USA Differential Diagnosis Exam #1 (Chapters 1-8)

1. Bleeding in the gastrointestinal (GI) tract can be manifested as a. dysphagia b. melena c. psoas abscess d. tenderness over McBurney's point

1. (B) Melena

1. What is the effect of NSAIDs (e.g., Naprosyn, Motrin, Anaprox, ibuprofen) on blood pressure? a. No effect b. Increases blood pressure c. Decreases blood pressure

1. (B) Nonsteroidal antiinflammatory drugs (NSAIDs) can be potent renal vasoconstrictors that cause increased blood pressure and resultant lower extremity edema as sodium and water are conserved by the body.

1. In the context of screening for referral, the primary purpose of a diagnosis is a. to obtain reimbursement. b. to guide the plan of care and intervention strategies. c. to practice within the scope of physical therapy. d. to meet the established standards for accreditation.

1. (B) The primary purpose of a diagnosis is to provide information (i.e., identify as closely as possible the underlying neuromusculoskeletal [NMS] pathology) that can guide efficient treatment and effective management of the client.

1. When assessing the abdomen, what sequence of physical assessment is best? a. Auscultation, inspection, palpation, percussion b. Inspection, percussion, auscultation, palpation c. Inspection, auscultation, percussion, palpation d. Auscultation, inspection, percussion, palpation

1. (C) Percussion and palpation can change bowel sounds. Look and listen before you palpate.

1. If a client reports that the shoulder/upper trapezius muscle pain increases with deep breathing, how can you assess whether this results from a pulmonary or musculoskeletal cause?

1. As always, look at past medical history, risk factors, clinical presentation, and associated signs and symptoms. Ask about a past medical history (within the last 6 to 8 weeks) of upper respiratory infection, pneumonia, pleurisy, or traumatic injury. Evaluate whether the symptoms can be reproduced with palpation or movement. Pulmonary symptoms may be exacerbated or increased by the supine position and alleviated or decreased when the patient is lying on the involved side (autosplinting). Look for associated signs and symptoms such as fever, chills, night sweats, digital clubbing, persistent cough, or dyspnea. Examine the client for trigger points; reexamine after any trigger points have been eliminated.

1. If rapid onset of anemia occurs after major surgery, which of the following symptom patterns might develop? a. Continuous oozing of blood from the surgical site b. Exertional dyspnea and fatigue with increased heart rate c. Decreased heart rate d. No obvious symptoms would be seen.

1. B

1. Pursed-lip breathing in the sitting position while leaning forward on the arms relieves symptoms of dyspnea for the client with a. orthopnea b. emphysema c. CHF d. A and C

1. B

1. What is the best follow-up question for someone who tells you that the pain is constant? a. Can you use one finger to point to the pain location? b. Do you have that pain right now? c. Does the pain wake you up at night after you have fallen asleep? d. Is there anything that makes the pain better or worse?

1. B

10. When exercising a client with known anemia, what two measures can be used as guidelines for frequency, intensity, and duration of the program?

10. (1) Client tolerance; (2) Perceived exertion levels

10. Referred pain from the viscera can occur alone but is usually preceded by visceral pain when an organ is involved. a. True b. False

10. (A) True. Visceral involvement can occur without preceding or prodromal symptoms, but most often, associated signs and symptoms are present. Because visceral pain can be referred to the neck, back, or shoulder, the client who experiences gastrointestinal (GI) or genitourinary (GU) symptoms does not report these additional symptoms to the therapist when providing information about the musculoskeletal condition.

10. 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 and 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.

10. (C) Pain from arterial disease is relieved by dangling (not elevating) the extremity to help blood flow distally; the feet are cold and demonstrate pallor from loss of blood flow.

10. You should assess clients who are receiving NSAIDs for which physiologic effect associated with increased risk of hypertension? a. Decreased heart rate b. Increased diuresis c. Slowed peristalsis d. Water retention

10. (D) Water retention. Look for sacral and pedal edema.

10. You notice a new client has an unusual (strong) breath odor. How do you assess this?

10. Bad breath (halitosis) can be a symptom of diabetic ketoacidosis, dental decay, lung abscess, throat or sinus infection, or gastrointestinal disturbance from food intolerance, Helicobacter pylori bacteria, or bowel obstruction. Keep in mind that ethnic foods and alcohol can affect breath and body odor. After past medical history has been assessed for any of these conditions, it may be necessary for the therapist to ask directly, "I notice an unusual smell on your breath. Do you know what might be causing this?" Ask appropriate follow-up questions depending on the type of smell that you perceive. You may wish to consider screening for alcohol use at a later time, after you have established a good rapport with the client.

