Differential Diagnosis Practice Questions Ch. 9-18 (Final Exam)
5. A positive Schober's test is a sign of: a. Reiter's syndrome b. Infectious arthritis c. Ankylosing spondylitis d. a or b e. a or c
(c) Schober's is a physical examination used to measure the ability of a patient to flex the lower back
7. What is the significance of "skin pain" over the T9/T10 dermatomes?
"Skin pain" may be a sign of referred pain from the upper urinary tract because visceral sensory fibers via the autonomic nervous system and cutaneous sensory fibers via the peripheral nervous system (dermatomes) enter the spinal cord in close proximity and even converge on some of the same neurons. When visceral pain fibers are stimulated, concurrent stimulation of cutaneous fibers also occurs that is then perceived as "skin pain."
1. The screening model used to help identify viscerogenic or systemic origins of hip, groin, and lower extremity pain and symptoms is made up of: a. Past medical history, risk factors, clinical presentation, and associated signs and symptoms b. Risk factors, risk reduction, and primary prevention c. Enteric disease, systemic disease, and neuromusculoskeletal dysfunction d. Physical therapy diagnosis, Review of Systems, and physician referral
(a)
17. A 49-year-old man was treated by you for bilateral synovitis of the proximal interphalangeal (PIP) joints in the second, third, and fourth fingers. His symptoms went away with treatment, and he was discharged. Six weeks later, he returned with the same symptoms. There was obvious soft tissue swelling with morning stiffness worse than before. He also reports problems with his bowels but isn't able to tell you exactly what's wrong. There are no other changes in his health. He is not taking any medications or over-the-counter drugs and does not want to see a doctor. Are there enough red flags to warrant medical evaluation before resumption of physical therapy intervention? a. Yes; age, bilateral symptoms, progression of symptoms, report of GI distress b. No; treatment was effective before—it's likely that he has done something to exacerbate his symptoms and needs further education about joint protection.
(a)
4. Screening for cancer may be necessary in anyone with hip pain who: a. Is younger than 20 or older than 50 b. Has a past medical history of diabetes mellitus c. Reports fever and chills d. Has a total hip arthroplasty (THA)
(a)
9. A 23-year-old woman was a walk-in to your clinic with sudden onset of left shoulder pain. She denies any history of trauma and has only a past history of a ruptured appendix three years ago. She is not having any abdominal pain or pain anywhere else in her body. How do you know if she is at risk for ectopic pregnancy? a. She is sexually active, and her period is late. b. She has a history of uterine cancer. c. She has a history of peptic ulcer. d. None of the above.
(a)
3. A positive Blumberg's sign indicates: a. Pelvic infection b. Ovarian varicosities c. Arthritis associated with IBD d. Sacral neoplasm
(a) Blumberg sign is a positve rebound tenderness sign and indicates peritonitis.
8. Clients with diabetes insipidus (DI) would most likely come to the therapist with which of the following clinical symptoms? a. Severe dehydration, polydipsia b. Headache, confusion, lethargy c. Weight gain d. Decreased urine output
(a) DI is caused by lack of secretion or action of vasopressin (ADH). Without ADH, patient is dehydrating (b) this is more with DM (c)DM type 2 (d) this is opposite.
2. Which of the following best describes the pattern of rheumatic joint disease? a. Pain and stiffness in the morning gradually improves with gentle activity and movement during the day. b. Pain and stiffness accelerate during the day and are worse in the evening. c. Night pain is frequently associated with advanced structural damage seen on x-ray. d. Pain is brought on by activity and resolves predictably with rest.
(a) (b) and (c) are more characteristic of osteoarthritis (OA); rheumatoid arthritis (RA) is rarely accompanied by night pain, and advanced structural damage is more typical of OA because RA has a tendency to "burn itself out"; answer (d) describes pain of vascular insufficiency.
18. A client with a past medical history of kidney transplantation (10 years ago) has been referred to you for a diagnosis of rheumatoid arthritis. His medications include tacrolimus, methotrexate, Fosamax, and Wellbutrin. During the examination, you notice a painless lump under the skin in the right upper anterior chest. There is a loss of hair over the area. What other symptoms should you look for as red flag signs and symptoms in a client with this history? a. Fever, muscle weakness, weight loss b. Change in deep tendon reflexes, bone pain c. Productive cough, pain on inspiration d. Nose bleeds or other signs of excessive bleeding
(a) A history of chronic immunosuppression (e.g., antirejection drugs for organ transplants, long-term use of immunosuppressant drugs for inflammatory or autoimmune disease, cancer treatment) in the presence of this clinical presentation is a major red flag. A painless, enlarged lymph node or skin lesion of this type, when associated with immunosuppression from organ transplantation, may be caused by lymphoma, in which case, it is followed by weakness, fever, and weight loss.
3. Referred pain patterns associated with impairment of the spleen can produce musculoskeletal symptoms in: a. The left shoulder b. The right shoulder c. The mid- or upper back, scapular, and right
(a) Kehr's sign
. A client complains of throbbing pain at the base of the anterior neck that radiates into the chest and interscapular areas and increases with exertion. What should you do first? a. Monitor vital signs, and palpate pulses b. Call the physician or 911 immediately c. Continue with the exam; find out what relieves the pain d. Ask about past medical history and associated signs and Symptoms
(a) Monitor vital signs and palpate pulses.
4. Referred pain patterns associated with hepatic and biliary pathology can produce musculoskeletal symptoms in: a. The left shoulder b. The right shoulder c. The mid or upper back, scapular, and right shoulder areas d. The thorax, scapulae, right or left shoulder
(c)
3. Match the following skin lesions with the associated underlying disorder: a. Raised, scaly patches b. Flat or slightly raised malar on the face c. Petechiae d. Tightening of the skin e. Kaposi's sarcoma f. Erythema migrans g. Hives h. Subcutaneous nodules ______ Psoriatic arthritis ______ Systemic lupus erythematosus ______ HIV infection ______ Scleroderma ______ Rheumatoid arthritis ______ Allergic reaction ______ Lyme disease ______ Thrombocytopenia
(a) Psoriatic arthritis (b) Systemic lupus erythematosus (subcutaneous nodules may also occur with SLE) (e) HIV infection (d) Scleroderma (h) Rheumatoid arthritis (g) Allergic reaction (see Table 12-1) (f) Lyme disease (c) Thrombocytopenia
8. A 60-year-old woman with a history of left breast cancer (10 years postmastectomy) presents with pain in her midback. The pain is described as "sharp" and radiates around her chest to the sternum. She gets some relief from her pain by lying down. Her vital signs are normal, and there are no palpable or aberrant lymph nodes. She denies any changes in breast tissue on the right or the scar and soft tissue on the left. You do not have adequate training to perform a clinical breast examination, but the client agrees to visual inspection, which reveals nothing unusual. All other findings are within normal limits; you are unable to provoke or aggravate her symptoms. Neurologic screening examination is within normal limits. The client denies any history of trauma. What plan of action would you recommend? a. Refer her to a physician before initiating treatment. b. Carry out a plan of care, and reassess after three sessions or 1 week, whichever comes first. c. Document your findings, and contact the physician by phone or by fax while initiating treatment. d. Eliminate TrPs, and then reassess symptoms.
