 8-10 reps.
Time 30-60 minutes per day.
Avoid exhaustive exercise with symptomatic individuals.
explain the 3 sub levels of the serious category of triage
urgent- have to go now (life threatening)
immediate - need to go soon (hours to a day)
delayed - can be seen by PCP within a week or so
high pressure irrigation for wound care starts at ___ PSI
8 and over
PSI you would never use for wound care
over 15 is not good
types of debridment
non selective selective auto bio sharp enzymatic
type of estim best for wound care
HVPC
contraindications for estim
malignancy
electronic implants
osteomyelitis
contraindications for US
Pregnancy
Over gonads, heart, or eyes
DVT
Malignancies
overall, foam pad dressings are used for
draining wounds
what are standard universal precautions
put a barrier btwn yourself and pt fluids at all times for any point of contact
wash/sanitize after every contact always
assume all pts are infectious
2 types contact precation type illness most prevelant in acute care
cdiff
staph/mrsa
contact precautions require
gloves, gown, any type of protection from you touching the source
droplet precautions require
Maintain at least 3 feet between you and patient
Room door may remain open
Wear a mask when working within 3 feet of patient
gloves when working with patient or environment
airborne precautions require
door shut private room pressure regulation resp protection (TB, measles, chicken pox)
drug to help tx mrsa
vancomyacin
what is VRE
vanco resistant enterococcus
bad GI issue that immunosuppressed/ill get in hospitals
pitting edema scale
1+ = Barely perceptible depression 2+ = Easily identified depression; depression takes up to 15 seconds for tissue to rebound 3+ = Depression takes 15-30 seconds to rebound 4+ = Depression lasts for 30 seconds or more
explain how to do ABI
The highest ankle SBP divided by the highest brachial SBP
never compress if ABI is
under .7 (arterial disease present)
never compress arterial insufficiency (venous only)
ABI over 1.2 means
venous disease, you need to compress (high pressure)
which type of heart failure would you NOT use compression with
left
would you use compression pumps for lymphedema
no
what must you always do before applying a compression pump
take BP
Red flags we may need to refer out for
*Fatigue • Malaise • Fever, Chills, Sweats (99.5 or higher for 2+ weeks) • Weight loss, gain (5‐10% body weight) • Nausea, vomiting • Dizziness, lightheadedness • Paresthesia, numbness • Weakness • Change in mentation, cognitive abilities
some differences btwn MSK and non MSK px
MSK -can usually be reproduced, typically has an MOI
non MSK -reproduction usually doesn’t occur, sx are vague and accompany other general complaints. Also, non MSK px will not respond to PT tx.
ringworm is aka
tinea corporis
they will need to get topical cream
narrow vs broad spectrum antibiotic and why would you use one over the other or visa versa
narrow- only txs against certain bacteria
broad -effective against many types of bacteria
cultures often take 72 hours, so rather than wait to see specific bacteria you can prescribe broad
however, using broad spectrum too much attributes to our “super bugs” like MRSA bc then only the strong survive
what is rule of 9s
way to determine extent of burn surface area
use pts palm (which is 1%) and determine % of involvment
explain 1st degree burn
superficial no blister just red pxful good healing on own
explain 2nd degree burn
superficial partial thickness OR deep partial thickness, erythema, blister, painful, wet, edema, re-epithelializes in 14-20 days
(typically second degree doesn’t have to get grafted, they typically heal on their own)
explain 3rd degree burn
will need grafting full thickness always brown-leathered no blisters no px
explain 4th degree burn
goes to muscle/tendon/bone
often has to amputate, but if good wound bed they can graft
which is more pxful, donor or graft site
donor site
sheet vs mesh graft
sheet is for skin that is exposed (face, hands)
mesh is for large surfaces not exposed
with any graft pt has to be immobile for at least
5 days
donor site area heals by
7-10days
PT role in acute setting for burn pt
Restorative Care (until wound closure)
i) infection control
ii) wound care
iii) skin grafts
iv) pain management/positioning
v) optimize functional recovery and cosmetic outcome
PT role in rehab setting burn pt
movement!! get that scar moving to full range to prevent contracture
positioning, splinting, ADLs
when to proceed with caution or not proceed with ROM for burn pts
- Cellulitis- don’t range with cellulitis
- Heterotopic ossifications – only perform AROM until surgically removed – don’t be aggressive
- Escharotomy – continue ROM but without dressings to view any signs of wound stress, no ambulation if on legs
- Fasciotomy – an incision with a scalpel through eschar down to the fascia, seen in deep injuries such as electrical contact, minimal to NO ROM depending on Dr recommendation
what is heterotopic ossifications
presence of bone in soft tissue
will have a block in ROM and no improvement
has to be surgically removed
due to repetetive trauma
when would you start resistance with burn pts
when they are in compression bc they will bleed
your saying to understand sens/spec
If the test has ____high/low ____sens/spec
if the test is ____(pos/neg) then it does a ____(good/bad) job of ruling the condition____ (in/out)
sens (highly sens if neg it rules out)
spec
sx of SEID
-Impairment of memory or concentration
‐ Sore throat
‐ Tender lymph nodes
‐ Muscle pain
‐ Multiple arthralgias without swelling or redness
‐ Headaches ‐ new tape, pattern, or severity
‐ Unrefreshing sleep (key component)
response will increase in intensity and speed each time pathogen appears
this describes what kind of immunity
aquired
what RPE do we use for SEID pts
9-12/20
full thickness always
brown-leathered
no blisters
no px
which degree burn
3rd