10. Common symptoms of respiratory acidosis would be most closely represented by which of the following descriptions? a. Presence of numbness and tingling in face, hands, and feet b. Presence of dizziness and lightheadedness c. Hyperventilation with changes in level of consciousness d. Onset of sleepiness, confusion, and decreased ventilation

10. D

10. A 64-year-old female with chronic rheumatoid arthritis fell and broke her hip. Six months after her total hip replacement, she is still using a walker and complains of continued loss of strength and function. Her family practice physician has referred her to physical therapy for a home program to "improve gait and increase strength." The client reports frequent episodes of lightheadedness when her legs feel rubbery and weak. She is taking a prescription NSAID along with an OTC NSAID 3 times each day and has been taking NSAIDs 3 years continuously. There are no reported GI complaints or associated signs and symptoms, but after completing the intake interview and objective examination, you think there may be weakness associated with blood loss and anemia secondary to chronic NSAID use. How would you handle a case like this?

10. Using Special Questions to Ask for possible GI involvement, carefully screen for any other associated signs and symptoms. Have the client pay close attention to digestion and bowel habit patterns over the next 24 to 48 hours. Ask her to report any gastrointestinal symptoms and any changes in bowel odor, color, or consistency. Provide her with a home program to improve strength, balance, and coordination, and observe or test for functional improvement. If she reports any additional gastrointestinal signs and symptoms, especially if no improvement in her physical status is observed, immediate medical referral is required. Otherwise, send the physician a brief note outlining your findings, your program, and any progress (or lack of progress), and include a question such as: Dr. Smith, Mrs. Jones has had several episodes of lightheadedness. At the same time, she says her legs feel "rubbery and weak." This is not a typical musculoskeletal pattern. Is there any connection between her use of NSAIDs (she is taking a prescription NSAID and an over-the-counter NSAID daily) and this pattern of weakness? Always remember to relay information and ask questions that demonstrate that you are practicing within the scope of physical therapy practice.

11. Instruct clients with a history of hypertension and arthritis to a. limit physical activity and exercise. b. avoid OTC medications. c. inform their primary care provider of both conditions. d. drink plenty of fluids to avoid edema.

11. (C) Inform the primary care provider of both conditions; the therapist can also screen for potential adverse effects of NSAIDs and can monitor blood pressure. ppp

11. A 48-year-old male presented with low back pain of unknown cause. He works as a carpenter and says he is very active, has work-related mishaps (accidents and falls), and engages in repetitive motions of all kinds using his arms, back, and legs. The pain is intense when he has it, but it seems to come and go. He is not sure if eating makes the pain better or worse. He has lost his appetite because of the pain. After conducting an examination including a screening examination, the clinical presentation does not match the expected pattern for a musculoskeletal or neuromuscular problem. You refer him to a physician for medical testing. You find out later he had pancreatitis. What is the most likely explanation for this pain pattern? a. Toxic waste products from the pancreas are released into the intestines causing irritation of the retroperitoneal space. b. Rupture of the pancreas causes internal bleeding and referred pain called Kehr's sign. c. The pancreas and low back structures are formed from the same embryologic tissue in the mesoderm. d. Obstruction, irritation, or inflammation of the body of the pancreas distends the pancreas, thus applying pressure on the central respiratory diaphragm.

11. (D) Irritation of the retroperitoneal space begins when bleeding occurs behind the stomach, most often from a posterior duodenal ulcer. Rupture of the spleen causes Kehr's sign. The pancreas and low back structures are not formed from the same embryologic tissue. Disease of the pancreas, whether it involves the head, the body, or the tail, can put pressure on the corresponding portion of the respiratory diaphragm, resulting in shoulder or low back pain according to the location of the diaphragmatic irritation. Central diaphragmatic pressure results in referred pain to the ipsilateral shoulder; peripheral involvement of the diaphragm results in low back pain. This can occur in the right shoulder when the head of the pancreas is distended far enough, but it is more likely to affect the left shoulder via disease in the tail of the pancreas.

11. What are the primary signs and symptoms of CHF? a. Fatigue, dyspnea, edema, nocturia b. Fatigue, dyspnea, varicose veins c. Fatigue, dyspnea, tinnitus, nocturia d. Fatigue, dyspnea, headache, night sweats

11. A

11. Why does postural orthostatic hypotension occur upon standing for the first time in a young adult who has been supine in skeletal traction for 3 weeks?

11. The patient's blood pressure (vasomotor) system is "untuned"; peripheral blood vessels do not constrict properly, so venous pooling may occur. The patient also may be receiving medication(s) that have the potential to reduce blood pressure directly or as an adverse effect of the drug or drugs in combination. Other factors may include dehydration, if the patient has not been on intravenous fluids and has not maintained adequate fluid intake.

