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Examine Complex Patient 6671 > Week4 6671/6611 > Flashcards

Week4 6671/6611 Flashcards

1
Q

Small, non palpable rash

A

Macule

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2
Q

Raised palpable rash

A

Papule

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3
Q

Rash contains pus

A

Pustule

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4
Q

Large palpable rash

A

Plaque

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5
Q

Rash- small with clear fluid

A

Vesicles

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6
Q

Allergic- raised edges, migratory

A

Urticaria

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7
Q

Allergic- watery edema

A

Angioedema

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8
Q

Thick swollen synovial membrane with granulation tissue (fibroblasts, myofibroblasts, and inflammatory cells)

A

Pannus

RA

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9
Q

Photo sensitivity can be caused by what meds?

A

Antibiotics
Diuretics
NSAIDS
Oral hypoglycemics

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10
Q

RA - joints?

A

Symmetrical
Multiple- usually 5 or more

Common:
Small joints first: MCP, PIP, MTP
As progresses…
Large joints: shoulders, elbows, knees, ankles

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11
Q

Unusual itching- skin disease screening

A

Liver disease
Renal disease
Elderly population
Dry skin

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12
Q

Specific RA deformities - hands

A
  1. Ulnar deviation
  2. Boutonnière deformity
    Extensor tendon splits- PIP flex, DIP hyper-ext
  3. Swan neck deformity
    PIP hyper-ext , DIP flex
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13
Q

Baker cyst

A

Popliteal cyst
Synovial sac of knee bulges posteriorly

(RA)

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14
Q

Felty syndrome

A

RA, Splenomegaly, and Granulocytopenia

Risk of life threatening infections

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15
Q

ABCDE mole/lesion

A 
Asymmetry 
Border
Color 
Diameter 
Evolve
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16
Q

Atopic dermatitis/Eczema

A

Chronic inflammatory skin disease
Usually children, but can affect adults

Flexor surfaces most involved

Dry skin, erythema, oozing and crusting
Scaling often present in adults

Very itchy
Often associated w/ other allergic conditions such as asthma and food allergy

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17
Q

Herpes zoster

A

Very common rash
Often in elderly

UNILATERAL distribution is hallmark

Can be triggered by stress, immunocompromise, illness

“Dew drop on a rose petal”

Effective vaccination is available
Post herpetic neuralgia is a significant complication

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18
Q

Abscess

A

Treatment is always drainage

Antibiotics may be needed for surrounding cellulitis

MRSA is an increasing problem

Any lesion with obvious purulence/pus should be referred for incision and drainage

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19
Q

Post op infection-

Physical exam

A

Sinus tract to joint is a definite infection

Warmth, redness or swelling

Low grade fever

Limited ROM due to pain and swelling

Err on side of caution

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20
Q

Post op infections- history

A

Persistent pain and stiffness at site of arthroplasty is associated w/ infection >90% of patients

Acute onset w/ swelling, tenderness, drainage

Chronic infections show pain and more subtle symptoms- function deteriorates and pain worsens over time

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21
Q

Vascular exam

A

Pulse palpitation
Capillary refill
Edema
Turgor

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22
Q

Dermatomyositis

A

Idiopathic inflammatory myopathy w/ proximal skeletal muscle weakness and muscle inflammation

Pink cheeks, purple “violaceous” hue over eyelids, rash along elbows, knuckles and knees
Rash classically does NOT spare nasal labial fold

Similar to polymyositis- but polymyositis does not have skin changes

Good prognosis, rarely recurrent

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23
Q

SLE -

Epidemiology

A

African-American, Latino and Asian women
Women 9-10:1
Typical onset 15-45

Chronic inflammatory disease
Can affect virtually every organ
Develop large number of antinuclear antibodies

Common pattern: constitutional complaints w/ skin, MSK, mild hematologic, and serologic involvement

Avoid sunlight, smoking, stress. Get Regular exercise and prolonged rest

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24
Q

SLE- constitutional symptoms

A

Fatigue
Fever
Myalgia

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25
Q

SLE- vascular

A

Raynaud’s phenomena
Vasculitis
Thromboembolic disease

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26
Q

SLE- skin changes

A

Butterfly rash

Photosensitivity

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27
Q

SLE- overview of affects

A 
Constitutional (Fever, fatigue and myalgia)
Arthritis and arthralgia 
Skin changes
Renal and cardiac disease 
Pulmonary disease 
Vascular disease
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28
Q