(a) Refer her to a physician before initiating treatment.
13. What is the significance of Beau's lines in a client treated with chemotherapy for leukemia? a. Impaired nail formation from death of cells b. Temporary longitudinal groove or ridge through the nail c. Increased production of the nail by the matrix as a sign of healing d. A sign of local trauma
(a) See Fig. 4-31 and discussion of Beau's lines, Chapter 4. horizontal line/depression across the nail. This occurs with shock, illness, malnutrition, or trauma severe enough to impair nail formation such as acute illness, prolonged fever, or chemotherapy. Can also occur as local trauma. Beau's lines are temporary until the impaired nail formation is corrected (if and when the individual returns to normal health).
1. Chest pain can be caused by trigger points of the: a. Sternocleidomastoid b. Rectus abdominis c. Upper trapezius d. Iliocostalis thoracis
(a) Sternocleidomastoid
12. Which glycosylated hemoglobin (A1C) value is within the recommended range? a. 6% b. 8% c. 10% d. 12%
(a) The American Diabetes Association recommends that people with diabetes maintain a level of 7% or below on the A1C; this reflects average blood-sugar levels over a period of 2 to 3 months.
7. A client reports shoulder and upper trapezius pain on the right that increases with deep breathing. How can you tell if this results from a pulmonary or a musculoskeletal cause? a. Symptoms get worse when lying supine but better when right sidelying when it is pulmonary b. Symptoms get worse when lying supine but better when right sidelying when it is musculoskeletal
(a) if msk, should get better in supine
3. In a physical therapy practice, clients are most likely to present with signs and symptoms of metastases to: a. Skeletal system, hepatic system, pulmonary system, central nervous system b. Cardiovascular system, peripheral vascular system, enteric system c. Hematologic and lymphatic systems d. None of the above
(a) see page 531 Integumentary system Pulmonary system Neurologic system Musculoskeletal Hepatic These are most likely bc they can refer sites of pain to what seems like msk patterns (i.e. shoulders, LBP, T/S, neurosymptoms like mms weakness, etc)
1. The most common sites of referred pain from systemic diseases are: a. Neck and back b. Shoulder and back c. Chest and back d. None of the above
(b)
16. A 70-year-old man came to outpatient physical therapy with a complaint of pain and weakness of his fingers and morning stiffness lasting about an hour. He presented with bilateral swelling of the metacarpophalangeal (MCP) joints of the index and ring fingers. He saw his family doctor 4 weeks ago and was given diclofenac, which has not changed his symptoms. Now he wants to try physical therapy. Since he last saw his physician, he has developed additional joint pain in the left knee and right shoulder. How can you tell if this is cancer, polyarthritis, or a paraneoplastic disorder? a. Ask about a previous history of cancer and recent onset of skin rash. b. You can't. This requires a medical evaluation. c. Look for signs of digital clubbing, cellulitis, or proximal muscle weakness. d. Assess vital signs.
(b)
5. The most common sites of referred pain from systemic diseases are: a. Neck and hip b. Shoulder and back c. Chest and back d. None of the above
(b)
9. True hip pain is characterized by: a. Testicular (male) or labial (female) pain b. Groin or deep buttock pain with active or passive range of motion c. Positive McBurney's test d. All of the above
(b) (a) and (c) indicate abdominal, pelvic, or systemic problem, etc
5. Pain on weight bearing may be a sign of hip fracture, even when x-rays are negative. Follow-up clinical tests may include: a. McBurney's, Blumberg's, Murphy's test b. Squat test, hop test, translational/rotational tests c. Psoas and obturator tests d. Patrick's or Faber's test
(b) (a) appendicitis, peritonitis, gallbladder (c) abscess (d) Pain provocation tests for the symphysis pubis and SI joint
10. An inpatient who has had a total hip replacement with a significant history of alcohol use/abuse has a positive test for asterixis. This may signify: a. Renal failure b. Hepatic encephalopathy c. Diabetes d. Gallstones obstructing the common bile duct
(b) Alcohol abuse should alert a red flag for liver pathology. Hepatic encephalopathy is the loss of brain function when a damaged liver doesn't remove toxins from the blood, asterixis (flapping tremors/liver flap) is an outwards sign of liver disease affecting the CNS dysfunction
6. Abscess of the hip flexor muscles from intra-abdominal infection or inflammation can cause hip and/or groin pain. Clinical tests to differentiate the cause of hip pain resulting from psoas abscess include: a. McBurney's, Blumberg's, or Murphy's test b. Squat test, hop test, translational/rotational tests c. Iliopsoas and obturator tests d. Patrick's or Faber's test
(c)
11. Parathyroid hormone (PTH) secretion is particularly important in the metabolism of bone. The client with an over-secreting parathyroid gland would most likely have: a. Increased blood pressure b. Pathologic fractures c. Decreased blood pressure d. Increased thirst and urination
(b) PTH regulates calcium and phosphorus metabolism. Parathyroid disorders include hyperparathyroidism and hypoparathyroidism. hyperparathyroidism will result in release of bone calcium into the bloodstream therefore demineralizing and weakening bone strength and density. Increase in bloodstream calcium can lead to renal stones. hyperparathy is common in postmenopausal women
8. Which of the following skin assessment findings in the HIV infected client occurs with Kaposi's sarcoma? a. Darkening of the nail beds b. Purple-red blotches or bumps on the trunk and head c. Cyanosis of the lips and mucous membranes d. Painful blistered lesions of the face and neck
(b) purplish-red lesions of the feet, trunk, and head (Fig. 12-2). The lesion is not painful or contagious. HIV infection is also associated with non-Hodgkin's lymphoma (NHL), AIDS- related primary central nervous system lymphoma, and hepatocellular carcinoma.
6. Which of the following are clues to the possible involvement of the GI system? a. Abdominal pain alternating with TMJ pain within a 2-week period of time b. Abdominal pain at the same level as back pain occurring either simultaneously or alternately c. Shoulder pain alleviated by a bowel movement d. All of the above
(b) (a) Temporomandibular joint (TMJ) pain is possible with cardiac involvement but not likely with gastrointestinal disease (c) pain alleviated by a bowel movement usually occurs with disease of the colon, which does not refer pain to the shoulder unless massive retroperitoneal bleeding occurs, in which case, earlier symptoms of pain, bowel distention, and blood in the stools would prevail.