12. Alcohol screening tools should be a. used with every client sometime during the episode of care. b. brief, easy to administer, and nonthreatening. c. deferred when the client has been drinking or has the smell of alcohol on their breath. d. conducted with one other family member present as a witness.

12. (B) It may not be necessary to screen every client for alcohol use. You may not conduct a full screening assessment when someone appears to have been drinking, but it may still be appropriate to ask, "I smell alcohol on your breath. How many drinks have you had?" Screening questions should be asked privately and confidentially without other family and friends listening.

12. When would you advise a client in physical therapy to take his/her nitroglycerin? a. 45 minutes before exercise b. When symptoms of chest pain do not subside within 10 to 15 minutes of rest c. As soon as chest pain begins d. None of the above. e. All of the above.

12. C

13. With what final question should you always end your interview?

13. Any of the following questions (or similar questions) is appropriate: • Are there any other symptoms of any kind anywhere else in your body that we haven't discussed yet? • Is there anything else you think is important about your condition that we have not discussed yet? • Is there anything else you think I should know?

2. Most of the information needed to determine the cause of symptoms is contained in the a. patient interview. b. Family/Personal History Form. c. physical examination d. All of the above. e. A and C

2. (A) Although all details obtained from the Family/Personal History form, interview, and objective examinations provide important information, it is well documented that 80% (or more) of the information needed to determine the cause of symptoms is actually gathered during the Core Interview of the Client Interview.

2. What is the significance of Kehr's sign? a. Gas, air, or blood in the abdominal cavity b. Infection of the peritoneum (peritonitis, appendicitis) c. Esophageal cancer d. Thoracic disk herniation masquerading as chest or anterior neck pain

2. (A) Kehr's sign (left shoulder pain) can occur as the result of blood (e.g., following trauma to the spleen, ruptured ectopic pregnancy) or air (laparoscopy) in the abdomen. Kehr's sign following a laparoscopy will resolve within 24 to 48 hours as the gas bubble is absorbed or passed. The physician must be notified of shoulder pain associated with traumatic injury, nonsteroidal antiinflammatory drug (NSAID)-associated gastrointestinal bleeding, or possible ectopic pregnancy for possible medical evaluation (even if the clinical presentation is consistent with musculoskeletal dysfunction) (see Shoulder, Chapter 18).

2. A 52-year-old female with shoulder pain tells you that she has pain at night that awakens her. After asking a series of follow-up questions, you are able to determine that she had trouble falling asleep because her pain increases when she goes to bed. Once she falls asleep, she wakes up as soon as she rolls onto that side. What is the most likely explanation for this pain behavior? a. Minimal distractions heighten a person's awareness of musculoskeletal discomfort. b. This is a systemic pattern that is associated with a neoplasm. c. It is impossible to tell. d. This represents a chronic clinical presentation of a musculoskeletal problem.

2. (A) Pain that wakes a client up as soon as he or she rolls onto that side is indicative of an acute inflammatory process. Night pain associated with neoplasm is more likely to wake the client up after he or she falls asleep, when the tumor keeps normal tissue from obtaining essential blood and nutrients, thus creating tissue ischemia and subsequent pain. With chronic musculoskeletal conditions, the client can often get to sleep with just the right positioning and may even be able to sleep on that side for up to an hour or two before pressure and ischemia develop, causing pain.

2. Direct access is the only reason physical therapists must screen for systemic disease. a. True b. False

2. (B) False—See Box 1-1.

2. A line drawn down the middle of a lesion with two different halves suggests a. a malignant lesion. b. a benign lesion. c. a normal presentation. d. a skin reaction to medication.

2. A

2. Chronic GI blood loss sometimes associated with use of NSAIDs can result in which of the following problems? a. Increased incidence of joint inflammation b. Iron deficiency c. Decreased heart rate and bleeding d. Weight loss, fever, and loss of appetite

2. B

2. Neurologic symptoms such as muscle weakness or muscle atrophy may be the first indication of a. cystic fibrosis. b. bronchiectasis. c. neoplasm. d. deep vein thrombosis.

2. C

2. Briefly describe the difference between myocardial ischemia, angina pectoris, and MI.

2. Myocardial ischemia is a deficiency of blood supply to the heart muscle that is usually caused by narrowing of the coronary arteries. Angina pectoris is the chest pain that occurs when the heart is not receiving an adequate supply of blood, and therefore, has insufficient quantities of oxygen for the workload. Myocardial infarction is death of the heart tissue when blood supply to that area is interrupted.

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 midback or upper back, scapular, and right shoulder areas. d. the thorax, scapulae, right shoulder, or left shoulder.

3. (A) Left shoulder pain associated with damage or injury to the spleen is called Kehr's sign.