SLE - medical therapy

A

Corticosteroid creams, pills and/or IV
NSAIDS
Anti malarial drugs
Drugs targeting B-cells

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29
Q

SLE- medical dx

A

Blood test - measure anti-nuclear antibodies

Tissue biopsy

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30
Q

Scleroderma

A

Hardening of skin
Affects different body parts
Prompt and proper referral may minimize symptoms, and reduce chances of irreversible damage

No cure or known cause
Localized- more common in children
Systemic- more common in adults

Women predominant (4:1)
Onset 25-55
May be genetic.

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31
Q

Crest syndrome

A 
Hands...
Calcium deposits 
Puffy fingers 
Raynaud’s 
Digital ulcers/scars

Form of scleroderma (systemic- limited)

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32
Q

Psoriatic disorder

A

Skin hyperproliferation as well as a complex immune mediated condition

Characterized by: well-demarcated, erythematous plaques w/ silver scale; dry cracked skin may bleed

Thickened, pitted or ridged nails

Assoc w/ comorbidities such as autoimmune thyroid disease, DM, metabolic syndrome and psoriatic arthritis

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33
Q

Psoriatic arthritis

A

Characteristic early nail separation (onycholsis) w/ erythema of fingers

Nail pits can develop into separation of lateral nail plate from nail bed

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34
Q

Clinical manifestations of psoriasis

A

Discomfort and pain
Routine tasks are difficult when hands involved
Concern about appearance of skin
Mgmt incl diet, exercise, weight control, avoid smoking and treat for signs of depression

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35
Q

Medical therapy- psoriasis

A

Topical corticosteroids and emollients for skin rash and plaques

Moderate to severe plaque disease can be treated with phototherapy

Systemic therapy w/ immunosuppressant or immunomodulatory drugs (MTX or retinoids)

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36
Q

SLE- prognosis

A

No cure

Self-management:
Avoid sunlight 
Avoid smoking 
Stress management 
Prolonged rest at night (12 hours) 
Regular exercise
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37
Q

SLE- common s/s

A 
Joint inflammation 
Kidney disease 
Skin rashes 
Fatigue 
Muscle pain 
Unexplained fever 
Loss of hair
Raynaud’s phenomenon 
Seizures 
Sensitive to sun 
Swelling- edema in legs or around eyes 
May affect: heart, lungs, blood and brain
38
Q

PT considerations for SLE and RA-

Treatment sought for?

A

Seek treatments related to:
Arthritis
Weakness/Fatigue
Pain reduction

39
Q

PT considerations for SLE and RA-

Education?

A

Education: skin care, prevention of breakdown (limit sun exposure); energy conservation techniques (avoid excessive bed rest)

40
Q

PT considerations for SLE and RA-

Other?

A

Assistive devices (consider hand deformities)

Infection control

41
Q

PT considerations for SLE and RA-

Acute inflammation

A

ROM and MMT testing

May be Contraindicated

42
Q

PT considerations for RA-

AA?

A

Atlanto-axial Instability in RA = contact MD immediately

Neuro signs
Progressive neck pain 
Paraplegia
Spasticity 
Hyperreflexia 
Ataxic gait
43
Q

PT considerations for SLE and RA-

Exercise?

A

Exercise in short, frequent sessions throughout day (vs 1 long session)

Avoid fatigue
Alternate activities

Stop activity when fatigue and pain begin
Decrease level or remove activity if pain lasts for more than 1-2 hrs after end of activity

44
Q

PT considerations for SLE and RA-

Other recommendations

A

Change positions every 20-30 min throughout day to avoid static positioning

Avoid high-impact and contact sports

During inflammation flare ups, avoid excessive bending and stooping

45
Q

Aerobic exercise- evidence SLE

A

Reduce fatigue
Increase QOL
Improve functional testing scores
No aggravation of symptoms

3x per week, 12 weeks
65-75% HRR
Cardio better than resistance for improved QOL
Does not demonstrate a change in disease activity

46
Q

Aquatics vs Land- evidence RA (RCT)

A

30 min week- 6 sessions
Aquatic vs land

Aquatic: 87% “much better or very much better”

No significant differences in 10 m walk, functional scores, QOL or pain scores

47
Q

Evidence- RA (RCT)