12. A suspicious skin lesion requiring medical evaluation has: a. Round, symmetric borders b. Notched edges c. Matching halves when a line is drawn down the middle d. A single color of brown or tan
(b) ABCDE of skin observations
11. A decrease in serum albumin is common with a pathologic condition of the liver because albumin is produced in the liver. The reduction in serum albumin results in some easily identifiable signs. Which of the following signs might alert the therapist to the condition of decreased albumin? a. Increased blood pressure b. Peripheral edema and ascites c. Decreased level of consciousness d. Exertional dyspnea
(b) Albumin is a protein that is formed in the liver and that helps to maintain normal distribution of water in the body. Also, if a liver is damaged and has cirrhosis, the pressure inside the liver's blood vessels increases. The increased pressure can force fluid into the abdominal cavity, causing ascites. Liver damage is the single biggest risk factor for ascites
2. During examination of a 42-year-old woman's right axilla, you palpate a lump. Which characteristics most suggest the lump may be malignant? a. Soft, mobile, tender b. Hard, immovable, nontender
(b) Hard, immovable, nontender
4. A 55-year-old grocery store manager reports becoming extremely weak and breathless whenever stocking groceries on overhead shelves. What is the possible significance of this complaint? a. TOS b. Myocardial ischemia c. TrP d. All of the above
(b) Myocardial ischemia
5. 67-year-old man was seen by a physical therapist for low back pain rated 7 out of 10 on the visual analogue scale. He was evaluated, and a diagnosis was made by the physical therapist. The client attained immediate relief of symptoms, but after 3 weeks of therapy, the symptoms returned. What is the next step from a screening perspective? a. The client can be discharged. Maximum benefit from physical therapy has been achieved. b. The client should be screened for systemic disease even if you have already included screening during the initial evaluation. c. The client should be sent back to the physician for further medical follow-up. d. The client should receive an additional modality to help break the pain-spasm cycle.
(b) Reevaluate findings and prescribed intervention, including a screening or rescreening examination; medical referral may be the final decision after this step is taken. Answer (c) may not be the best answer because reevaluation and screening/rescreening may provide additional information that may be helpful to the physician.
7. Which one of the following is a yellow (caution) flag? a. Sacral pain occurs when the examiner performs a sacral spring test (posterior-anterior glide of the sacrum). b. Sacral pain is relieved when the client passes gas or has a bowel movement. c. Sacral pain occurs following a history of overuse. d. Sacral pain is reduced or relieved by release of trigger points.
(b) Relief of low back and/or sacral pain that occurs when passing gas or stool is not a "normal" finding; although it is often a symptom of constipation (GI dysfunction), it can also be a symptom of a tumor or even mechanical dysfunction of the sacrum putting pressure on the sacral plexus. Regardless of the underlying cause, the symptom is a warning flag that indicates the need for further investigation. The other answers indicate msk problem and would not be a yellow or red flag. Example of a red flag would be constant pain that doesn't have any relief
10. Symptoms of anaphylaxis that would necessitate immediate medical treatment or referral are: a. Hives and itching b. Vocal hoarseness, sneezing, and chest tightness c. Periorbital edema d. Nausea and abdominal cramping
(b) Symptoms of hives, itching, periorbital edema, and gastrointestinal involvement may occur with allergic reactions, but these do not usually require immediate medical treatment. The possible exception may include facial hives accompanied by constriction of the throat or upper respiratory symptoms (listed in answer [b]), leading to an inability to breathe.
9. Reproduced or increased abdominal or pelvic pain when the iliopsoas muscle test is performed suggests: a. Iliopsoas trigger point b. Inflammation or abscess of the muscle from an inflamed appendix or peritoneum c. Abdominal aortic aneurysm d. Neoplasm
(b) tensioning the fascial layer that connects iliopsoas and the abdomina region increases pressure on the abscess causing pain (a) would indicate msk problem (c) this is tested with inspection, auscultation, and palpation of the aa
8. Organ systems that can cause simultaneous bilateral shoulder pain include: a. Spleen b. Heart c. Gallbladder d. None of the above
(b); also liver if widespread enough spleen left, gallbladder right
2. Pain that is relieved by placing a pillow or support under the hips and buttocks describes: a. Constitutional symptom b. Infectious process c. Response to vascular congestion d. Trigger point pattern
(c)
4. Which statement is the most accurate? a. Arterial disease is characterized by intermittent claudication, pain relieved by elevating the extremity, and history of smoking. b. Arterial disease is characterized by loss of hair on the lower extremities, throbbing pain in the calf muscles that goes away by using heat and elevation. c. Arterial disease is characterized by painful throbbing of the feet at night that goes away by dangling the feet over the bed. d. Arterial disease is characterized by loss of hair on the toes, intermittent claudication, and redness or warmth of the legs that is accompanied by a burning sensation.
(c) Answer (a) is not correct because pain from arterial disease is not relieved by elevating the extremity; (b) is not correct for the same reason; (d) is not correct because arterial disease is characterized by cold skin temperature and pallor caused by the lack of oxygen and blood flow to the lower extremities; venous disease is characterized by redness or warmth caused by blood that gets pooled in the lower extremities and cannot return centrally because of valve insufficiency.
1. Fibromyalgia syndrome is a: a. Musculoskeletal disorder b. Psychosomatic disorder c. Neurosomatic disorder d. Noninflammatory rheumatic disorder
(c) Although the muscles and connective tissues are involved, the underlying cause is thought to be dysregulation of the autonomic nervous system as it interfaces with the neurohormonal system.
8. Preventing falls and trauma to soft tissues would be of utmost importance in the client with liver failure. Which of the following laboratory parameters would give you the most information about potential tissue injury? a. Decrease in serum albumin levels b. Elevated liver enzyme levels c. Prolonged coagulation times d. Elevated serum bilirubin levels
(c) Answer (a) (decreased serum albumin) is not a good laboratory measure because serum albumin has to be severely decreased for tissue damage to occur (b) Monitoring for elevated serum liver enzymes and creatine kinase are significant laboratory indicators of muscle and liver impairment; moreso liver injury or inflammation which is causing leaking of liver enzyme into the blood stream (c) coagulation times is a much better indicator of potential tissue injury in a clinical setting. (d) normal is 0-0.4 mg/dL; coag time is better for clinical seting (this is more biliary than hepatic)
7. You are evaluating a 30-year-old woman with left chest pain that starts just below the clavicle and extends down to the nipple line. The majority of test results point to thoracic outlet syndrome. Her blood pressure is 120/78 mm Hg on the right (sitting) and 125/100 on the left (sitting). She is in apparent good health with no history of surgeries or significant health problems. What plan of action would you recommend? a. Refer her to a physician before initiating treatment. b. Carry out a plan of care, and reassess after three sessions or 1 week, whichever comes first. c. Document your findings, and contact the physician by phone or by fax while initiating treatment. d. Eliminate trigger points, and then reassess symptoms.
(c) Document your findings, and contact the physician by phone or by fax while initiating treatment.
