study guide #4 Flashcards
1
Q
list the common causes of non-cardiac chest pain
A
- peptic ulcer disease -PPI & abt
- gastroesophogeal reflex disease -give trial dose of PPI for 1-2 mos
- CAD- EKG & check for lipids
- costochondritis -heat, NSAIDs reassurance self limiting, avoid over use, take NSAIDs with food. F/U rtc if symptoms worsen
- acute anxiety
- MS pain
2
Q
life threaten cardiac chest pain
A
**Aortic Dissection: tear in aorta- sudden tear pain located in ant. or post. may radiate to arms/leg/ back, may have hypotension
**pulmonary embolism: able to localize painful area over lung s/x dyspnea apprehension, hemoptysis gripping or stabbing pain that is mod-severe and may increase with deep breaths, may radiate to neck or shoulder, crackles over site
risk factor: bed rest, orthopedic surgery
3
Q
explain life span considerations in determining the dx when pt. has chest pain
A
after cardiac & life threatening non-cardiac conditions are excluded, the pt’s age is often the most important factor in determining the dx.
- -> younger pts chest pain generally caused by more benign underlying conditions
- ->older pts with more risk factors and comorbid conditions are more likely to have serious causes of their chest pains
- ->regardless of age cardiac & life threatening noncardiac complications should be rule out first
- *under 40 : normal EKG sufficient to r/o cardiac chest pain
- *older than 40 or risk factors : cardiac enzyme, stress test, coronary angiography may be necessary
- *risk smoking, DM, obesity stress hyperlipidemia
- *women: ECG stress test is less reliable as dx, more invasive image based stress tests are more accurate
4
Q
discuss risk factors for coronary artery disease
A
male >45 y.o female >55 family hx of premature coronary heart disease cigarette smoking hypertension low HDL 130
5
Q
when should the patient with chest pain be sent to ED ?
A
NON-LOCALIZED pain
lasting >20 minutes
associated with diaphoresis dyspnea n/v dizziness radiation to neck jaw shoulder or arm
6
Q
life threatening condition : MI
A
- -> sudden onset not relieved by rest or nitro
- ->associated symptoms
7
Q
life threatening condition: Aortic dissection
A
- -> sudden tearing pain located in the anterior or posterior chest
- -> may radiate to arm, legs, abd, or back
8
Q
life threatening condition PE
A
- -> able to point to area over the lung
- ->dyspnea
- -> apprehension
- -> hemoptysis
- -> gripping or stabbing pain of moderate or severe intensity that may increase with deep breathing
- -> may radiate to neck or shoulder
- ->bed rest and orthopedic surgery are risk factors
- -> women older adults and DM pts may present with atypical symptoms
9
Q
how might a pt. describe angina?
A
demonstrates characteristic symptoms that occur with predictable frequency severity duration and provocation
the symptoms occur with exertion, are relieved by rest or no more than one nitro tablet and generally last for 1-3 minutes.
10
Q
angina
A
often occurs with nausea, fatigue, SOB, sweating. may be stable or unstable. stable goes away unstable stays >30 minutes. stable is usually with exertion but unable may be with rest and different from usual pattern
11
Q
classic angina
A
Classic: the chest pain & discomfort common with angina may be described as pressure, squeezing fullness or pain in the center of your chest. some people with angina symptoms describe angina as feeling like a vise is squeezing their chest or feeling like heavy weight has been placed on their chest
12
Q
woman experience angina
A
different from classic symptom
nausea SOB abdominal pain or extreme fatigue, with or w/o chest pain.
may feel discomfort in the neck jaw or back or STABBING PAIN instead of the more typical chest pressure.
this lead to delays tx*
13
Q
- Describe the physical examination findings when your patient has sustained an MI. (Remember that about 90% of the diagnosis of an acute coronary event is made from the patient’s history
A
Sx: sudden onset of non-localized pressure/pain, constrictive (not a sharp stabbing pain), not relieved with nitro, associated sx (cool, pale, moist skin)
14
Q
MI -General appearance
A
-grimacing, diaphoresis, cyanosis, pallor, tachypnea
15
Q
MI - VS
A
B/P may be elevated in MI
16
Q
MI - Heart sounds
A
- -Auscultate
- a new transient, paradoxical S2 during pain can indicate coronary ischemia
- S4 (atrial gallop) indicates stressed heart which can result from MI hypertension or CAD
- irregular heart rhythms are often heard during
17
Q
MI-Examine Extremities
A
- peripheral cyanosis can indicate hypoxia
- lower extremity edema may indicate CHF
18
Q
Which is more predictive of an acute MI – EKG with ST elevations or history and presenting symptoms?