Person-centered PT on fatigue

A

12 weeks
Self care plan development with focus on balance of physical and life activities

Reduced general fatigue
Less anxiety

48
Q

Commonalities among chronic pain syndromes

A

Chronic widespread pain
Often with fatigue, sleep, memory and mood disturbances
May represent a central pain syndrome: doesn’t r/o peripheral nociceptive input or neuropathic conditions; makes id of pain source less clear leading to treatment difficulties

Dx often overlap and assoc with anxiety and depression

Similarities between MPS, FMS, and CFS increases risk of misdiagnosis

49
Q

The pain continuum

A

Nociceptive Centralized

50
Q

______ Pain related to damage of somatic or visceral tissue, due to trauma or inflammation

A

Nociceptive

51
Q

_____ Pain related to damage of peripheral or central nerves

A

Neuropathic

52
Q

___ Pain without identifiable nerve or tissue damage; thought to result from persistent neuronal dysregulation

A

Centralized

53
Q

Key characteristic-

Acute pain

A

First time event

54
Q

Key characteristic-

Recurrent pain

A

Relapsing/Remitting

Episodic vs Constant

55
Q

Key characteristic-

Chronic pain

A

Neural adaptation
Sympathetic alterations
Bio psychosocial consequences

56
Q

Acute vs Recurrent vs Chronic Pain (global and local)

Myofascial example

A

Acute: strain

Recurrent:
Global-Myofascial pain syndrome
Local- Epicondylalgia; Impingement; Recurrent tension HA

Chronic:
Global-Fibromyalgia; Chronic Fatigue Syndrome
Local-Chronic tension HA

57
Q

Increased pain response to normally painful stimulus

A

Hyperalgesia

58
Q

Painful response to a normally innocuous stimulus

A

Allodynia

59
Q

Pain caused by a lesion or disease of the somatosensory nervous system

A

Neuropathia

60
Q

Pain that is enhanced or maintained by a functional abnormality of the SNS

A

Sympathetically maintained pain

61
Q

Progressive increase in frequency and magnitude of firing of dorsal horn neurons by the repetitive activation of C fibers above a critical threshold, leading to a perceived increase in pain intensity

A

Windup

62
Q

CMP: Chronic myofascial pain

Characterized by?

A

Myofascial pain syndrome

Pain caused by facial constrictions and multiple trigger points

Non-symmetrical pain pattern

May be in response to tissue injury

Possible progression to FMS or CFS with chronicity and central sensitization

63
Q

CMP: Chronic myofascial pain

Mechanisms of development?

A

Persistent load from…

Low-level muscle contractions
Uneven intramuscular pressure distribution
Unaccustomed eccentric contractions, eccentric contractions in unconditioned muscle
Maximal or submaximal concentric contractions

64
Q

CMP: Chronic myofascial pain

Persistent skeletal muscle ____

A

Nociceptor activity

Trigger point (TrP) -

Taut, palpable bands
Pain with palpation
Can be active or latent:
-Active: “jump sign” on palpation
-Latent: nodular/taut band w/o pain on palpation
-2ndary: hyper irritable point that becomes active as muscular overactivity in another muscle occurs
Possible non-radicular, referred pain w/ consequences

65
Q

CMP: Chronic myofascial pain
Myofascial pain syndrome
Pathophysiology

A 
Abnormal ACh release->
Increased tension in muscle fiber->
Blood flow constriction and hypoxia-> 
Disrupted mitochondrial metabolism->
Release of sensitizing substances-> 
Pain and tenderness

(Cycle repeats through Autonomic modulation)

66
Q

CMP: Chronic myofascial pain
Myofascial pain syndrome
Diagnostic criteria

A
  1. Taut band within muscle
  2. Exquisite tenderness at point on taut band
  3. Reproduction of pt pain
    ^ essential for dx
Local twitch response 
Referred pain 
Weakness 
Restricted ROM 
Autonomic signs (skin warmth or erythema, tearing, piloerection)
67
Q

CMP: Chronic myofascial pain /
Myofascial pain syndrome
Perpetuating factors

A

Mechanical:
Scoliosis, leg length discrepancies, joint hyper mobility, muscle overuse

Psychosocial: stress, anxiety

Systemic/Metabolic: hypothyroidism, iron insufficiency, Vit C, D or B12 deficiency