5. Chest pain of a pleuritic nature can be distinguished by: a. Increases with autosplinting (lying on the involved side) b. Reproduced with palpation c. Exacerbated by deep breathing d. All of the above
(c) Exacerbated by deep breathing Autosplinting refers to lying on one side to decrease respiratory movements; the client will use autosplinting when pain is induced by lung excursion
15. When is it advised to take a work or military history? a. Anyone with head and/or neck pain who uses a cell phone more than 8 hours/day b. Anyone over age 50 c. Anyone presenting with joint pain of unknown cause accompanied by multiple other signs and symptoms d. This is outside the scope of a physical therapist's practice
(c) Taking an environmental, occupational, or military history may be appropriate when a client has a history of asthma, allergies, or autoimmune disease, along with puzzling, nonspecific symptoms such as myalgias, arthralgias, headaches, back pain, sleep disturbance, loss of appetite, loss of sexual interest, and recurrent upper respiratory problems. The affected individual often presents with an unusual combination of multiorgan signs and symptoms. A medical diagnosis of chronic fatigue syndrome, fibromyalgia, or another more nonspecific disorder is a yellow flag. When and how to take the history and how to interpret the findings are discussed in Chapter 2.
1. Referred pain patterns associated with hepatic and biliary pathologic conditions produce musculoskeletal symptoms in the: a. Left shoulder b. Right shoulder c. Mid-back or upper back, scapular, and right shoulder areas d. Thorax, scapulae, right or left shoulder
(c) Technically, answer (b) is also correct because referred shoulder pain may be the only presenting symptom of hepatic or biliary disease. However, when the overall referral pattern is viewed, answer (b) leaves out the upper back and scapulae; answer (d) refers to the part of the body between the neck and the abdomen and includes the primary pain pattern present in the right upper quadrant but not the mid or upper back associated with the referred pain pattern. Kehr's sign—left shoulder pain associated with blood or air in the abdominal cavity—is not part of the hepatic/biliary system.
6. A 28-year-old mechanic reports bilateral shoulder pain (right more than left) whenever he has to work on a car on a lift overhead. It goes away as soon as he puts his arms down. Sometimes, he has numbness and tingling in his right elbow going down the inside of his forearm to his thumb. The most likely explanation for this pattern of symptoms is: a. Angina b. Myocardial ischemia c. Thoracic outlet syndrome d. Peptic ulcer
(c) Thoracic outlet syndrome (TOS) is discussed more completely in Chapter 17.
10. When tumors produce signs and symptoms at a site distant from the tumor or its metastasized sites, these "remote effects" of malignancy are called: a. Bone metastases b. Vitiligo c. Paraneoplastic syndrome d. Ichthyosis
(c) When tumors produce signs and symptoms at a site distant from the tumor or its metastasized sites, these "remote effects" of malignancy are collectively referred to as paraneoplastic syndromes. Paraneoplastic syndromes with musculoskeletal manifestations are of clinical importance for physical therapy because they may accompany relatively limited neoplastic growth and may provide an early clue to the presence of certain types of cancer.
8.Vascular diseases that may cause referred hip pain include: a. Coronary artery disease b. Intermittent claudication c. Aortic aneurysm d. All of the above
(c) aortic aneurysm may cause low back pain that radiates into the buttock and hip (a) Coronary artery disease does not cause referred hip pain (it is a disease of the heart that causes angina with chest, neck, or upper extremity pain or discomfort) (b) Intermittent claudication is a symptom, not a disease
4. A 33-year-old pharmaceutical sales representative reports pain over the mid-sacrum radiating to the right PSIS. Overpressure on the sacrum does not reproduce symptoms. This signifies: a. Neoplasm is present b. Red flag sign of sacral insufficiency fracture c. A lack of objective findings d. Coccygodynia
(c). Further testing would be needing to get more objective findings
1. Pelvic pain that is made worse after 5 to 10 minutes of physical activity or exertion but goes away with rest or cessation of the activity describes: a. Constitutional symptom b. Infectious process c. Symptom of osteoporosis d. Vascular pattern of ischemia
(d)
10. Hip pain associated with primary or metastasized cancer is characterized by: a. Bone pain on weight bearing; may not be able to stand on that leg b. Night pain that is relieved by aspirin c. Positive heel strike test with palpable local tenderness d. All of the above
(d)
10. Signs and symptoms of Cushing's syndrome in an adult taking oral steroids may include: a. Increased thirst, decreased urination, and decreased appetite b. Low white blood cell count and reduced platelet count c. High blood pressure, tachycardia, and palpitations d. Hypertension, slow wound healing, easy bruising
(d)
14. A 16-year-old boy was hurt in a soccer game. He presents with exquisite right ankle pain on weight bearing but reports no pain at night. Upon further questioning, you find he is taking Ibuprofen at night before bed, which may be masking his pain. What other screening examination procedures are warranted? a. Perform a heel strike test. b. Review response to treatment. c. Assess for signs of fracture (edema, exquisite tenderness to palpation, warmth over the painful site). d. All of the above
(d)
19. A 55-year-old man with a left shoulder impingement also has palpable axillary lymph nodes on both sides. They are firm but movable, about the size of an almond. What steps should you take? a. Examine other areas where lymph nodes can be palpated. b. Ask about history of cancer, allergies, or infections. c. Document your findings and contact the physician with your concerns. d. All of the above
(d)
2. To screen for back pain caused by systemic disease: a. Perform special tests (e.g., Murphy's percussion, Bicycle test) b. Correlate client history with clinical presentation and ask about associated signs and symptoms c. Perform a Review of Systems d. All of the above
(d)
2. Which of the following would be useful information when evaluating a 57-year-old woman with shoulder pain? a. Influence of antacids on symptoms b. History of chronic NSAID use c. Effect of food on symptoms d. All of the above
(d)
3. Hip and groin pain can be referred from: a. Low back b. Abdomen c. Retroperitoneum d. All of the above
(d)
3. Important functions of the kidney include all the following except: a. Formation and excretion of urine b. Acid-base and electrolyte balance c. Stimulation of red blood cell production d. Production of glucose
(d)
7. Anyone with hip pain of unknown cause must be asked about: a. Previous history of cancer or Crohn's disease b. Recent infection c. Presence of skin rash d. All of the above
(d)
10. The most significant red flag for shoulder pain secondary to cancer is: a. Previous history of coronary artery disease b. Subscapularis trigger point alleviated with trigger point therapy c. Negative neurologic screening exam d. Previous history of breast or lung cancer
(d) (a) Probably more CV systemic indicator (b) more msk (c) negative neuro signs is good
9. Clients who are taking corticosteroid medications should be monitored for the onset of Cushing's syndrome. You will need to monitor your client for which of the following problems? a. Low blood pressure, hypoglycemia b. Decreased bone density, muscle wasting c. Slow wound healing d. b and c
(d) (a) DM (b) and (c) due to protein catabolic activity
9. Decreased level of consciousness, impaired function of peripheral nerves, and asterixis (flapping tremor) would probably indicate an increase in the level of: a. AST (aspartate aminotransferase) b. Alkaline phosphatase c. Serum bilirubin d. Serum ammonia
(d) Liver dysfunction results in increased serum ammonia (bc ammonia from protein breakdown is no longer properly being detoxified by the liver when it is impaired). This ammonia is sent to the brain and reacts with glutamate producing glutamine. This decreases the glutamate available and impairs neurotransmission leading to confusion, sleep disturbances, muscle tremors, hyperreactive reflexes, and asterixis). Peripheral nerve function is impaired. Flapping tremors (asterixis) and numbness/tingling (misinterpreted as carpal/tarsal tunnel syndrome) can occur
7. Clients with significant elevations in serum bilirubin levels caused by biliary obstruction will have which of the following associated signs? a. Dark urine, clay-colored stools, jaundice b. Yellow-tinged sclera c. Decreased serum ammonia levels d. a and b only
(d) Normally, bilirubin, excreted in bile and carried to the small intestines, is reduced to a form that causes the stool to assume a brown color. a) Light-colored (almost white) stools and urine the color of tea or cola indicate an inability of the liver or biliary system to excrete bilirubin properly. Gallbladder disease, hepatotoxic medications, or pancreatic cancer blocking the bile duct may cause light (clay-colored) stools. Jaundice of skin occurs with 5-6 mg/dL of bilirubin b) yellow sclera occurs at 2-3mg/dL of bilirubin levels c) Liver dysfunction results in increased serum ammonia (bc ammonia from protein breakdown is no longer properly being detoxified by the liver). This ammonia is sent to the brain and reacts with glutamate producing glutamine. This decrease in glutamate impairs neurotransmission leading to confusion, sleep disturbances, muscle tremors, hyperreactive reflexes, and asterixis). Peripheral nerve function is impaired. Flapping tremors (asterixis) and numbness/tingling (misinterpreted as carpal/tarsal tunnel syndrome) can occur
9. The most common cause of change in mental status of the HIV-infected client is related to: a. Meningitis b. Alzheimer's disease c. Space-occupying lesions d. AIDS dementia complex
(d) AIDS dementia complex also known as HIV encephalopathy is the most common neurologic complication and the most common cause of mental status change. It is characterized by cognitive, motor, and behavioral dysfunction. This disorder is similar to Alzheimer's dementia but has less impact on memory loss and a greater effect on time-related skills c) Toxoplasmosis is the most common space-occupying lesion in HIV-infected clients. Presenting symptoms may include headache, focal neurologic deficits, seizures, or altered mental status.