A
- The history and presenting symptoms is the short answer. A normal ECG can rule out MI in patients below 40. However, this is not the case in older patients (pg 435). If a patient presents with a hx and physical exam consistent with MI and has a normal ECG, further testing is definitely indicated (as noted in previous response). Essentially, the history and physical trumps the ECG
19
Q
- A normal ECG in a patient younger than 40 yo is generally sufficient to rule out a cardiac problem. What will patients older than this and/or with risk factors require in terms of diagnostic testing? Will this vary with gender?
A
Cardiac Workup:
- Cardiac troponins (I&T): Rise within 2-4 hrs post MI and remain elevated 7-10 days
- Serum cardiac enzymes (CPK): Rise 4-8 hrs after MI and return to normal 48-72 hours
- SGOT and LDH: elevated later and not indicators of acute MI
- Elevated leukocytes, ESR: non specific indicators
- EKG: does not completely rule out, but decreases odds by 70-90%
- ECG
- Labs- CKMB, troponins, myoglobin
- Stress Test
- Echocardiogram
- Testing will vary with gender. False positive results in women more likely occur with many of the cardiac tests and speculation suggests it’s because of women’s lower hematocrit level and higher circulating estrogen level.
- Stress echocardiography may prove a more accurate method of noninvasice CAD testing in women
20
Q
Pulmonary embolus
A
dyspnea, hemoptysis, sharp pain
- decreased breath sounds - orthopedic surgery is a risk factor
21
Q
PE
What diagnostic tests are needed? Give your rationale.
A
-according to a discussion posting you would refer to the hospital STAT and they would run tests
22
Q
Costochondritis-
A
inflammation of the rib cartilage. Pain with palpation over cartilage between ribs and sternum
23
Q
Costochondritis H & P , management
A
• often is history of recent
o illness with coughing
o strenuous exercise
• precipitating and relieving factors - usually pain affected by movement or inspiration
• sometimes trauma, strain, or relation to emotional stress
• any other joints involved
- application of heat and NSAIDs*
- Condition is self-limiting, avoid overuse and trauma, take NSAIDs with food
- Return if condition worsens or no improvement
24
Q
peptic ulcer disease
A
- episodic gnawing or burning epigastric pain
- pain occurring 2-5 hours after meal or on empty stomach
- nocturnal pain relieved by food, antacids, or antisecretory agents
- it is usually related to meals
25
MI management
ASA, Nitrates, O2, beta blockers
26
Define dizziness and vertigo
Vertigo: condition that causes dizziness
Dizziness: is a symptom, sx of vertigo, sensation of spinning, tilting, or moving back and forth of ones self or the environment
-less than half of pts complaining of dizziness actually have vertigo
27
Differentiate vertigo, disequalibrium and presyncope/syncope.
Disequilibrium: loss of balance and lack of coordination, may accompany dizziness
Presyncope/syncope: feeling like you’re about to faint/faint
28
vertigo causes : vestibular
Vestibular: imbalance in vestibular system
- -->Peripheral: problems of inner ear or cranial nerve 8, most common type
1. Benign positional paroxysmal vertigo
2. Meniere’s disease
3. Vestibular neuronitis
- --> Central: includes brainstem ischemia and infarction and demylenating diseases such as MS (much less common) usually accompanied with other brainstem deficits. Can be associated with sx such as diplopia (double vision), and motor deficits
29
vertigo causes: Non vestibular:
other causes include systemic viral or bacterial infections causing postural hypotension; metabolic issues such as hypo/hyperglycemia, electrolyte disturbance, anemia; drugs (hypnotics, ETOH, antihypertensive’s, tranquilizers, analgesics)
30
Verstibular neuronitis
Sarah V., a 55 year old waitress, comes to clinic complaining of dizziness and vertigo that began as she was recovering from an upper respiratory infection. She is very nauseated and tells the provider that she vomited this morning.