3. A risk factor for NSAID-related gastropathy is the use of a. antibiotics. b. antidepressants. c. antihypertensives. d. antihistamines.

3. (B) Antidepressants Antidepressants are divided into three groups: tricyclics, monoamine oxidase inhibitors (MAOIs), and miscellaneous antidepressants. The tricyclics work by blocking reuptake of norepinephrine and serotonin into nerve endings and increasing the action of norepinephrine and serotonin in nerve cells. Any of the antidepressants can have gastrointestinal adverse effects, but especially, the selective serotonin uptake inhibitors (SSRIs) such as Paxil, Zoloft, Prozac, and Celexa.

3. Preoperatively, clients cannot take aspirin or antiinflammatory medications because these a. decrease leukocytes. b. increase leukocytes. c. decrease platelets. d. increase platelets. e. None of the above.

3. (C) Platelets are affected by anticoagulant drugs, including aspirin and heparin. Platelets are important in the coagulation of blood, a necessary process during and after surgery.

3. A patient/client gives you a written prescription from a physician, chiropractor, or dentist. The first screening question to ask is a. what did the physician (dentist, chiropractor) say is the problem? b. did the physician (dentist, chiropractor) examine you? c. when do you go back to see the doctor (dentist, chiropractor)? d. how many times per week did the doctor (dentist, chiropractor) suggest you come to therapy?

3. B

3. Pulse strength graded as 1 means a. easily palpable, normal. b. present occasionally. c. pulse diminished, barely palpable. d. within normal limits.

3. C

3. What areas of the body can GI disorders refer pain to? a. Sternum, shoulder, scapula b. Anterior neck, mid-back, lower back c. Hip, pelvis, sacrum d. All of the above.

3. D

3. What should you do if a client complains of throbbing pain at the base of the neck that radiates into the interscapular areas and increases with exertion?

3. Monitor vital signs and palpate pulses. Evaluate past and current medical history for the presence of coronary artery disease. Any suspicion of thoracic aneurysm must be reported to the physician immediately. It is beyond the scope of a physical therapist's practice to suggest the possibility of an aneurysm. Rather, clinical observations should be documented and submitted to the physician. A summary comment can be made such as, "This clinical presentation is not consistent with a musculoskeletal problem. Please evaluate."

3. Back pain with radiating numbness and tingling down the leg past the knee does not occur as a result of a. postoperative thrombus. b. bronchogenic carcinoma. c. Pott's disease. d. trigger points.

3. Pott's disease

4. Associated signs and symptoms are a major red flag for pain of a systemic or visceral origin compared with musculoskeletal pain. a. True b. False

4. (A) True. See Table 3-2.

4. After interviewing a new client, you summarize what she has told you by saying, "You told me you are here because of right neck and shoulder pain that began 5 years ago as a result of a car accident. You also have a 'pins and needles' sensation in your third and fourth fingers but no other symptoms at this time. You have noticed a considerable decrease in your grip strength, and you would like to be able to pick up a pot of coffee without fear of spilling it." This is an example of a. an open-ended question. b. a funnel technique. c. a paraphrasing technique. d. None of the above.

4. (C)

4. Pain associated with pleuropulmonary disorders can radiate to the a. anterior neck. b. upper trapezius muscle. c. ipsilateral shoulder. d. thoracic spine. e. A and C f. All of the above.

4. (F) Pain can also radiate to the costal margins or upper abdomen (see Figs. 7-9 and 7-10).

4. Skin color and nail bed changes may be observed in the client with a. thrombocytopenia resulting from chemotherapy. b. pernicious anemia resulting from Vitamin B12 deficiency. c. leukocytosis resulting from AIDS. d. All of the above.

4. B

4. During auscultation of an adult client with rheumatoid arthritis, the heart rate gets stronger as she breathes in and decreases as she breathes out. This sign is a. characteristic of lung disease. b. typical in coronary artery disease. c. a normal finding. d. common in anyone with pain.

4. C

4. Screening for medical disease takes place a. only during the first interview. b. just before the client returns to the physician for his/her next appointment. c. throughout the episode of care. d. None of the above.

4. C

4. A 56-year-old client was referred to PT for pelvic floor rehab. His primary symptoms are obstructed defecation and puborectalis muscle spasm. He wakes nightly with left flank pain. The pattern is low thoracic, laterally, but superior to iliac crest. Sometimes he has buttock pain on the same side. He doesn't have any daytime pain but is up for several hours at night. Advil and light activity do not help much. The pain is relieved or decreased with passing gas. He has very tight hamstrings and rectus femoris. Change in symptoms with gas or defecation is possible with a. thoracic disk disease. b. obturator nerve compression. c. small intestine disease. d. large intestine and colon dysfunction.

