Week 2 Guiding Q's (Exam 1)

Question 1

Develop a few examples of open-ended questions you can utilize in the patient interview.

Answer 1

• Tell me how I can help you?
• Tell me why you are here today?
• Tell me about your injury?
• What do you think is causing your problem/pain?

Question 2

What 2 questions are essential to ask every patient in order to screen for depression?

Answer 2

oDuring the past month have you been feeling down, depressed or hopeless?
oDuring the past month have you been bothered by having little interest or pleasure in doing things?

Question 3

List 5-8 signs that you might observe that may indicate an individual has an eating disorder.

Answer 3

1. Discoloration or staining of the teeth from contact with stomach acid
2. Broken blood vessels in eyes from vomiting
3. Dry skin and hair; brittle nails; hair loss and growth of downy hair all over the body (lanugo), including the face
4. Tooth marks, scratches, scars or calluses on the backs of hands from inducing vomiting (Russell’s sign)
5. Weight loss/gain
6. Irregular or absent menstrual periods
7. Inability to tolerate cold
8. Reports of heartburn, abdominal bloating or gas, constipation or diarrhea
9. Bradycardia or low blood pressure
10. Enlarged parotid glands from repeated contact with vomit
11. Skeletal myopathy & weakness
12. Chronic fatigue
13. Dehydration or rebound water retention (pitting edema)

Question 4

List the behavioral signs/symptoms of a potential eating disorder.

Answer 4

• Preoccupation with weight, food, calories, fat grams, dieting clothing size, body shape
• Mood swings
• Frequent comments about being fat or overweight despite looking very thin
• Excessive exercise to burn off calories
• Use of diuretics, laxatives, enemas, other drugs to induce urination, bowel movements or vomiting
• Binging and purging
• Food restriction

Question 5

Detail how you would handle addressing a patient that you believed showed up to their appointment intoxicated.

Answer 5

Example: I’m concerned because of your behavior…. you’re not going to get much out of it.

(It’s not safe to participate if they are on drugs or intoxicated.)

Question 6

Why is it important that PT’s screen for smoking? What impact may it have on the patient’s healing?

Answer 6

It is related to wound healing, DDD, acute disc herniation, in general not good for health

Question 7

What outcome measure would you use in clinical practice for an individual you are concerned is a fall risk? (note: these do not have to only be those listed in the PowerPoint. Feel free to include those you have learned or prefer).

Answer 7

Performance-based tests

• Functional Reach Test
• Berg Balance Scale
• Timed up and go

Balance confidence/Fear of Falling

• Activities-Specific Balance Confidence Scale (ABC)
• Falls Efficacy Scale (FES)
• Survey of Activities and Fear of Falling in the Elderly (SAFE)

Question 8

What warning signs may be indicative of elder abuse?

Answer 8

oMultiple trips to ER
oDepression
o“Falls”/fractures
oBruising/suspicious sores
oMalnutrition/weight loss
oPressure ulcers
oChanging MDs/therapists often
oConfusion attributed to dementia

Question 9

List the common MSK side effects associated with antibiotics, NSAIDs and statins.

Answer 9

oAntibiotics- skin reactions, noninflammatory joint pain, tendinopathy/tendon rupture

oNSAIDs- back and or shoulder pain

oStatins (Lipitor, Crestor)- myalgia; if you’re working with a patient on statin and they aren’t improving it won’t change until the medication is addressed

Question 10

Name a few examples of NSAIDs.

Answer 10

Ibuprofen, naproxen, diclofenac, celcoxib

Question 11

Name a few examples of statins.

Answer 11

Lipitor and Crestor

Question 12

What are some signs/symptoms of NSAID related gastropathy?

Answer 12

Damage to GI tract

• Stomach upset and pain
• Increased blood pressure and peripheral edema
• Confusion and memory loss in the elderly

Use in surgical patients may cause post-op complications

• Wound hematoma
• Upper GI tract bleeding
• Hypotension
• Impaired bone or tendon healing

Question 13

What are risk factors for NSAID Gastropathy?