31
management for vestibular neuronitis
bed rest while symptoms are severe
- antibiotics if it is associated with a bacterial infection
- Methylprednisone
32
List the vestibular suppressants (pharmacological) that may be used for vertigo and associated nausea, vomiting, and anxiety. Which one is the drug of choice? Can it be used in pregnancy?
Methylprednisolone can be given once daily for 22 days
- Pregnancy use is class C, so it shouldn’t be recommended in pregnancy
- symptom relief with anticholinergics, antihistamines, long acting benzodiazepines, or antiemetics
* **antivert and antiemetics can be helpful during an attack but should be stopped after 3 days since continuing may slow recovery
- symptoms resolve spontaneously in 3-6 weeks with no sequelea
33
education for pt with vestibular neuronitis
- slowly change positions
- adequate hydration and safety
- avoid driving and operating heavy equipment while taking sedatives or antihistamines
34
when to consult with otolaryngologist for vestibular neuronitis
consult if diagnosis is unclear, the bacterial infection is severe, or symptoms do not resolve within 4-6 weeks
F/U eval should be scheduled to reassess the pt. and to ensure that vertigo is resolving
35
differentiate vestibular neuronitis from Meniere's disease
hearing is not affected in vestibular neuronitis whereas hearing loss is experienced in Meniere’s
36
Benign paroxysmal positional vertigo (BPPV)
head trauma
- prior viral inner ear infection
- symptoms intermittent
- nausea or imbalance is not typical
37
Hallpike Dix maneuver
```
sitting then quickly lay back and put head below exam table.
Vestibular peripheral issues (intense vertigo, 3-10 second delay in nystagmus, lessens with repetition, in a fixed direction)
central issues (mild vertigo, immediate nystagmus in any changing positions, does not fatigue with repetition)
```
38
3. How would you manage this condition, including patient education. What is a complication or concern for someone with BPPV?
may resolve in a few days or weeks w/o any treatment
- referral for vestibular PT may shorten recovery time
- epleys maneuver- can be taught to do at home, especially if recurrence (50% of pts)
- meclizine (antivert) can be used but is not as effective as exercises and do not suppress acute attacks-pregnancy cat B
- acute vertigo can be frightening so information about evaluation, prognosis, and treatment options will help alleviate fears of a more serious condition
- emphasize that the most effective treatment (vestibular therapy and exercises) may initially cause increased symptoms, but the treatment must continue for the symptoms to subside.
- vestibular disorders website has helpful info for pts and providers
39
complications of BPPV
Complication of BPPV are indirect such as falling and the risk of inherent self imposed decreased mobility. Safety issues should be addressed r/t driving with head turning
40
follow up for BPPV
- referral to PT should be first line, rather than medication treatment
- if BPPV is likely the diagnosis but symptoms are refractory to liberatory maneuvers refer to a specialist
- RTC if no improvement
41
Meniere’s Disease
diagnostic criteria for Meniere’s disease.
- 2 episodes
- last at least 20 minutes each
- accompanied by hearing loss, tinnitus, or aural fullness
42
Weber and a Rinne test
- Weber- lateralization to unaffected with sensorineural hearing loss
- Rinne (AC:BC) with sensorineural loss, BC and AC are both reduced but ratio remains the same
43
management for Meniere
- refer to otolaryngologist for testing and management
- bed rest during an attack
- may recommend decreasing NA, caffeine, alcohol and tobacco but benefit unclear
- antivert and antiemetics with severe symptoms may help
- diuretics may reduce severity of attacks
44
Meningitis
History should include exposures
- travel, food consumption, sexual practices, drug use
- History of infectious disease
- immunocompromised
45
Kernig's and Brudinski's signs.