14. All of the following are common signs or symptoms of insulin resistance except: a. Acanthosis nigricans b. Drowsiness after meals c. Fatigue d. Oliguria
(d) Oliguria is the production of abnormally small amounts of urine. May occur with liver or renal patholgies, some CV
10. A 75-year-old woman with a known history of osteoporosis has pain over the sacrum radiating to the right PSIS and right buttock. How do you rule out an insufficiency fracture? a. Perform Blumberg's test. b. Conduct a sacral spring test (posterior-anterior overpressure of the sacrum). c. Perform Murphy's percussion test. d. Diagnostic imaging is the only way to know for sure.
(d) (a) Blumberg sign for peritonitis (b) The sacral spring test or overpressure is contraindicated in the presence of osteoporosis; even minor trauma can result in fracture. (c) renal pathology
13. A 38-year-old man comes to the clinic for low back pain. He has a new diagnosis of Graves' disease. When asked if there are any other symptoms of any kind, he replies "increased appetite and excessive sweating." When you perform a neurologic screening examination, what might be present that would be associated with the Graves' disease? a. Hyporeflexia but no change in strength b. Hyporeflexia with decreased muscle strength c. Hyperreflexia with no change in strength d. Hyperreflexia with decreased muscle strength
(d) hyperreflexia due to excess thyroxine telling nerves to go faster, and muscle strength loss due to muscle wasting
7. Percussion of the costovertebral angle resulting in the reproduction of symptoms signifies: a. Radiculitis b. Pseudorenal pain c. Has no significance d. Medical referral is advised
(d) A positive Murphy's percussion test for renal disease is suspected; Murphy's percussion should be negative in the presence of pain and symptoms caused by radiculitis or pseudorenal pain from any cause. (b) pseudorenal pain will reproduce symptoms with palpation and positional changes
9. You are working with a client in his home who had a total hip replacement 2 weeks ago. He describes chest pain with increased activity. Knowing what could cause this symptom will help guide you in asking appropriate screening questions. Can this be a symptom of: a. Asthma b. Angina c. Pleuritis or pleurisy d. All of the above
(d) All of the above
6. A 66-year-old woman has come to you with a report of anterior neck pain radiating down the left arm. Her past medical history is significant for chronic diabetes mellitus (insulin dependent), coronary artery disease, and peripheral vascular disease. About 6 weeks ago, she had an angioplasty with stent placement. Which test will help you differentiate a musculoskeletal cause from a cardiac cause of neck and arm pain? a. Stair climbing or stationary bike test b. Using arms overhead for 3 to 5 minutes c. TrP assessment d. All of the above
(d) Although you can use all three of these tests, answer (a) Stair climbing or stationary bike test, is likely the most definitive of the tests listed for cardiac causes of symptoms.
11. A client who has recently completed chemotherapy requires immediate medical referral if he has which of the following symptoms? a. Decreased appetite b. Increased urinary output c. Mild fatigue but moderate dyspnea with exercise d. Fever, chills, sweating
(d) See discussion of Leukopenia in Chapter 5. Remember nadir is 7-14 days after chemotherapy where WBC is lowest making the patient susceptible to infections and complications. PT must have good hygiene in these days and fevers, chills, sweating may indicate infection.
1. Percussion of the costovertebral angle that results in the reproduction of symptoms: a. Signifies radiculitis b. Signifies pseudorenal pain c. Has no significance d. Requires medical referral
(d) This is Murphy's Percussion test
10. Cardiac pain in women does not always follow classic patterns. Watch for this group of symptoms in women at risk: a. Indigestion, food poisoning, jaw pain b. Nausea, tinnitus, night sweats c. Confusion, left biceps pain, dyspnea d. Unusual fatigue, shortness of breath, weakness, or sleep disturbance
(d) Unusual fatigue, shortness of breath, weakness, or sleep disturbance.
8. A 53-year-old woman comes to physical therapy with a report of leg pain that begins in her buttocks and goes all the way down to her toes. If this pain is of a vascular origin she will most likely describe it as: a. Sore, hurting b. Hot or burning c. Shooting or stabbing d. Throbbing, "tired"
(d) Vascular pain is often described as "throbbing"; vascular claudication may be described as "aching" or "cramping" or "tired," but this could be caused by the aggravating factors (increases with physical exertion, promptly relieved by resting); remains unchanged regardless of the position of the spine. Neurogenic pain may be described as hot or burning, stabbing, shooting, or tingling. Look for other neurologic changes; perform the bicycle test. Pain increased by spinal extension and relieved by spinal flexion is a positive sign of neurologic involvement. Muscular pain is often described as dull, sore, aching, and hurting; palpate for myalgia and trigger points, and perform resistive muscle testing.