Answer 13

• 65 years and older
• History of peptic ulcer disease, GI disease, or RA
• Chronic use of NSAIDS (duration of > or = to 3 months)
• Use of acid suppressants
• Tobacco or alcohol use
• NSAIDs combined with oral corticosteroid use
• NSAIDs combined with anticoagulants
• NSAIDs combined with selective serotonin reuptake inhibitors (ie Prozac, Zoloft, Celexa, Paxil)
• Higher doses of NSAIDs (or duplicate use)
• Concomitant infection w/ H. pylori

Question 14

What are the signs and symptoms of NSAID complication as it relates to the GI system? MSK system?

Answer 14

GI
oIndigestion/heartburn/epigastric or abdominal pain
oEsophagitis, dysphagia, odynophagia
oNausea
oUnexplained fatigue lasting more than 1-2 wks
oUlcers, perforations, bleeding
oMelena

Musculoskeletal
oIncreased symptoms after taking the med
oSymptoms linked with ingestion of food
oMidthoracic back, shoulder or scapular pain
oMuscle weakness
oRestless leg syndrome
oParesthesias

Question 15

What are the signs and symptoms of NSAID complication as it relates to the GI system?

Answer 15

1. Increased symptoms after taking the med
2. Symptoms linked with ingestion of food
3. Midthoracic back, shoulder or scapular pain
4. Muscle weakness
5. Restless leg syndrome
6. Paresthesias

Question 16

What 2 questions should all patients be asked to screen for depression?

Answer 16

o First 2 questions of the PHQ-9:

In the last 2 weeks have you:
Little interest or pleasure in doing things
Feeling down, depressed or hopeless

Question 17

What do you do if a patient answer yes to 1 or both of the depression screening questions?

Answer 17

??

Give them the full PHQ-9.

(Or is this only if they answer yes to both questions?)

Question 18

How would you proceed if you are treating a patient that you are concerned is suicidal?

Answer 18

oDirect question
Are you having thoughts of attempting to harm yourself?
o“Yes”=initiate facility protocol
oFollow-up questions
oDo you have a plan in place?
oAre the resources related to the pts plan readily available?
oContact appropriate individual

Question 19

Compare and contrast insufficiency vs fatigue fracture.

Answer 19

oUsually a non-displaced fracture (not a displaced fracture)
Insufficiency = osteoporosis
Fatigue = repetitive motion

Question 20

Describe the risk factors of femoral head & neck fractures. (7)

Answer 20

1. Female gender; hormonal, menstrual irregularities
2. Involvement in running, jumping and marching activities
3. Change in training program or routine (upping it)
4. Nutritional deficiencies
5. Leg length discrepancy
6. Diminished muscle strength
7. Osteoporosis

Question 21

Describe the clinical manifestations of femoral head and neck fractures (8)

Answer 21

1. Pain in groin, greater trochanter and/or buttock
2. Referred pain to anteromedial thigh may be chief complaint
3. Provoked with increased WBing
4. Relieved with reduced WBing
5. Insidious onset
6. Hip ROM reveals minor if any pain provocation
7. Plain films often negative
8. displaced fx

Question 22

What is the difference between a non displaced and a displaced femoral/head neck fracture?

Answer 22

Displaced Femoral Head/Neck Fracture:

• Compromised WBing status
• Onset of pain usually secondary to trauma
• May or may not be ecchymosis or edema
• Palpatory tenderness is questionable
• Shortened lower limb
• Position of comfort ER and abduction

Non-displaced Femoral Head/Neck Fracture:

• Insufficiency or fatigue fracture
• Typically not marked by major trauma
• Nondisplaced fx have more confusing or much less severe presentation which can result in delayed diagnosis and or ultimately progression to

Question 23

What physical exam techniques would you utilize if you suspected a femoral head or neck fracture?