Temp, pulse and RR
Signs of meningeal irritation
-brudinski’s sign- hip and knee flexion with the neck flexed
-Kernig’s sign- inability to fully extend the legs
brudinski sign (appearance of involuntary lifting of the legs when lifting a patient's head off the examining couch, with the patient lying supine)
kernig sign (positive when the thigh is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful-leading to resistance, pos in hemorage or men)
Assess for Altered LOC (confusion, lethargy, stupor, coma)
Assess Cranial nerves (may see diplopia, deafness, facial weakness, pupil abnormalities)
46
manage Meningitis
-S/S indicate possible meningitis, immediate referral to a neurologist or ED
47
Trigeminal Neuralgia
H/A, acoustic neuroma, trigeminal neuroma, meningioma, aneurysms, acute polyneuropathy, chronic meningitis, MS, tumor, dental disorders, abscess, TMJ, sinusitis, migrainous neuralgia
Is the pain triggered by cold, chewing, touch, talking, or facial movements within the trigger zone?
- recurrent episodes of intense sharp, penetrating electric pain on one side of the face
- frequency and duration varies
- most cases are idiopathic
48
Trigeminal Neuralgia drug of choice
Carbamazepine (Tegretol) 100 mg BID, may increase to a max of 1200/day
-need serial blood counts and LFTs
- abrupt withdrawal should be avoided
- can cause aplastic anemia, drowsiness, dizziness, or ataxia
49
Trigeminal follow up /consultation
Refer to neuro for eval, may be managed by PCP after. Refer to neurosurgeon if limited pain relief
50
Bell’s Palsy
genetic, autoimmune, infectious, vascular, entrapment, and metabolic causes have been proposed as etiologic factors; viral causation in the most popular theory
51
Bell's palsy physical examination
head and neck
- cranial nerve assessment
- corneal light reflex may be decreased
- eyeball may roll upward with closed eyelid
52
Bell's Palsy dx
usually not indicated
- may be useful to exclude other conditions such as Lyme disease (titer) or other infection (CBC with diff)
- TSH, blood glucose and serum angiotensin-converting enzyme to exclude thyroid, diabetes, and sarcoidosis
53
Bell's palsy management
PREDNISONE & ACYCLOVIR
-*Prevention of eye injury is the most important goal
-prevent exposure keratitis by protecting cornea with eye drops (methylcellulose bid_ and lubricant at HS)
-protective eyewear
-patching at bedtime
-Massage facial muscles
-Pharm therapy within the first week of onset
-prednisone recommended in all patients
-antiviral (acyclovir) preg cat B recommended for pts with severe facial paralysis
-NSAIDs for associated pain
Outcome
-most recover in 4-6 months, 12 at the most. Continue f/u. monitor facial function.
54
indication for MRI
is more commonly used since it can identify degenerative disk disease, annular tears, disk herniations, spinal stenosis, and cord or nerve root compression (not seen with a CT)
**CT exposed pt to a lot of radiation & more expensive
55
Spurling manuever
The Spurling’s manuever is done by having the patient sitting with the provider behind them
→The provider’s hands are placed palm down on the patient’s head with fingers interlocked
Stage 1 - pressure is applied to top of the head when the neck is in a neutral position
Stage
Stage 2 - pressure is applied to the top of the head when the neck is in a slightly extended position
Stage 3 - pressure is applied to the top of the head when the neck is in a slightly extended position and is laterally flexed to the involved side
positive test if radiating pain is elicited
56
Lhermitte's test
Lhermitte’s test is done by again having the patient sitting with the provider behind them
the provider places their hand on the back of the patient’s head and when the patient flexes their neck the provider presses into the flexion to elicit pain
57
Refer to specialists
→Refer to the ED with suspected fracture or instability of the spine
Refer to the PT to help with strength, endurance and flexibility
Referral to an orthopedic spine physician if no response to conservative tx, progressive weakness or neurologic deficits, gait disturbance, bowel or bladder incontinence, incapacitating neck pain
58
Neck Pain without Neurologic Signs
sustained a "whiplash" injury two days ago and is in clinic today for evaluation and treatment neck pain and muscle spasm. The APRN can find no evidence of neurologic involvement
Refer for physical therapy: Range of motions, flexibility (stretching), motor control and neuromuscular reeducation, strengthening/endurance, and postural exercise.