6. McBurney's point for appendicitis is located: a. Approximately one-third the distance from the ASIS toward the umbilicus, usually on the left side b. Approximately one-half the distance from the ASIS toward the umbilicus, usually on the left side c. Approximately one-third the distance from the ASIS toward the umbilicus, usually on the right side d. Approximately one-half the distance from the ASIS toward the umbilicus, usually on the right side e. Impossible to tell because the appendix can be located anywhere in the abdomen
(d) When present, McBurney's point is found approximately one-half the distance from the anterior superior iliac spine (ASIS), moving toward the umbilicus (see Fig. 8-8); if the appendix is located somewhere else, McBurney's point is likely to be negative. Blumberg's sign for rebound tenderness (see Fig. 8-10) can be used to assess for appendicitis when generalized peritonitis is present, or when the appendix is located somewhere in the abdomen other than at the end of the cecum.
8. Cancer as a cause of sacral or pelvic pain is usually characterized by: a. A previous history of reproductive cancer b. Constant pain c. Blood in the urine or stools d. Constitutional symptoms e. All of the above
(e)
2. Renal pain is aggravated by: a. Spinal movement b. Palpatory pressure over the costovertebral angle c. Lying on the involved side d. All of the above e. None of the above
(e) Renal pain is typically felt in posterior subcostal and costovertebral regions (b) percussion over CVA will elicit renal pain; palpation pressure may elicit pain/tenderness of involved peripheral nerve in pseudorenal pain, but the percussion is needed to indicate a deeper visceral sensation associated with infection/inflammation (pyelonephritis, phrenic abscess, other kidney problem)
5. Pain associated with pleuropulmonary disorders can radiate to: a. Anterior neck b. Upper trapezius muscle c. Ipsilateral shoulder d. Thoracic spine e. All of the above
(e) Pain associated with pulmonary disorders can occur anywhere over the lung fields (see Fig. 7-1), with the possibility of additional referral to the neck and shoulder on the involved side(s).
4. Disorders of the endocrine glands can be caused by: a. Dysfunction of the gland b. External stimulus c. Excess or insufficiency of hormonal secretions d. a and b e. b and c f. All the above
(f)
7. Proximal muscle weakness may be a sign of: a. Paraneoplastic syndrome b. Neurologic disorder c. Myasthenia gravis d. Scleroderma e. b, c, and d f. All of the above
(f) proximal weakness can be a MSK effect of endocrine or metabolic disorder (hypothyroidism, hyperparathyroidism, diabetic amyotrophy, etc) Scleroderma - one of the lesser-known chronic multisystem diseases in the family of rheumatic diseases, is characterized by inflammation and fibrosis of many parts of the body, including the skin, blood vessels, synovium, skeletal muscle, and certain internal organs such as kidneys, lungs, heart, and GI tract. Muscle involvement is usually mild, with weakness, tenderness, and pain of proximal muscles of the upper and lower extremities. Late scleroderma is characterized by muscle atrophy, muscle weakness, deconditioning, and flexion contractures.
8. How do you screen for possible prostate involvement in a man with pelvic/low-back pain of unknown cause?
A physical therapist who is screening for prostate involvement must ask direct questions. A medical evaluation is necessary to identify actual prostate disease. Questions may include the following (see also Appendix B-27): • Are you experiencing any other symptoms of any kind? (If no, you may have to prompt with specifics: Have you had any fever or chills? Muscle or joint aches?) • Have you ever had any problems with your prostate in the past? • When you urinate, do you have trouble starting or continuing the flow of urine? • (Alternate questions): Has your urine stream changed in size? Do you urinate in a steady stream, or does the flow of urine start and stop? • Are you getting up to urinate at night? (If the answer is "yes," make sure this is something new or unusual for the client.) • Have you noticed any blood in your urine (or change in the color of your urine)?
6. What is Lhermitte's sign, and what does it signify?
An electric shock sensation down the spine and radiating to the extremities when the neck is flexed; this is a fairly common sign in multiple sclerosis but may also accompany disc protrusion against the spinal cord.
Chapter 09: Screening for Hepatic and Biliary Disease
Answers to Practice Questions
Chapter 10: Screening for Urogenital Disease
Answers to Practice Questions
Chapter 11: Screening for Endocrine and Metabolic Disease
Answers to Practice Questions
Chapter 12: Screening for Immunologic Disease
Answers to Practice Questions
Chapter 13: Screening for Cancer
Answers to Practice Questions
Chapter 14: Screening the Head, Neck, and Back
Answers to Practice Questions
Chapter 15: Screening the Sacrum, Sacroiliac, and Pelvis
Answers to Practice Questions
Chapter 16: Screening the Lower Quadrant: Buttock, Hip, Groin, Thigh, and Leg
Answers to Practice Questions
Chapter 17: Screening the Chest, Breasts, and Ribs
Answers to Practice Questions
Chapter 18: Screening the Shoulder and Upper Extremity
Answers to Practice Questions
1. Name three predisposing factors to cancer that the therapist must watch for during the interview process as red flags.
Any of the following: Previous personal history of cancer; age in correlation with a personal or family history of cancer; age and gender in correlation with incidence of certain cancers; exposure to environmental and occupational toxins; geographic location; lifestyle (e.g., consumption of alcohol, smoking cigarettes, poor diet)
2. When would you use the iliopsoas, obturator, or Blumberg's test?
Any time you suspect an infectious or inflammatory cause of hip, groin, or pelvic symptoms. Abdominal or intraperitoneal inflammation leads to irritation and/or abscess formation of the psoas muscle, causing musculoskeletal pain. These tests are especially appropriate for the client who has a history of Crohn's disease, diverticulitis, pelvic inflammatory disease, or Chlamydia with a new onset of hip and/or groin pain. Combined with findings of Blumberg's rebound test and McBurney's point, the information gained can help the clinician to identify signs and symptoms of possible appendicitis.
4. Who should be screened for possible renal/urologic involvement?
Anyone with back pain or shoulder pain of unknown origin, especially when accompanied by changes in urination, blood in the urine, or constitutional symptoms.
4. When a client with bilateral carpal tunnel syndrome is being evaluated, how do you screen for the possibility of a pathologic condition of the liver?
Ask about numbness and tingling in the feet. Tarsal tunnel symptoms do not always occur with upper extremity numbness and tingling, but when both are present, a medical evaluation is required. Ask the client about any associated signs and symptoms, especially constitutional symptoms (see Systemic Signs and Symptoms Requiring Physician Referral at the end of this chapter). Look for liver flap, liver palms, and other skin and nailbed changes. Look for risk factors associated with liver impairment (e.g., alcohol use, hepatotoxic medications, previous history of any type of cancer). If subjective and objective examinations do not reveal any red flags, treatment may be initiated. If treatment does not result in objective or subjective improvement, ask the client again about the development of any new symptoms, especially constitutional symptoms or other associated symptoms discussed here. Failure to progress in treatment should result in physician evaluation or reevaluation. The development of any new systemic symptoms requires medical evaluation as well.
3.What are two ways of classifying back pain (as presented in the text)?
Back pain can be examined and classified in many ways. We have presented (1) Sources of Back Pain (e.g., visceral, neurogenic, vasculogenic, spondylogenic, psychogenic, neoplasm; see Table 3-3) and (2) Location of Back Pain (e.g., cervical spine, scapula, thoracic spine, lumbar spine, sacrum, sacroiliac; see Table 14-1).
