Week 12 Flashcards by John Shaffer

Describe what Temporal arteritis is:

a condition marked by vasculitis(inflammation) of the temporal and cranial arteries, these are the most common sites for vasculitis to occur.
When the temporal artery is involved patients may
present to a physical therapist with complaints of
headache or craniomandibular pain, very common
reasons for patients seeking care from a physical
therapist

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Serious symptom pts feel when experiencing temporal arteritis

-blurred or lost vision, diplopia
-headache typically unilateral (typically over anterior internal auditory meatus), severe, and continuous (pounding, throbbing)
-onset is typically sudden
-scalp hypersensitivity
-flu-like symptoms, fever, chills, malaise
-extreme tenderness to touch over artery

HALLMARK SIGN: PAIN OVER TEMPORAL ARTERY

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Which artery does the temporal artery branch off of? And where can you palpate it?

-external carotid artery
-just anterior to auditory meatus

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What lining of the artery does vasculitis primarily affect?

-the media (middle lining of artery)
-causing decreased blood flow and tissue ischemia

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Demographics of populations affected from arterial arteritis:

-Mainly elderly and increase after 50 yo
-3x more common in W; b/w 70-79 most effected

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Most common co-morbidity associated with temporal arteritis:

-polymyalgia rheumatica (diffuse muscle pain and stiffness in proximal muscles; shoulder/pelvic girdle

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Aggravating factor of temporal arteritis

-chewing (particularly tough/bulky foods; due to muscle vascular ischemia), talking, swallowing may increase headache intensity
-use of mastication muscles (masseter, temporalis, pterygoids)

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What’s a pancoast tumor?

Other info about this?

-non-small cell lung cancer within the apex of the lung (superior lobe)
-associated pain in the shoulder girdle region (may have neurological symptoms due to possible compression on the brachial plexus

-highest rank in cancer deaths typically is diagnosed in later stages)

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Pt demographics and primary risk factors for Pancoast tumor:

-pts 50 yo and older
-Risk factors:
-smoking history (especially 20 or more/day)
-occupation has high exposure to air pollutants, asbestos
-history of COPD and emphysema
-previous diagnosis of malignancy
lung is #1 site for metastatic disease

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Chief complaints of symptoms:

-insidious onset and progresses slowly over time
-pain not influenced by mvts, postures initially
NON-MECHANICAL PAIN PATTERN

-typically initially with dull/diffuse shoulder ache and/or neck
-of pleura involved.. pain can be sharper and severe
-if brachial plexus involved…UE radicular pain (burning, paresthesia) typically C8-1 nerve roots

-as tumor progresses:
-unexplained weight loss
-fatigue
-malaise
pulmonary system symptoms typically absent

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Physical exam findings (potential unusual):

-surface anatomy changes
-digital clubbing
-Horner’s syndrome (disrupted nerve pathway to face/eye; miosis-smaller pupil, ptosis-drooping eyelid, little/no sweat on contralateral side of face)
Neurological deficits

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Area of the body that may show a potential pancoast tumor and what it looks like

-supraclavicular area (should be concave shape
-fossa may appear “filled in” in the region that should be concave
-may feel a mass/lump on 1 side

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Describe some info related to digital clubbing

-sign of chronic hypoxia that may be associated with pulmonary disease
-bulbous-shaped distal digit
-normal angle: <180 degrees b/w nail and nail bed
-abnormal angle: >180 degrees

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Physical examination findings (potentially unusual) for Pancoast tumor:

-Neurological deficit(s)
• Often the C8 and T1 nerve roots are involved
first, which may lead to
• Muscle wasting of the intrinsic hand
musculature
• Sensory changes in the C8 and T1
distributions

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Which of the following is the most common initial
manifestation of a patient with a Pancoast Tumor?
a.Dyspnea and a chronic cough
b. Dull and diffuse shoulder ache
c. Fever and night sweats
d. Loss of sense of smell and taste

Final word with Temporal arteritis & pancoast tumor

-Temporal arteritis and Pancoast tumor are 2 very
different conditions
-The first is marked by a sudden onset of a severe and disabling headache
-the 2nd is marked by a slow progressive dull shoulder
ache
*Both carry a poor prognosis if there is a delay in diagnosis

What is gout?
Primary vs Secondary

-an acute inflammatory joint condition marked by the presence of uric acid crystals within the joint (healthy individuals dissolve uric acid n blood then excrete it thru urine but some may accumulate on articular cartilage and periarticular structures leading to an acute inflammatory response)
-This metabolic disorder is marked by elevated serum
uric acid that results in these crystals being deposited not
only in the joints, but also potentially in the kidneys and
soft tissues

-Primary: inherited condition

-Secondary: secondary to a number of pre-existing conditions and/or can be medication
related. The result is urate overproduction or decreased
urinary excretion of uric acid.
*Conditions that result in urate OVERPRODUCTION include:
• Leukemia
• Lymphoma
• Psoriasis
• Hemolytic disorders
• Patients receiving chemotherapy
* Conditions that result in DECREASED excretion of uric
acid include:
• Renal insufficiency
• Hypertension
• Hypothyroidism
• Hyperparathyroidism
• Obesity
• Heavy Alcohol intake
*Medications: thiazide, diuretics, levodopa

Gout pt demographics

-more common in men (90%) in 30s-40s
*primary gout most common inflammatory disease
-diets rich in purines can increase risk of gout: shellfish, trout, sardines, organ meats, pease, beans

Chief complaints of Gout:

-Usually monoarticular, exquisite joint pain,
hypersensitivity and tenderness
-1st MTP joint the most common, but can occur
in any small peripheral joint
-Ankle, mid-foot, knee, elbow, wrist and finger joints

-Onset:
• Insidious, sudden and acute onset
• Often during sleep (2.4x higher vs day time hours; low body temp/cortisol lvls, some dehydration)

Aggravating factors for Gout

-pain increases drastically with WB activities for LE joints
-any attempts to actively move the involved joint

Alleviating factors for Gout

-even with rest, pain is still high
-slight relief with NSAIDs but only temporary

Physical examination findings for Gout:

-Review of symptoms
-chills, fever,tachycardia
-HALLMARK= TENDERNESS WITH PALPATION
-pain with active mvt.
-antalgic gait for LE sites
-Erythema, warmth
-classic site is at 1st MTP joint

How to properly diagnosis Gout

-with joint aspiration (reveals urate crystals) and bloodwork (elevated serum uric acid levels) -once diagnosis ex, pts typically enter the inter-critical phase (asymptomatic phase lasting months-years)

The onset of gout is marked typically by which of the following? a. Sudden onset and often nocturnal b. Preceded by unexplained weight loss c. Slow gradual onset after lots of physical activity d. Multiple joints, often bilateral and symmetric involvement

Describe compartment syndrome,name each compartment, and pt demographics

•Abnormal increased pressure within fascial compartment can lead to nerve and vascular compromise, a potential medical emergency •This condition can potentially occur in any compartment (anterior, posterior-superficial & posterior-deep, lateral, but the most common location is in lower leg •There are different sub-types; acute and chronic exertional (exercise induced) compartment syndrome -More commonly occurs in people who are physically active. They are more prone to accidents and repetitive injuries. -These are important pre-requisites for the onset of this condition

Chief complaints and onset of symptoms with Compartment Syndrome

-complain of calf pain (posterior compartment) or shin splints (anterior compartment)- often a cramping and intense tightness -May also complain of neurological symptoms; paresthesia, numbness or weakness -The more rapidly progressing symptoms the more concern is raised regarding the neurovascular status Onset: one or the other of these scenarios- -local blunt trauma or crush injury -unaccustomed repetitive activity (correlative to stress fracture)

Actions associated with pain for each compartment

Anterior: DorsiFlexion Posterior: plantar flexion Lateral: eversion

Aggravating vs Alleviating factors for Acute Compartment Syndrome

Aggravating: -Activity – the harder the muscle(s) have to work the more intense the pain will be. -When acute stretching the involved muscle groups can be painful (pain is secondary to ischemia; pt will need to stop activity for proper circulation to occur) Alleviating: -minimize activity but in extreme cases a compartment decompression may be warranted

Physical examination findings for Compartment syndrome

-Palpatory pain along the compartment with "firmness”, of the muscle groups -May have difficulty finding the peripheral pulses -Pallor and decreased skin temperature may be noted due to decreased arterial blood flow -Sensory and motor deficit may be present at rest or only with activity

6 Ps for Compartment syndrome

-Pain (severe cramping, tightness) -Palpatory tenderness/hard-firm feel -Paresthesia (nervous system) -Paresis (nervous system) -Pulselessness (arterial system) -Pallor (arterial system)

What nerve/artery/muscle group is within the anterior compartment?

-deep peroneal nerve, anterior tibial artery, dorsiflexors

6 Ps for Anterior Compartment syndrome

-Pain – “I have shin splints”! • Palpatory tenderness/hard-firm feel along the anterior compartment • Paresthesia – Web space digits I and II deep peroneal nerve • Paresis – dorsi-flexion deep peroneal nerve • Pulselessness – dorsal pedal artery • Pallor * typically the first two Ps just need a good rehab program *Paresis- patient can try heel walking to assess DF strength[

6 Ps for posterior compartment syndrome

-Pain – “I have a calf strain”! • Palpatory tenderness/hard-firm feel along posterior compartment • Paresthesia – plantar surface of foot – tibial nerve • Paresis – plantar-flexion; tibial nerve • Pulselessness – posterior tibial artery • Pallor – plantar surface of foot

4 Ps for lateral compartment syndrome

-Pain – “My outer leg hurts” (traumatic event) • Palpatory tenderness/hard-firm feel along outside lower leg region • Paresthesia – Dorsum of foot excluding web-space- digits I and II; superficial peroneal nerve • Paresis – eversion; superficial peroneal nerve Pulselessness – ??? Pallor-??

Notes to know about screening for compartment syndrome

-Trauma or unaccustomed activity needs to be part of the patient history • The pain location and palpatory findings will help direct potential type of compartment syndrome • If there are no neurological or vascular findings and the pain has not recently dramatically progressed, a rehabilitation program is warranted & If there are new or worsening neurological or vascular findings and/or the pain has recently dramatically progressed, an urgent referral to a physician is warranted

Anterior compartment syndrome is marked by which of the following? a. Numbness of the plantar surface of the foot b. Weakness with ankle eversion c. Pallor of the lateral aspect of the foot d. Numbness in the web-space between the 1st and 2nd toes

D (deep peroneal nerve) *A->posterior compartment syndrome *B-> lateral compartment syndrome

The onset of gout is marked typically by which of the following? A. Sudden onset and often nocturnal B. Preceded by unexplained weight loss C. Slow gradual onset after lots of physical activity D. Multiple joints, often bilateral and symmetric involvement