Tylenol or NSAIDs or higher doses of NSAIDs (RX) NSAIDs= GI upset
A muscle relaxant (tizanidine or cyclobenzaprine) =drowsiness
Opioids or tramadol if OTC w/o relief= drowsiness, GI upset, dizziness.
No collar.
Early mobilization improves pain and contributes to a quicker recovery
59
What is bursitis
→Pathologic inflammatory disorder of the bursae.
60
What is the most common cause bursitis
→ Over use.
| → Other causes: trauma, autoimmune disease, crystal deposits and infection
61
Neer’s Impingement sign
Raise and pull on straightened arm forcibly from the side to full abduction above the head. = causes pain in patients with impingement
62
Hawkins’ Impingement sign:
Flex elbow to 90 degrees and raise the upper arm to 90 degrees of abduction (parallel to floor), then rotate the arm internally across the front of the body, causing compression of the rotator cuff and subacromial bursa between the head of the humerus and coracoacromial ligament= causes pain in patients with impingement.
63
treat bursitis
```
Gentle ROM
NSAIDs or stronger prn especially for night use
Avoid immobilization
PT referral prn
Ortho referral prn
```
64
warning signs to return for further eval. bursitis
→If pain worsening or not improving with recommendations or with new symptoms.
→Suspected septic bursitis….MD or ortho specialist
→May need fluid analysis, antibx therapy
→If pt is diabetic or immunocompromised, may need hospitalization
→If no improvement to conservative tx in a reasonable amt of time…ortho or rheumatologist
65
Shoulder Pain (Rotator Cuff Tear or Rupture)
Common as pts age…progressing from inflammation (Grade I) to tear (Grade III)
→Being unable to abduct the arm and instead producing a shoulder shrug is characteristic of rotator cuff tear/rupture
→Tears, not painful but may see muscle atrophy
→Cannot palpate the rotator cuff but greater tuberosity of the humerus palpation will be tender
→Lateral deltoid pain; one side is weaker
66
rotator cuff tear or rupture diagnostic testing
```
CBC w/ diff
ESR
Serologic tests fro rheumatologic disease
→Imaging
X-ray: anteroposterior view, axillary lateral views, scapular Y view
→MRI
→CT scan
→ Ultrasound
→Arthrography
→Arthrocentesis
```
67
Neer's test--> assesses for possible rotator cuff impingement.
Stabilize the scapula and with the thumb pointing down and passively flex the arm. Pain is a positive test.
68
Hawkin's test assesses for possible rotator cuff impingement.
Stabilize the scapula, passively abduct the shoulder to 90 degrees, flex the shoulder to 30 degrees, flex the elbow to 90 degrees, and internally rotate the shoulder. Pain is a positive test
69
rotator cuff--> Impingement test
Have pt elevate arm slowly into overhead position; suggests rotator cuff strain, tendinitis, or tear if pt experiences sharp “catch” of pain or impingement w/ this maneuver
70
Empty can test
• Have pt hold out affected arm as if offering a can of soda and then have pt turn arm to “empty” contents, rotator cuff tendinitis or tear if pain is produced by the maneuver of “emptying can
71
Rotator Cuff ---> What treatment is recommended? (include medication, activity restriction, and any exercise that may be indicated)
→Alternating ice/heat packs and graded exercise
→NSAIDS, PT, deep friction massage, ROM exercises (pendulum swing, wall climb..pt walks fingers up wall)
→weight/resistant exercises for strengthening (Thera-band)
→Need to prevent frozen shoulder; but rest is also needed
72
What is adhesive capsulitis
→Most common and worrisome complication of chronic shldr pain
→Characterized by a gradual, progressive decline in shldr mobility, results from prolonged joint immobilization after a painful episode
73
Discuss the best follow-up plan : rotator cuff
→If failure to respond to conservative, nonoperative therapy or if s/s escalate…may need referral
→Referral will likely include additional dx testing
→Give pt 6 wks to recover
→Will need referral if not responding for poss surgical tx
74