Other: infectious disease, parasitic (Lyme), polymyalgia rheumatica, Statins

68
Q

CMP: Chronic myofascial pain /
Myofascial pain syndrome
Medical therapy

A

NSAIDS alone have limited effectiveness (injected may help)

Muscle relaxants not effective (TrPs NOT a spasm)

Invasive:
Anesthetic injections (lidocaine)
Botulism toxin A injections (if resistant to conventional rx)

69
Q

CMP: Chronic myofascial pain /
Myofascial pain syndrome
PT

A

Invasive: dry needling

Non-Invasive: 
US
TENS
Stretching (spray and stretch) 
Post-isometric relaxation 
Trigger point pressure release 
Massage

Multi-modal protocols show good results
Correction of perpetuating factors

70
Q

CMP: Chronic myofascial pain /
Myofascial pain syndrome
PT: correction of perpetuating factors

A

Abnormal posture
Incorrect muscle activity or movement patterns
Anatomical defect correction (ie leg length)
Sleep hygiene

71
Q

CMP: Chronic myofascial pain /
Myofascial pain syndrome
PT- multimodal protocols

A

Combo: myofascial TrP dry needling, spray and stretching, kinesio-tape, eccentric exercise, and pt education

Low visits stretched out over long duration (ie 5 visits over 4 weeks)

72
Q

Fibromyalgia

Definition/Description

A

Syndrome of central sensitivity

Generalized soft tissue syndrome caused by limbic and/or neuroendocrine dysfunction
Systemic involving biochemical, neuro endocrine and physiological abnormalities
Leads to disorder of pain processing and perception (allodynia, hyperalgesia)

Heightened/augmented sensitivity to pain and other stimuli (sounds, smell, heat)

73
Q

Fibromyalgia

Clinical dx

A 
Widespread pain at least 3 months 
AND 
Presence of all the following:
11 out of 18 Tender points 
Pain above and below waist
Pain on bilateral side of body
74
Q

Fibromyalgia tender points

A
  1. Occiput
  2. Trapezius
  3. Supraspinatus
  4. Gluteal
  5. Greater trochanter
  6. Low cervical
  7. Second rib
  8. Lateral epicondyle
  9. Knee

One per side of body for 18 total
11 out of 18 for dx

75
Q

Fibromyalgia

Clinical presentation

A 
Widespread chronic, unrelenting pain
Fatigue 
Insomnia 
Impaired thought processes 
Altered sensation 
Poor physical function and balance 
Oral and ocular problems
HA
Sexual dysfunction 
Psychological effects
76
Q

Common symptoms of FMS and CMP/MPS

A 
Mild to severe soft tissue pain 
HA, migraines
Disturbed sleep 
Balance problems/dizziness 
Tinnitus 
Memory problems 
Unexplained swelling 
Worsening symptoms from stress, changes/extremes in weather, physical activity
77
Q

Differentiating FMS and CMP/MPS

A

Tender points in fibromyalgia NOT same as TrP (trigger points) in CMP/MPS

CMP/MPS- pain generally confined to TrPs (but may refer); TrPs CAN be eliminated

FMS can be a progression from CMP/MPS

FMS- pain widespread and around tender points and DOES NOT refer

78
Q

FMS (fibromyalgia) pathophysiology

A

Uncertain

Suspected...
Low serotonin 
Increase in Substance P
Elevated levels of nerve growth factor
Dysfunction of HPA-axis 
Central sensitization phenomena
79
Q

FMS (fibromyalgia)

Co-morbidities

A 
Sleep disturbance/apnea 
Depression 
Anxiety 
PTSD 
May need labs to rule out other conditions
80
Q

Fibromyalgia

Medical management

A

Local anaesthetics- reduction of peripheral deep tissue pain

Anti-epileptics/Antidepressants-
Improve/prevent central sensitization

GABA agonists- normalization of sleep abnormalities

Antidepressants- esp Tricyclics- treatment of negative effect, particularly depression

81
Q

Fibromyalgia

PT interventions

A

Improve physical fitness and function

Reduce fibromyalgia symptoms

Optimize overall health and well-being

Minimize effect of illness and injury on fibromyalgia symptoms

82
Q

Fibromyalgia
PT interventions
Exercise considerations

A

Sedentary lifestyle and general deconditioning assoc w/ FMS increases risk of chronic disease

Greater levels of FMS symptoms assoc w/ lower aerobic fitness (but don’t assume!)