Answer 23

Fulcrum and pubic percussion tests

Question 24

Describe the risk factors of CES.

Answer 24

o Carries significant risk of irreversible neurologic compromise
o Loss of bladder bowel and sexual function possible
o May require urgent surgical intervention
o Incidence with disk herniation 1-16%
o Incidence with disk surgery 1-3%
o Other causes of CES
 Tumor
 Infections
 Spinal stenosis
 Hematoma
o Risk Factors
 Low back injury, central disk herniation
 Congenital or acquired spinal stenosis
 Spinal fracture
 Ankylosing spondylitis
 Tuberculosis, Pott’s Disease (type of TB, extrapulmonary TB not in the lungs (spine))

Question 25

Describe the clinical manifestations of CES.

Answer 25

1. Urinary dysfunction (retention, incontinence)
2. Bowel dysfunction (incontinence, loss of anal tone, trouble voiding is more common than unable to control at all)
3. Sexual dysfunction (reduced sensation during intercourse, impotence)
4. Sensory deficits
5. Perineum and “saddle” regions
6. Lower extremities motor deficits

Question 26

Describe the risk factors of cervical myelopathy.

Answer 26

1. Cervical spondylosis
2. Spinal degeneration from neck trauma (ie MVA, sports injury)
3. Rheumatoid arthritis

Question 27

Describe the clinical manifestations and physical exam for cervical myelopathy.

Answer 27

o Clinical Manifestations
 History
 Impaired hand dexterity
 Gait, balance difficulties (legs weak, stiff)
 Numbness, paresthesia-extremities (upper and possibly lower)
 Neck stiffness
 Urinary dysfunction (retention and possible urgency and frequency)
o Physical Exam
 Hand-intrinsic atrophy
 Muscle weakness, often triceps; hand intrinsic
 Muscle weakness of lower extremities (proximal muscles)
 Upper motor neuron signs

Question 28

• What are the clustered clinical findings associated with cervical myelopathy as outlined by Cook et al? How do you interpret the clinical findings to rule cervical myelopathy in? How do you interpret the clinical findings to rule cervical myelopathy out?

Answer 28

o Clustered Clinical Findings
 1. Gait Abnormality
 2. + Hoffmann’s test
 3. Inverted supinator sign
 4. + Babinski test
 5. Age >45 years
o 1/5 = ability to rule out myelopathy
o Sensitivity of 0.94 (rule out)
o 3/5= ability to rule in myelopathy
o Specificity of 0.99 (rule in)

Question 29

Describe the risk factors of an AAA.

Answer 29

o Visceral causes of back pain are uncommon (2%)

o Most AAA occur in individuals 60 years and older
 10th leading cause of death in males 65 and older
 13th leading cause of death in females 75 and older
o AAA defined as vessel diameter >3 cm or more
o Risk of rupture increases as diameter approaches 5-6 cm

Risk Factors
◦ Age
◦ Male gender
◦ History of smoking
◦ History of hypercholesterol and coronary heart disease
◦ Family history of AAA

Question 30

Describe the clinical manifestations of an AAA.

Answer 30

◦ Asymptomatic in most
◦ If pain is present, most likely back pain
◦ Abdominal, hip, groin or buttock pain also possible
◦ Nonmechanical properties – no specific pattern
◦ Insidious onset
◦ May report early satiety, weight loss and nausea
◦ Vascular dissection (rupture) must be considered with pain described as hot, searing, ripping, tearing pain
Burit – turb BF at AAA auscultation (shouldn’t hear anything except digestion)

Question 31

• Describe the risk factors of a DVT.

Answer 31

o Affects ~ 2 million individuals in US
o Carries significant risk for development of
 PE
 Postphlebitic syndrome
 Chronic thromboembolic pulmonary hypertension

• ~ 50% of those with DVTs are asymptomatic in early stages

• Risk Factors
o Previous history of DVT
o History of Cancer
o History of CHF
o History of SLE
o Receiving chemotherapy
o Major surgery
o Major trauma
o Immobility
o Limb paralysis
o Women during pregnancy
o Women taking oral contraceptives, hormone replacement therapy
o Age >60 years

Question 32

Describe clinical manifestations of a DVT.