5. Complete the following mnemonic: CAUTIONS
C - Changes in bowel or bladder habits A - A sore that does not heal within 6 weeks U - Unusual bleeding or discharge T- Thickening or lump in the breast or elsewhere I - Indigestion or difficulty in swallowing O - Obvious change in a wart or mole N - Nagging cough or hoarseness S- Supplemental signs and symptoms (rapid unintentional weight loss, changes in vital signs, frequent infections, night pain, pathologic fracture, proximal muscle weakness, change in deep tendon reflexes)
3. What are the mechanisms by which carpal tunnel syndrome occurs?
Depends on the underlying disease process. For example, thickening of the transverse carpal ligament is associated with acromegaly and myxedema. Increased volume of the contents of the carpal tunnel occurs with pregnancy, neoplasm, gouty tophi deposits, and lipids in diabetes mellitus. Hormonal changes (e.g., menopause, pregnancy) can also result in carpal tunnel syndrome (CTS). See also liver-related causes in Chapter 9).
5. What do the following terms mean? • Dyspareunia • Dysuria • Hematuria • Urgency
Dyspareunia—Difficult or painful sexual intercourse in women Dysuria—Painful or difficult urination Hematuria—Blood in the urine Urgency—A sudden, compelling desire to urinate
2. What systemic conditions can cause carpal tunnel syndrome?
Endocrine disorders, infectious diseases, collagen disorders, cancer, liver disease (see Table 11-2).
11. Autosplinting is the preferred mechanism of pain relief for back pain caused by kidney stones. T/F
False. Autosplinting refers to lying on one side to decrease respiratory movements; the client will use autosplinting when pain is induced by lung excursion.
6. You are treating a 53-year-old woman who has had an extensive medical history that includes bilateral kidney disease with kidney removal on one side and transplantation on the other. The client is 10 years posttransplant and has now developed multiple problems as a result of the long-term use of immunosuppressants (cyclosporine to prevent organ rejection) and corticosteroids (prednisone). For example, she is extremely osteoporotic and has been diagnosed with cytomegalovirus and corticosteroid-induced myopathy. The client has fallen and broken her vertebra, ankle, and wrist on separate occasions. You are seeing her at home to implement a strengthening program and to instruct her in a falling prevention program, including home modifications. You notice the sclerae of her eyes are yellow-tinged. How do you tactfully ask her about this?
Given most people's concern about their physical appearance, it is best not to point out the change in eye color directly, but rather, ask some questions that may provide you with the information needed. For example, • Mrs. Jackson, have you ever been given a diagnosis of jaundice, hepatitis, or anemia? • Are you experiencing any new symptoms or problems that we haven't discussed? • Have you noticed any smells or foods that you cannot tolerate? • Have you (or your husband) noticed any changes in your skin or eyes? • At this point, if nothing comes to light, you may broach your observation by saying, "I have noted some yellowing of the white part of your eye. Is this something you have noticed or discussed with your physician?"
10. What is the mechanism of referral for urologic pain to the shoulder?
If the diaphragm becomes irritated as the result of pressure from a distended kidney (caused by tumor, cyst, inflammation), pain can be referred via interconnections between the phrenic nerve (innervating the diaphragm) and the cervical plexus (innervating the shoulder).
4. What is the significance of nerve root compression in relation to cancer?
In any individual, any neurologic sign may be the presentation of a silent lung tumor.
2. How do you monitor exercise levels in the oncology patient without laboratory values?
In any patient or client who is undergoing cancer treatment (especially chemotherapy), laboratory values offer a guide for determining appropriate frequency, intensity, and duration of exercise. In an outpatient setting, laboratory values may be unavailable or outdated. Without the benefit of laboratory values (and even when laboratory values are available), the therapist can and should monitor vital signs and rate of perceived exertion (RPE), and should look for associated signs and symptoms (e.g., pallor, dyspnea, unexplained or excessive diaphoresis, heart palpitations, visual changes, dizziness). Anything out of the ordinary should be considered a yellow (cautionary) flag that requires careful observation, further evaluation, and possibly medical referral.
5. What is the first most common sign associated with liver disease?
Jaundice is first noted as a yellowing of the sclera of the eyes. The skin may take on a yellow hue as well, but this is not as easily observed as the change in the eye. This change in eye and skin color can also occur with pernicious anemia (A decrease in red blood cells when the body can't absorb enough vitamin B-12.), a condition that may be accompanied by peripheral neuropathy as well.
4. A new client has come to you with a primary report of new onset of knee pain and swelling. Name three clues that this client might give from his medical history that should alert you to the possibility of immunologic disease.
Many red flag clues must be considered. The therapist may observe or hear reports of any one or combination of the following: • Previous history of allergies, especially if the client has received medications over the past 6 weeks (even if the client is no longer taking the medications) • Recent history or presence of burning or urinary frequency (urethritis) • Recent history or presence of conjunctivitis or eye crusting, redness, burning, or tearing that lasts only a few days • Recent report or presence of skin rash, especially combined with a report of exposure to ticks • Positive family history for arthritis, spondyloarthropathy, psoriasis • Recent report of dry mouth or sore throat • Recent history of operative procedure • Other extra-articular signs or symptoms, such as diarrhea, constitutional symptoms, or other symptoms already mentioned • Enlarged lymph nodes
3. Why does someone with liver dysfunction develop numbness and tingling that is sometimes labeled carpal tunnel syndrome?
Normally, the breakdown of protein in the gut (whether derived from food or blood in the stomach) produces ammonia that is transformed by the liver to urea, glutamine, and asparagine. These substances are then excreted by the renal system. When the liver is diseased and unable to detoxify ammonia, ammonia is transported to the brain, where it reacts with glutamate, an excitatory neurotransmitter, thus producing glutamine. Reduction in brain glutamate impairs neurotransmission, leading to altered nervous system metabolism and function. Additionally, ammonia may cause the brain to produce false neurotransmitters. The result of this ammonia abnormality is peripheral nerve disease with numbness and tingling of the hands and/or feet that can be misinterpreted as carpal/tarsal tunnel syndrome. Check also for asterixis
1. A 66-year-old woman has been referred to you by her physiatrist for preprosthetic training after an above-knee amputation. Her past medical history is significant for chronic diabetes mellitus (insulin dependent), coronary artery disease with recent angioplasty and stent placement, and peripheral vascular disease. During the physical therapy evaluation, the client experienced anterior neck pain radiating down the left arm. Name (and/or describe) three tests you can do to differentiate a musculoskeletal cause from a cardiac cause of shoulder pain.
Orthopedic evaluation: Palpate structures of the shoulder, including trigger point assessment; perform special orthopedic tests such as Yergason's, apprehension test, relocation test, and Speed's test; perform neurologic screening examination, including reflex testing, coordination, manual muscle testing, and sensory testing; screen for mechanical dysfunction above and below (temporomandibular joint, cervical spine, elbow). Systemic evaluation: Assess the effects of stair climbing or stationary bicycle riding (using only the lower extremities) on shoulder pain; assess for associated signs and symptoms (e.g., dyspnea, fatigue, palpitations, diaphoresis, cough, dizziness), and perform a systems review; measure vital signs on both sides.