4. D

4. What are the 3Ps? What is the significance of each one?

4. The three Ps include: • Pleuritic pain (exacerbated by respiratory movement involving the diaphragm, such as sighing, deep breathing, coughing, sneezing, laughing, or the hiccups; this may be cardiac with pericarditis, or it may be pulmonary); have the client hold his or her breath, and reassess symptoms—any reduction or elimination of symptoms with breath holding or the Valsalva maneuver suggests a pulmonary or cardiac source of symptoms. • Pain on palpation (musculoskeletal origin) • Pain with changes in position (musculoskeletal or pulmonary origin; pain that is worse when lying down and that improves when sitting up or leaning forward is often pleuritic in origin).

5. Screening for alcohol use would be appropriate when the client reports a history of accidents. a. True b. False

5. (A) True

5. Words used to describe neurogenic pain often include a. throbbing, pounding, beating. b. crushing, shooting, pricking. c. aching, heavy, sore. d. agonizing, piercing, unbearable.

5. (B) Throbbing, pounding, and beating are more often associated with pain of a vascular nature. Aching, heavy, and sore are words used to describe musculoskeletal pain. According to the McGill Pain Questionnaire, words like agonizing, piercing, and unbearable convey more emotional content than is communicated by actual descriptors of organic disease. See Table 3-1; see also Fig. 3-11.

5. Bleeding under the skin, nosebleeds, bleeding gums, and black stools require medical evaluation as these may be indications of a. leukopenia. b. thrombocytopenia. c. polycythemia. d. sickle cell anemia.

5. B

5. Name two of the most common medications taken by clients seen in a physical therapy practice likely to induce GI bleeding. a. Corticosteroids b. Antibiotics and anti-inflammatories c. Statins d. None of the above.

5. B

5. Medical referral for a problem outside the scope of the physical therapy practice occurs when a. no apparent movement dysfunction exists. b. no causative factors can be identified. c. findings are not consistent with neuromuscular or musculoskeletal dysfunction. d. client presents with suspicious red-flag symptoms. e. Any of the above. f. None of the above.

5. E

5. The presence of a persistent dry cough (no sputum or phlegm produced) has no clinical significance to the therapist. True or false?

5. False. However, medical referral is usually not considered necessary when a client presents with a singular systemic sign or symptom, especially in the presence of a clear clinical presentation of a musculoskeletal pattern.

5. When are palpitations clinically significant?

5. Palpitations may be considered physiologic (i.e., "within normal limits") when they occur at a rate of less than six per minute. Palpitations lasting for hours or occurring in association with pain, shortness of breath, fainting, or severe lightheadedness require medical evaluation. Palpitations in any person with a history of unexplained sudden death in the family require medical referral. Palpitations can also occur as an adverse effect of some medications, through the use of drugs such as cocaine, as the result of an overactive thyroid, or because of caffeine sensitivity. Palpitations as a recurring symptom (even if less than six/minute) should always be reported to the physician.

5. Body temperature should be taken as a part of vital sign assessment a. only for clients who have not been seen by a physician. b. for any client who has musculoskeletal pain of unknown origin. c. for any client reporting the presence of constitutional symptoms, especially fever or sweats. d. B and C e. All of the above.

5. We confess this is a bit of a "trick" question. Thoughts on this topic vary. Some therapists advocate taking each client's body temperature (answer "E") as one of the simplest and most inexpensive ways to screen for the presence of systemic problems. Others are more selective in the screening process and advise answer "D" (B and C) as the most appropriate response. The decision may depend, in part, on the type of practice or clinical setting in which you practice. For the new graduate, it is highly recommended that all vital signs be taken on all clients until the therapist is proficient in this skill area. With experience, each clinician will develop the decision-making skills needed to determine when additional screening, and which screening tests, should be carried out.

6. Pain (especially intense bone pain) that is disproportionately relieved by aspirin can be a symptom of a. neoplasm. b. assault or trauma. c. drug dependence. d. fracture.

6. (A) Neoplasm, in particular, primary bone cancer.

6. What is the significance of sweats? a. A sign of systemic disease b. Side effect of chemotherapy or other medications c. Poor ventilation while sleeping d. All of the above. e. None of the above.

6. (D)

6. A 23-year-old female presents with a new onset of skin rash and joint pain followed 2 weeks later by GI symptoms of abdominal pain, nausea, and diarrhea. She has a previous history of Crohn's disease, but this condition has been stable for several years. She does not think that her current symptoms are related to Crohn's disease. What kind of screening assessment is needed in this case? a. Vital signs only b. Vital signs and abdominal auscultation c. Vital signs, neurologic screening, and abdominal auscultation d. No further assessment is needed; there are enough red flags to advise this client to seek medical attention.