Elbow pain - “tennis elbow” (Lateral Epicondylitis)
Gradual to acute onset of pain; w/ or w/o radiation
→Impt to ask activities prior to experiencing pain, type of work will likely be tied to type of pain or high performance athlete (think tennis player, golf)
→Exam both elbows, looking for alteration in carrying angle, posture, strength and ROM
→Bone and soft tissue landmarks for asymmetry, malalignment, erythema, edema and tenderness
→Also examine bone landmarks at medial and lateral epicondyles of the humerus and olecranon process of the ulna
→ROM (flexion & extension, pronation & supination): Normal ROM rules out involvement of the elbow joint itself
→Resisted wrist extension can help dx lateral epicondylitis
-->Pt will have local tenderness over or just distal to affected epicondyle; possible tenderness of flexor and extensor muscles
75
manage elbow pain (tennis elbow ) lateral epicondylitis
Conservative tx: NSAIDS, tennis elbow splint, “palms up” lifting, toning exercises of wrist extensors
→If conservative tx unsuccessful…steroid tx
→Usually self-limiting but can take several months for a full recovery
**Refer when there is no relief in pain :o)
76
possible low back pain causes
Osteoporotic compression fx, infection, trauma, inflammatory dis, myositis, fibromyalgia, neoplasm, malignant dis, acute abd aneurysm, referred pain, peripheral neuropathy, spinal stenosis
77
low back pain--> diagnostic testing
→Plain XR of lumbar spine if acute hx of trauma, hx of CA, long-standing hx of corticosteroid use, osteoporosis, drug or ETOH abuse, or any neuro s/s (use clinical judgment so as to not expose pt to unnecessary radiation)
→Radionuclide bone scintigraphy…suspicion of osteomyelitis, bone neoplasm, occult fx + bone scan with single-photon emission CT…recent pars fx and facet osteoarthritis
→Other possible tests for low back but NOT indicated for this pt…CT, MRI.
→New guidelines state that CT/MRI are indicated if pt has severe or progressive neurologic deficits or s/s of a serious underlying condition
→Labs : ESR, C-RP, CBC, alkaline phos, calcium…may be warranted depending on pts hx and presenting s/s
→Electromyography…neuro changes assoc w/ denervation and reinnervation caused by subacute and chronic radiculopathy
78
how to manage low back pain
→Pt education…proper lifting technique
→Bedrest, only if truly needed…no longer than 2 days
→Heat, ice, massage, exercise (prevents deconditioning, improves strength, flexibility and endurance)
→Walking is good, wt loss, stop smoking
→OTC analgesics, NSAIDS…opioids and tramadol only if other options were tried and were not successful
79
education need for low back pain
→Yes. Reassurance and support.
→Pain may come and go
→Proper body mechanics (sitting, standing, lying and lifting)
80
when to refer for low back pain
→Low back pain in acute and subacute phases, generally does not need further referral or hospitalization
→If unable to control pain and maintain function w/ outpatient measures, refer
81
Low back pain and Neurological signs
complains of back pain. on examine you find numbness of the lateral toes and an absent ankle jerk
lumbar Radiculopathy
82
straight leg test
+ if pts typical pain is reproduced at any point when the leg is in 20-70 deg of hip flexion
83
what is radiculopathy mean
Nerve root damage; “pinched nerve” **
| What are the indications for MRI of the back?
84
indication for MRI of the back
MRI indicated if suspected cord/root compression
| →Addition of gadolinium can be used to look for infection or tumor
85
management of lumbar radiculopathy
→Any radicular s/s need to be referred to a specialist
| →Can prescribe meds until they are seen
86
muscle relaxant
Tizanidine, cyclobenzaprine (flexaril)
87
drug seeking
Something that we will all run into as NPs. Need to consider the pt and his hx. Be suspicious of pain-pill seekers. But definitely need to tx the pts pain. Some w/ chronic pain truly know what works for them and are not pain-pill seekers…a good question to think about.