9. Why is weight loss a significant red flag sign in a physical therapy practice?
Pain, movement dysfunction, and disability usually result in weight gain due to inactivity. When someone is experiencing back pain, for example, and reports a significant weight loss, this may be a red flag for systemic origin of the problem.
5. List three of the most common symptoms of diabetes mellitus.
Polydipsia - increased thirst in response to polyuria Polyuria - increased urination caused by osmotic diuresis Polyphagia - increased appetite and ingestion of food (usually only in type 1)
1. What are the most common musculoskeletal symptoms associated with endocrine disorders?
Proximal muscle weakness, myalgia, carpal tunnel syndrome, periarthritis, adhesive capsulitis (shoulder) (see Table 11-1)
2. What is the mechanism for referred right shoulder pain from hepatic or biliary disease?
Radiating pain to the mid back, scapula, and right shoulder occurs as the result of splanchnic fibers (a network of nerves innervating the viscera of the abdomen) that synapse with adjacent phrenic nerve fibers—the branch of the celiac plexus (also known as the solar plexus) that innervates the diaphragm. The liver is innervated by the hepatic plexus, also a part of the celiac plexus (see Fig. 3-3). Interconnecting nerve fibers between the phrenic nerves and the brachial plexus then refer pain to the right shoulder. These connections occur bilaterally, but most biliary fibers reach the dorsal spinal cord through the right splanchnic nerve to produce pain primarily in the right shoulder.
13. 53-year-old postmenopausal woman with a history of breast cancer 5 years ago with mastectomy presents with a report of sharp pain in her mid-back. The pain started after she lifted her 2-year-old granddaughter 3 days ago. Tylenol seems to help, but the pain is keeping her awake at night. Once she wakes up, she cannot find a comfortable position to go back to sleep. What are the red flags? What will you do to screen for a medical cause of her symptoms?
Red flags include age (over 50), previous history of cancer, and lack of pain relief with recumbency. Screening should follow the decision-making model presented in Chapter 1. Conduct a careful history of symptoms, and ask about symptoms anywhere else in the body. Find out when the last medical follow-up was done by the oncologist and when the patient had her last clinical breast examination and mammogram. Clinical assessment should include vital signs, lymph node palpation, skin inspection that includes the mastectomy site, and a neurologic screening examination. Palpate the painful area, and perform a percussive Tap test.
11. What is the importance of the pelvic floor musculature in relation to the abdominal and pelvic viscera?
See Figs. 15-2 and 15-3. Pelvic sling. Puborectalis muscle forms a U-shaped sling encircling the posterior aspect of the rectum and returns along the opposite side of the levator hiatus to the posterior surface of the pubis. This shows how the condition and position of the pelvic sling contribute to the function of the pelvic floor and the encircled viscera. Obesity, multiparity, and prolonged pushing during labor and delivery are just a few of life's events that can disrupt the integrity of the pelvic sling and the pelvic floor. (p. 616) Normal female reproductive anatomy (sagittal view). Note the size, shape, and orientation of each of these structures (rectum, uterus, bladder, vagina, and cervix in this illustration). The rectum turns away from the viewer in this sagittal section, giving it the appearance of ending with no connection to the intestines. Understanding the normal orientation of these structures will help when each of the diseases that can cause low back pain is considered. (p 617)
8. Give a general description and explanation of the changes seen in deep tendon reflexes associated with cancer.
Space-occupying lesions (whether discogenic, bony spurs in the foraminal spaces, or tumor cells invading and occupying the spaces next to nerve roots) may cause an increase in deep tendon reflexes when compression irritates the nerve but does not obstruct the reflex arc. When any anatomic obstruction is large enough to compress the nerve and interfere with the reflex arc, the deep tendon reflex is diminished or absent.
6. What is the primary difference between the two hyperglycemic states: diabetic ketoacidosis (DKA) and hyperglycemic, hyperosmolar, nonketotic coma (HHNC)?
The major differentiating factor between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) is the absence of ketosis in HHS DKA will also present with hyperventilation (related to ketoacidosis)
7. How can the therapist determine whether a client's symptoms are caused by the delayed effects of radiation as opposed to being signs of recurring cancer?
This is a medical decision and is not within the scope of physical therapist practice. If the clinician has any doubt, the physician should be contacted. The therapist can certainly take vital signs, ask about the presence of constitutional symptoms such as fever, weight loss, nausea, vomiting, and look for and document associated signs and symptoms. All of these findings can be submitted to the physician for consideration.
10. Skin pain over T9 to T12 can occur with kidney disease as a result of multisegmental innervation. Visceral and cutaneous sensory fibers enter the spinal cord close to each other and converge on the same neurons. When visceral pain fibers are stimulated, cutaneous fibers are stimulated, too. Thus visceral pain can be perceived as skin pain. a. True b. False
True
9. Twenty-five percent of the people with GI disease, such as Crohn's disease (regional enteritis), irritable bowel syndrome, or bowel obstruction, have concomitant back or joint pain. T/F
True. Joint pain affects the hips, sacrum, and sacroiliac most often and may be preceded or accompanied by skin lesions or rash.
12. Back pain from pancreatic disease occurs when the body of the pancreas is enlarged, inflamed, obstructed, or otherwise impinging on the diaphragm. T/F
True. Pancreatic disease can also refer pain to the shoulder, depending on which portion of the pancreas is affected.
6. What is the difference between urge incontinence and stress incontinence?
Urge incontinence—Inability to hold back urination when one is feeling the urge to void (putting the key in the door or passing by a bathroom may trigger urine to leak) Stress incontinence—Involuntary escape of urine due to strain on the bladder (e.g., cough, sneeze, standing up, lifting, exercising)
9. Explain why renal/urologic pain can be felt in such a wide range of dermatomes (i.e., from the T9 to L1 dermatomes).
Visceral pain is not well differentiated because innervation of the viscera is multisegmental with few nerve endings (see Fig. 3-3). As was previously discussed in question (7), renal/urologic pain enters the spinal cord at the same level and in close proximity to cutaneous nerves in these multiple segments (from T10 to L1). Stimulation of these renal/urologic fibers can lead to stimulation of cutaneous fibers. As a result, renal and urethral visceral pain may be felt as skin pain throughout the T10-L1 dermatomes.
7. Is it safe to administer a source of sugar to a lethargic or unconscious person with diabetes? Why?
Yes. If their glucose levels are high, you will not endanger them any further with a small amount of sugar, and you may help someone who is experiencing hypoglycemia associated with diabetes mellitus.
6. Whenever a therapist observes, palpates, or receives a client report of a lump or nodule, what three questions must be asked?
• How long have you had this area of skin discoloration/mole/spot/lump? • Has it changed over the past 6 weeks to 6 months? • Has your physician examined this area? (Alternate question: Has your physician seen this?)