6. (D) You may decide to conduct additional tests and provide the information to the physician. This should include a review of past medical history, current medications, and any pharmaceuticals she may be taking, as well as any other symptoms present but unnoticed or unreported. Carry out a screening interview using Special Questions for Joint Pain (see Appendix B-16).

6. Dyspnea associated with emphysema is the result of a. destruction of the alveoli. b. reduced elasticity of the lungs. c. increased effort to exhale trapped air. d. A and B e. All of the above.

6. (E)

6. Physical therapy evaluation and intervention may be a part of the physician's differential diagnosis. a. True b. False

6. A

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. 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.

6. B

6. A 48-year-old female with TMJ syndrome has been referred to you by her dentist. How do you screen for the possibility of medical (specifically cardiac) disease?

6. Past medical history/risk factors—Personal or family history of coronary artery disease, heart disease, angina, myocardial infarction, or risk factors associated with these (see Table 6-3). Assess menstrual history: A menopausal or postmenopausal woman with a high risk for heart disease may develop symptomatic coronary artery disease. Clinical presentation—Objective findings from the clinical evaluation do not seem consistent with temporomandibular dysfunction; assess the effect of using a stationary bicycle or treadmill (stairs or walking will also work) without upper extremity exertion on jaw pain. Increased pain or symptoms with increased lower body exertion may be a sign of cardiac involvement and should be reported to the referring dentist. Associated signs and symptoms—Assess for coincident nausea, diaphoresis, pallor, or dyspnea during painful or symptomatic periods. Look for recent history (last 6 weeks to 6 months in onset) of shortness of breath at night, extreme fatigue, lethargy, and weakness. Ask about the presence of other body aches and pains (be alert for "heartburn" unrelieved by antacids, isolated right biceps muscle aching, and breast or chest pain). Measure vital signs for any unusual findings, and assess changes in vital signs with changes in workload during exercise.

6. Under what circumstances would you consider asking a client about a recent change in altitude or elevation?

6. When you live at an elevation of 3500 feet above sea level (or higher) and the client describes symptoms of unknown origin such as headache, dizziness, fatigue, and changes in sensation of the feet and hands (decreased feeling, burning, numbness, tingling, [polycythemia] or joint pain, swelling, and loss of motion [sickle cell disease])

7. Spontaneous uterine bleeding after 12 consecutive months without menstrual bleeding requires medical referral. a. True b. False

7. (A) True. This includes any woman who has experienced a surgical menopause (e.g., oophorectomy for ovarian cancer) or any postmenopausal woman who is not taking hormone replacements.

7. A 65-year-old client is taking OxyContin for a "sore shoulder." She also reports aching pain of the sacrum that radiates. The sacral pain can be caused by a. psoas abscess caused by vertebral osteomyelitis. b. GI bleeding causing hemorrhoids and rectal fissures. c. Crohn's disease manifested as sacroiliitis. d. pressure on sacral nerves from stored fecal content in the constipated client taking narcotics.

7. (D) Psoas abscess can affect the hip, buttock, groin, and parts distal but does not cause sacral pain; hemorrhoids and rectal fissures may cause rectal or anal pain, but not sacral pain; Crohn's disease can be accompanied by sacroiliitis, but this client does not have a reported history of Crohn's disease; narcotics are well known for constipation as a common adverse effect, especially in the older adult.

7. Joint pain can be a reactive, delayed, or an allergic response to a. medications. b. chemicals. c. infections. d. artificial sweeteners. e. All of the above.

7. (E) Artificial sweeteners have come under fire, primarily by manufacturers of artificial sweeteners. Evidence supplied by two prominent board certified neurosurgeons (see text) combined with the author's own clinical experience is sufficient to include this agent as a causative factor in joint pain.

7. What is the difference between a yellow- and a red-flag symptom?

7. A yellow flag is a cautionary or warning symptom that signals, "Slow down, and think about the need for screening." A red flag symptom requires immediate attention, either to pursue further screening questions or tests, or to make an appropriate referral. The presence of a single yellow or red flag is not usually a cause for immediate medical attention. Each cautionary or warning flag must be viewed in the context of the whole person, given his or her age, gender, past medical history, and current clinical presentation.

7. What is the significance of autosplinting?

7. Autosplinting occurs when lying on the involved side quiets respiratory movement and reduces or eliminates symptoms. Most musculoskeletal problems are made worse by placing this kind of pressure on the symptomatic shoulder, neck, or thoracic spine. The therapist must also evaluate the presence of associated signs and symptoms, the effect of increased respiratory movements on symptoms, and the effect of the supine position (recumbency) on shoulder/upper trapezius pain.