→So many answers to this question, use your best judgment with the info about the pt, their condition and what will be the best for them for the present situation
88
Hand Pain (Osteoarthritis)
Heberden’s nodes.
89
manage OA
→Ibuprofen at lowest effective dose, taken with food. Rest. PT referral .
potential complications: GI upset GI bleed
90
Knee injury (meniscus tear)
active extension or flexion of the knee. What kind of injury do you suspect?
→Meniscus tear
91
Mc murrays test
Patient is supine with provider at the patient’s side
provider holds patient’s heel with the distal hand and places the proximal hand on knee in fully flexed position
provider externally rotates the tibia then with gentle force on the knee extends the leg
provider internally rotates the tibia then with gentle force on the knee extends the leg
positive sign is pain, popping or clicking along the joint line
92
Apley's test:
→The patient lies prone with the involved knee flexed to 90 %
The provider stands beside the patient with both hands on the plantar aspect of the patient’s foot and heel
The provider presses gently on the foot to press knee against the table and laterally and medial rotates the foot
Then the provider places pressure on the upper leg so that they can provide medial and lateral rotation with upward pulling on the foot
positive sign is pain, popping or clicking along the joint line
93
Thessaly test
→The Thessaly test is done by: the patient standing only on the affected leg being supported in the front by the practitioner
the patient rotates the knee and body internally and externally three times keeping the knee in slight flexion (5%)
Repeat with the knee in greater flexion (20%)
positive sign is pain, sense of locking or catching in the tested knee
94
X-ray for knee pain ?
Yes, plain films can exclude bone abnormalities before an MRI is done
95
→RICE:
Rest (crutches, etc.), Ice (or cold water immersion for 15 to 20 min q 2-3 hrs for the first 48 hours), Compression (elastic bandage or air cast) and Elevation (to the level of the heart) to decrease swelling
quadriceps muscle strengthening (such as a simple leg raise to begin then move to swimming/ riding a stationary bike )
96
Ankle Pain (second degree sprain)
swelling erythema damage to ankle
| palpate for pain and do a passive ROM test if crepitus = fx
97
Do the squeeze test
Athlete is sitting or lying prone with his/her knee extended
Examiner cups his/her hands behind the tibia & fibula, away from the site of pain
Examiner compresses the tibia & fibula, gradually adding more pressure
Positive Test - pain distal to the force
98
Do the external rotation test
Athlete is sitting with his/her legs over the edge of the table
Examiner stabilizes the lower leg with one hand
Examiner grasps the medial aspect of the foot while supporting the ankle in neutral
Examiner rotates the foot laterally
Positive Test; Medial/lateral joint pain; syndesmosis (anterior Tib–fib) pain
Positive Test Implications; Deltoid ligament sprain (medial/lateral joint pain); syndesmosis involvement (syndesmosis/tib–fib pain)
99
Anterior drawer test
Athlete is sitting over the edge of the table with the knee bent
Examiner stabilizes the lower leg with one hand & cups the calcaneus with the forearm supporting the foot in slight plantar flexion (~ 20° ) and slight inversion (few degrees)
Examiner draws the calcaneus & talus anteriorly and slightly medially
Positive Test - Pain, anterior translation, dimple/sulcus, and/or "clunk
100
Talar tilt test
Athlete is sitting over the edge of the table with the knee bent
Examiner stabilizes the lower leg with one hand & cups the calcaneus with the forearm supporting the foot in dorsiflexion (~10° )
Opposite hand stablizes the lower leg
Thumb is placed on the calcaneofibular ligiment and rotate the talus medially
Examiner draws the calcaneus & talus anteriorly and slightly medially
Positive Test - talus gaps or tilts excessively or pain is produced (compare to uninjured side)
Positive Test Implications - ligament sprain
101
first degree sprain
mild with microscopic tears, mild swelling and tenderness, no joint instability, able to bear weight and ambulate with minimal pain
102
second degree sprain
2nd degree - more severe injury involving an incomplete tear of a ligament, moderate pain, swelling, tenderness, ecchymosis, mild to moderate joint instability with restriction of ROM, weight bearing and ambulation is painful.