Narrow therapeutic window: too little exercise = no benefits; too much exercise = exacerbations

Minor injuries/illness may sustain process of central sensitization

83
Q

Fibromyalgia

PT interventions

A 
1- Education 
Self-efficacy 
Trusting therapeutic relationships
Stress management 
Activity management

Multi-modal multidisciplinary approach:
combo of aerobic, strength and flexibility
Aquatics (not better than land for FMS)
Alternative: tai chi, Nordic walking, Pilates, relaxation/visualization
“Increased home based physical activity”- pedometer step counts etc

84
Q

Fibromyalgia

“Start low, go slow”

A

Gradual progression low-intensity->

Aerobic: Start just below capacity and gradual increase to 20-30 min 2-3x/wk
HR not specific, be able to “speak fluently w/ another”
Duration of at least 4 weeks

Strength: start at lower levels than age-predicted norms. Reduce intensity/duration w/ post-exertion pain/fatigue
Intensity increased 10% after 2 weeks w/o exacerbation

85
Q

CFS: Chronic Fatigue Syndrome

Definition/description

A

Debilitating and complex disorder
Intense fatigue not improved by bed rest and may be worsened with physical activity/mental exertion

Substantially lower level of function than prior to illness
May have flu-like symptoms at onset, w/ progression to muscle pain and forgetfulness
Often disturbance in autonomic regulation of BP and HR (lower)
Varies person to person; May be cyclical
Hallmark- post-exertional malaise
Multitude of immune and neuro symptoms

86
Q

CFS: Chronic Fatigue Syndrome
And FMS: Fibromyalgia
Shared symptoms

A 
Chronic pain 
Fatigue, sleep difficulties 
Stiffness 
Anxiety/Depression 
Frequent HA 
Sensitivity to light 
Cognitive issues 
Exertional malaise
87
Q

CFS: Chronic Fatigue Syndrome and FMS: Fibromyalgia

Differences

A

FMS: Pain is dominant symptom
CFS: Fatigue is dominant symptom

FMS: May be triggered by trauma
CFS: May be preceded by flu-like or infectious illness

FMS: Substance P elevated (is not in CFS)
CFS: Greater exercise intolerance

88
Q

CFS: Chronic Fatigue Syndrome

Pathophysiology

A

Mostly unknown etiology
No biomedical tests for dx - must be clinical dx and one of exclusion

Common pathological processes in both FMS and CFS:
HPA suppression
Autonomic dysfunction
Disturbed Stage 4 sleep
Decreased serotonin/suppression of growth hormone

89
Q

CFS: Chronic Fatigue Syndrome

Dx criteria

A 
Fatigue 6 or more months 
Substantial reduction in work, personal, school, social...
Unrelieved w/ rest
Other medical/psychiatric conditions excluded 
AND
4 or more of following....
Post-exertion malaise lasting > 24hra
Impaired memory or concentration 
Non refreshing sleep 
Muscle pain 
Pain in multiple joints w/o inflammation 
HA PF new type or severity 
Sore throat 
Tender cervical or axillary lymph nodes
90
Q

CFS: Chronic Fatigue Syndrome

Medical management

A

Symptom relief, improved function, and sleep disturbance

No specific approved drug therapies
Many similar meds as FMS

NSAIDS May be more beneficial for CFS
Antidepressants- more for assoc between depression and CFS, and assist w/ sleep
SSRI/SNRI May help w/ neuropathic pain assoc w/ CFS but do not address immune system dysregulation

91
Q

CFS: Chronic Fatigue Syndrome

GET- Graded Exercise Therapy

A

Best clinical evidence in combo w/ strategies of pacing to promote energy conservation and rest

Best outcomes when in combo w/ cognitive-based therapies

Once maintenance achieved, progress slowly to graded aerobic exercise

92
Q

Graded exercise guidelines for

CFS: Chronic Fatigue Syndrome

A
  1. Time contingent (not symptom)
  2. Home exercise:
    5x/week starting at 5-15 min per session, gradual increase to 30 min
  3. Number of sessions, length and duration:
    10-11 sessions over 4-5 months (excluding home exercise sessions)
  4. Aerobic exercise- walking, swimming or cycling

Examine Complex Patient 6671 (8 decks)

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