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
SLE- vascular
Raynaud’s phenomena Vasculitis Thromboembolic disease
26
SLE- skin changes
Butterfly rash | Photosensitivity
27
SLE- overview of affects
``` Constitutional (Fever, fatigue and myalgia) Arthritis and arthralgia Skin changes Renal and cardiac disease Pulmonary disease Vascular disease ```
28
SLE - medical therapy
Corticosteroid creams, pills and/or IV NSAIDS Anti malarial drugs Drugs targeting B-cells
29
SLE- medical dx
Blood test - measure anti-nuclear antibodies | Tissue biopsy
30
Scleroderma
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.
31
Crest syndrome
``` Hands... Calcium deposits Puffy fingers Raynaud’s Digital ulcers/scars ``` Form of scleroderma (systemic- limited)
32
Psoriatic disorder
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
33
Psoriatic arthritis
Characteristic early nail separation (onycholsis) w/ erythema of fingers Nail pits can develop into separation of lateral nail plate from nail bed
34
Clinical manifestations of psoriasis
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
35
Medical therapy- psoriasis
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)
36
SLE- prognosis
No cure ``` Self-management: Avoid sunlight Avoid smoking Stress management Prolonged rest at night (12 hours) Regular exercise ```
37
SLE- common s/s
``` 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
PT considerations for SLE and RA- | Treatment sought for?
Seek treatments related to: Arthritis Weakness/Fatigue Pain reduction
39
PT considerations for SLE and RA- | Education?
Education: skin care, prevention of breakdown (limit sun exposure); energy conservation techniques (avoid excessive bed rest)
40
PT considerations for SLE and RA- | Other?
Assistive devices (consider hand deformities) Infection control
41
PT considerations for SLE and RA- | Acute inflammation
ROM and MMT testing | May be Contraindicated
42
PT considerations for RA- | AA?
Atlanto-axial Instability in RA = contact MD immediately ``` Neuro signs Progressive neck pain Paraplegia Spasticity Hyperreflexia Ataxic gait ```
43
PT considerations for SLE and RA- | Exercise?
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
PT considerations for SLE and RA- | Other recommendations
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
Aerobic exercise- evidence SLE
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
Aquatics vs Land- evidence RA (RCT)
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
Evidence- RA (RCT) | Person-centered PT on fatigue
12 weeks Self care plan development with focus on balance of physical and life activities Reduced general fatigue Less anxiety
48
Commonalities among chronic pain syndromes
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
The pain continuum
Nociceptive Centralized
50
______ Pain related to damage of somatic or visceral tissue, due to trauma or inflammation
Nociceptive
51
_____ Pain related to damage of peripheral or central nerves
Neuropathic
52
___ Pain without identifiable nerve or tissue damage; thought to result from persistent neuronal dysregulation
Centralized
53
Key characteristic- | Acute pain
First time event
54
Key characteristic- | Recurrent pain
Relapsing/Remitting | Episodic vs Constant
55
Key characteristic- | Chronic pain
Neural adaptation Sympathetic alterations Bio psychosocial consequences
56
Acute vs Recurrent vs Chronic Pain (global and local) | Myofascial example
Acute: strain Recurrent: Global-Myofascial pain syndrome Local- Epicondylalgia; Impingement; Recurrent tension HA Chronic: Global-Fibromyalgia; Chronic Fatigue Syndrome Local-Chronic tension HA
57
Increased pain response to normally painful stimulus
Hyperalgesia
58
Painful response to a normally innocuous stimulus
Allodynia
59
Pain caused by a lesion or disease of the somatosensory nervous system
Neuropathia
60
Pain that is enhanced or maintained by a functional abnormality of the SNS
Sympathetically maintained pain
61
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
Windup
62
CMP: Chronic myofascial pain | Characterized by?
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
CMP: Chronic myofascial pain | Mechanisms of development?
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
CMP: Chronic myofascial pain | Persistent skeletal muscle ____
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
CMP: Chronic myofascial pain Myofascial pain syndrome Pathophysiology
``` 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
CMP: Chronic myofascial pain Myofascial pain syndrome Diagnostic criteria
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
CMP: Chronic myofascial pain / Myofascial pain syndrome Perpetuating factors
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
CMP: Chronic myofascial pain / Myofascial pain syndrome Medical therapy
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
CMP: Chronic myofascial pain / Myofascial pain syndrome PT
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
CMP: Chronic myofascial pain / Myofascial pain syndrome PT: correction of perpetuating factors
Abnormal posture Incorrect muscle activity or movement patterns Anatomical defect correction (ie leg length) Sleep hygiene
71
CMP: Chronic myofascial pain / Myofascial pain syndrome PT- multimodal protocols
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
Fibromyalgia | Definition/Description
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
Fibromyalgia | Clinical dx
``` 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
Fibromyalgia tender points
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
Fibromyalgia | Clinical presentation
``` 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
Common symptoms of FMS and CMP/MPS
``` 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
Differentiating FMS and CMP/MPS
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
FMS (fibromyalgia) pathophysiology
Uncertain ``` Suspected... Low serotonin Increase in Substance P Elevated levels of nerve growth factor Dysfunction of HPA-axis Central sensitization phenomena ```
79
FMS (fibromyalgia) | Co-morbidities
``` Sleep disturbance/apnea Depression Anxiety PTSD May need labs to rule out other conditions ```
80
Fibromyalgia | Medical management
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
Fibromyalgia | PT interventions
Improve physical fitness and function Reduce fibromyalgia symptoms Optimize overall health and well-being Minimize effect of illness and injury on fibromyalgia symptoms
82
Fibromyalgia PT interventions Exercise considerations
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
Fibromyalgia | PT interventions
``` 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
Fibromyalgia | “Start low, go slow”
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
CFS: Chronic Fatigue Syndrome | Definition/description
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
CFS: Chronic Fatigue Syndrome And FMS: Fibromyalgia Shared symptoms
``` Chronic pain Fatigue, sleep difficulties Stiffness Anxiety/Depression Frequent HA Sensitivity to light Cognitive issues Exertional malaise ```
87
CFS: Chronic Fatigue Syndrome and FMS: Fibromyalgia | Differences
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
CFS: Chronic Fatigue Syndrome | Pathophysiology
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
CFS: Chronic Fatigue Syndrome | Dx criteria
``` 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
CFS: Chronic Fatigue Syndrome | Medical management
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
CFS: Chronic Fatigue Syndrome | GET- Graded Exercise Therapy
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
Graded exercise guidelines for | CFS: Chronic Fatigue Syndrome
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