management RICE
103
3rd degree sprain
3rd degree - involves a complete tear of a ligament, severe pain, swelling, tenderness, ecchymosis, significant mechanical instability and loss of function and motion, unable to bear weight or ambulate
104
rehabilitation for ankle sprain
Rehabilitation should begin as soon as possible after the injury and should include ROM and strengthening exercises. Active and passive resistive exercises progresses as ROM and strength improve. Will take weeks
complication: Sprain can recur within the first month if not fully rehabilitated, 2nd and 3rd degree sprains increase the possibility of joint instability and traumatic arthritis. Also increases the risk of fracture.
105
carpal tunnel syndrome
Carpal tunnel is median nerve entrapment of the wrist. A bony canal bordered by the carpal bones on the radial, ulnar and dorsal sides is roofed by the transverse carpal ligament. The canal provides a passage for the nine digital flexor tendons, blood vessels and the median nerve of the hand.
→Pregnancy can cause swelling in the canal, impinging on the median nerve of the hand. Recent studies may contradict prior thoughts that repetitive motion contributes to carpel tunnel syndrome.
106
dx testing for carpal tunnel syndrome
By history and exam a preliminary diagnosis can usually be made with formal testing (xray, EMG with nerve conduction studies, Cervical films) completed as necessary.
107
Tenel’s signs
Ask patient to raise the thumb straight up as you apply downward resistance- weakness on thumb abduction is a positive test. Tap lightly over the course of the median nerve in the carpal tunnel – aching and numbness in the median nerve is a positive test.
108
Phalen’s signs
Ask patient to hold wrists in flexion x 60 seconds. Numbness and tingling in the median nerve distribution within 60 seconds is a positive test
109
tx carpal tunnel syndrome
Acetaminophen and splinting at night for pain relief. Refer to OT for splinting. Will resolve post-delivery when swelling resolves. Only severe cases (pain, debilitation) need to be referred to a specialist.
110
education & f/u carpal tunnel syndrome
1. Resolution with delivery
2. May recur with future pregnancies
3. Avoid overexertion, frequent rest periods
4. Ice packs
5. Compliance with splints
→ Follow up in 3 weeks and refer to hand specialist if interventions without help.
--> if severe, debilitating sx w/o relief --> refer
111
Back, Shoulder and Hip pain for 3 months (Fibromyalgia)
→History of trauma, viral illness, stress (FMS usually follows these), other somatic complaints: cognitive difficulties, auditory, vestibular, and ocular complaints; chronic rhinitis or “allergies”, migraines, palpitations, IBS, joint swelling, mood disorders
elicit tenderness on 11 of the 18 points locations (pg 913 - Buttaro), should be no evidence of synovitis or soft tissue inflammation, muscle strength is normal
CBC, erythrocyte sedimentation rate, rheumatoid factor, antinuclear antibodies, TSH, can exclude underlying autoimmune disease
112
dx fibromyalgia (FM)
→hallmark of the syndrome is widespread persistent (3 months) pain along with chronic fatigue
--> CNS dysfunction (mostly it is unknown)
113
criteria for fibromyalgia (FM)
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widespread persistent (3 months) pain (must include right and left sides of the body, above and below the waist, and axial skeletal pain)
chronic fatigue
elicit tenderness on 11 of the 18 points locations (is being challenged as diagnostic criteria
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114
manage fibromyalgia
→encourage exercise (critical)
→cognitive behavioral therapy
→strength training, acupuncture, hypnotherapy, biofeedback, medicinal baths
→Tricyclic antidepressant (like amitriptyline for sleep)
Lyrica, Cymbalta, Savella
115
Why is it that NSAIDs do not work?
FM is not an inflammatory process, it does not cause muscle, joints or oragan damage. /KR
What is your teaching/education for Polly?
Education is critical since the syndrome is chronic, family should be involved in education
Exercise and adequate rest needs to be emphasized
Support groups should be offered and encouraged