7. In the case of a client with hemarthrosis associated with hemophilia, what physical therapy intervention would be contraindicated?

7. Local heat applied to the involved joint(s)

7. A 55-year-old male grocery store manager reports that he becomes extremely weak and breathless when he is stocking groceries on overhead shelves. What is the possible significance of this complaint?

7. The onset of myocardial infarction can be precipitated by working with the arms extended over the head. Ischemia or infarction may be the cause of this client's symptoms. Assess for history of heart disease and the presence of known hypertension, angina, past episodes of heart attack, or congestive heart failure. Assess vital signs and changes in vital signs with increased workload and assess the effect of increasing the workload of the lower extremities only. Evaluate for thoracic outlet syndrome (TOS), especially with a cardiovascular component (see Table 17-5). Evaluate for and treat trigger points of the chest, upper abdomen, and upper extremity. This client should be evaluated by his physician; the therapist's information gathered from the assessment will be helpful in the medical differential diagnosis.

7. A 76-year-old male was referred to physical therapy after a total hip replacement (THR). The goal is to increase his functional mobility. Is a health assessment needed even though he was examined just before the surgery 2 weeks ago? The physician conducted a systems review and summarized the medical record by saying the client was in excellent health and a good candidate for THR.

7. Yes. The therapist must be familiar with past medical history and any factors that could put the client at risk for a medical incident of any type. Health status can change for any client within a 2-week period, but especially, the aging adult. Surgery is a major event that is traumatic to the physiologic body, despite the client's previous excellent health. Surgery can trigger the onset of new health problems or may bring to fulmination something that was present only sub clinically before the operation. Some postoperative complications do not develop until 10 to 14 days later. Exercise is an additional physiologic stressor. Symptoms may not be seen when the client is at rest or sedentary and may occur only after exercise has been initiated. Time pressure and the complexities of today's health care delivery system can also result in conditions remaining unnoticed by the examining health care professional. Systemic diseases often develop slowly and gradually over time. It is not until the disease has progressed enough that the client shows any signs and symptoms of visceral or systemic involvement. What the physician, physician's assistant, nurse, or nurse practitioner observed preoperatively may not be the clinical presentation seen by the therapist postoperatively.

8. Describe the two tests used to distinguish an iliopsoas bleed from a joint bleed.

8. (1) Trunk flexion over the hips produces severe pain in the presence of iliopsoas bleeding. Only mild pain occurs on trunk flexion over the hips for a hip hemorrhage. (2) Gently rotating the hip internally or externally causes severe pain in the presence of a hip hemorrhage but only minimal (or no) pain with iliopsoas bleeding.

8. Bone pain associated with neoplasm is characterized by a. increases with weight bearing. b. negative heel strike. c. relieved by Tums or other antacid in female. d. goes away after eating.

8. (A) Bone pain would be accompanied by a positive heel strike test. Symptoms of angina are sometimes relieved by antacids in women. Even if bone pain were caused by metastases from the GI tract, eating would not alleviate the symptoms.

8. Body temperature should be taken as part of vital sign assessment a. for every client evaluated. b. for any client who has musculoskeletal pain of unknown origin. c. for any client reporting the presence of constitutional symptoms, especially fever or night sweats. d. B and C

8. (A) or (D) Some physicians and physical therapists advocate taking the body temperature as part of a vital sign assessment in all clients (answer [A]). Others suggest that this may not be necessary in cases in which a clear musculoskeletal cause is noted for the clinical presentation, as well as an absence of any systemically associated signs and symptoms. As a general guideline, vital sign assessment can provide valuable screening and overall health information. For the student and inexperienced clinician, we highly recommend this practice. For further discussion of this topic, see Chapter 4.

8. Which of the following are red flags to consider when screening for systemic or viscerogenic causes of neuromuscular and musculoskeletal signs and symptoms? a. Fever, (night) sweats, dizziness b. Symptoms are out of proportion to the injury c. Insidious onset d. No position is comfortable. e. All of the above.

8. (E) All of these are red flags, along with previous history of cancer, symptoms that last longer than expected (beyond physiologic time period for healing), age, gender, comorbidities, bilateral symptoms, other constitutional symptoms, unexplained falls, substance use/abuse, unusual vital signs, and constant and intense pain; see also Appendix A-2.

8. You are seeing an 83-year-old female for a home health evaluation after a motor vehicle accident (MVA) that required a long hospitalization followed by transition care in an intermediate care nursing facility and now home health care. She is ambulating short distances with a wheeled walker, but she becomes short of breath quickly and requires lengthy rest periods. At each visit the client is wearing her slippers and housecoat, so you suggest that she start dressing each day as if she intended to go out. She replies that she can no longer fit into her loosest slacks and she cannot tie her shoes. Is there any significance to this client's comments, or is this consistent with her age and obvious deconditioning? Briefly explain your answer.