Answer 32

• Clinical Manifestations
o Ache, tightness, tenderness
o General edema
o Pitting edema
o Prominent superficial venous plexus
o Increased local skin temperature
o Redness

Question 33

• How do you interpret the Wells Clinical Prediction rule for DVT? What probability would warrant a referral for further screening?

Answer 33

o Active Cancer (treatment ongoing or within previous 6 months)
o Paralysis, paresis or recent plaster immobilization of the LE
o Recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring anesthesia
o Localized tenderness along the distribution of the deep venous system
o Entire leg swelling
o Calf Swelling at least 3cm larger than asymptomatic leg (measured 10cm below tibial tub)
o Pitting Edema confined in symptomatic leg
o Collateral superficial veins (nonvaricose)
o Previous DVT
o Subtract 2 if there is an alternative diagnosis at least as likely as a DVT
o
• High Probability if score is > 3 (75%)
• Moderate if score is 1-2 (17%)
• Low score if 0 (3%)

Question 34

Describe risk factors and clinical manifestations of a PE

Answer 34

o Associated with high morbidity and mortality
o Researchers estimate that more than 50% of PE-related deaths are potentially preventable
o Proximal DVTs are most common cause
o PE related mortality estimated at 5-20%

• Risk Factors
o Previous history of PE
o History of DVT
o Immobility
o History of abdominal, pelvic surgery
o Total hip, knee replacement
o Late-stage pregnancy
o Lower limb fractures
o Malignancy of pelvis or abdomen

• Clinical Manifestations
o Dyspnea
o Tachypnea (increased RR)
o Pleuritic chest pain, intensified w/ deep respiration and cough
o Persistent cough
o Apprehension, anxiety
o Tachycardia
o Palpitations

Question 35

• How do you interpret the Wells Clinical Prediction rule PE? What probability would warrant a referral for further screening?

Answer 35

Anyone with a mod to high probability -refer them to seek care

Scoring:

• High risk: >6
• Mod risk: 3-6
• Low risk: 1-2

Question 36

• Describe the risk factors and clinical manifestations of atypical myocardial infarction.

Answer 36

o Not everyone suffering from MI present with the classic pattern
o L sided chest tightness, pressure or and pain
o Referral into L upper extremity
o Less typical for women than men to present with classic pattern
o Only 50% of women experience chest pain
o Cardiac death leading cause of death in women of all ages

Question 37

List the difference in scoring for Wells Criteria for PE vs. DVT

Answer 37

Wells Criteria for DVT Scoring:

• High Probability: >3
• Moderate Probabilty: 1-2
• Low Probability: 0

Wells Criteria for PE Scoring:

• High Probability: >6
• Moderate Probability: 3-6
• Low Probability: 0-2

Question 38

modifiable risk factors for an MI

Answer 38

 Cigarette smoking
 High cholesterol levels
 HTN
 DM
 Obesity
 Sedentary lifestyle
 Excessive alcohol consumption

Question 39

non modifiable risk factors for an MI

Answer 39

 Age: >55 yr for women: >45 yr for men
 Family history
 Ethnicity
• highest in African Americans

Question 40

Clinical Manifestations in Women of an MI

Answer 40

◦ Shortness of breath
◦ Fatigue
◦ Sleep disturbance
◦ Nausea (with or without vomiting)
◦ Palpitations
◦ Dizziness
◦ Diaphoresis
◦ Anxiety

Question 41

• What are the pain locations associated with atypical MI?

Answer 41

 Upper abdominal/epigastric
 Neck, jaw and tooth
 Interscapular and mid to lower thoracic
 R arm pain (possibly isolated in biceps)