8. Examine this client for the presence of cyanosis, orthopnea, and tachycardia; for changes in renal function (decreased urination during the day but frequent urination at night); and for a spasmodic cough triggered by lying down or at night. These may be indicators of congestive heart failure and must be reported to the physician. Take note of whether this client is taking NSAIDs and digitalis together; this combination of medications can cause ankle swelling—a symptom that must also be reported to the physician.

8. How do you plan or modify an exercise program for a client with cancer without the benefit of blood values?

8. First of all, do you need to? How far out from the first medical diagnosis and final treatment is the client? Is the client still being treated? Without laboratory values, physical assessment becomes much more important. Check vital signs; observe the skin, eyes, and nail beds, and ask about the presence of associated signs and symptoms.

8. What are the major decision-making tools used in the screening process?

8. Past medical history, risk factor assessment, clinical presentation (including pain types and pain patterns), associated signs and symptoms, review of systems. Each client can be framed by these five components. Any suspicious finding or response in any of these areas warrants a closer look.

8. Which symptom has greater significance: dyspnea at rest or exertional dyspnea?

8. These have equal significance when viewed as part of a continuum; dyspnea that has progressed from exertional to rest is a red flag symptom. The usual progression of dyspnea is for a client to first notice shortness of breath after a specific length of time or intensity while engaging in an activity such as walking or climbing stairs. Progression to dyspnea at rest usually occurs after the client notices shortness of breath sooner and with less intensity in the activity. Exertional dyspnea may be the result of deconditioning alone without a specific pulmonary disease. In addition, early, mild congestive heart failure may be characterized by shortness of breath at rest that is not present with exertion. In such a case, increased stroke volume that results from increased activity may improve venous return enough to alleviate dyspnea with exertion. Over time, as the congestion progresses, dyspnea will increase with less provocation and will occur at rest as well as with exertion. Either exertional dyspnea or dyspnea at rest that is out of proportion to the situation should be considered a red flag. Progression to dyspnea at rest usually occurs after the client notices shortness of breath that occurs sooner and with less intensity in the activity.

9. Pain of a viscerogenic nature is not relieved by a change in position. a. True b. False

9. (B) False. Some types of viscerogenic pain can be relieved by a change in position early in the disease process. For example, pain from an inflammatory or infectious process that affects the kidney may be reduced by leaning toward the involved side and applying pressure to that area. Gallbladder pain is sometimes relieved by leaning forward. Cardiac pain brought on by use of the upper extremities overhead may be relieved by bringing the arms back down to the sides.

9. Peripheral vascular diseases include a. arterial and occlusive diseases. b. arterial and venous disorders. c. acute and chronic arterial diseases. d. All of the above. e. None of the above.

9. (D) Arterial and occlusive diseases are synonymous for the same thing: Occlusion of the arteries produces arterial disease; occlusion of the veins produces venous disorders. Arteries and veins constitute the major peripheral blood vessels; therefore, any diseases or disorders of the arteries and/or veins are included in peripheral vascular disorders.

9. The presence of pain and anxiety in a client can often lead to hyperventilation. When a client hyperventilates, the arterial concentration of carbon dioxide will do which of the following? a. Increase b. Decrease c. Remain unchanged d. Vary depending on potassium concentration

9. B

9. When would you consider listening for femoral bruits?

9. Bruits are abnormal blowing or swishing sounds heard on auscultation of narrowed or obstructed arteries. Bruits with both systolic and diastolic components suggest the turbulent blood flow of partial arterial occlusion that is possible with aneurysm or vessel constriction. The therapist is most likely to assess for bruits when the client or patient is older than 65 years of age and describes problems (i.e., neck, back, abdominal, or flank pain) in the presence of a history of syncopal episodes, a history of cardiovascular disease (CVD), serious risk factors for CVD, or a previous history of aortic aneurysm. Look for other signs of peripheral vascular disease that may account for the client's current symptoms. Symptoms may be described as "throbbing" and may increase with activity and decrease with rest. In the most likely candidate, neck or back pain is not affected by physical therapy intervention. The client is an older adult, a postmenopausal woman, and/or has significant risk factors for CVD or a history of CVD.

9. What is the significance of the psoas sign?

9. Infection of the peritoneum (e.g., peritonitis, appendicitis) can cause abscess formation of the psoas (or obturator) muscle, resulting in right lower quadrant (abdominal or pelvic) pain in association with specific movements of the right leg (see Iliopsoas Muscle Test, Fig. 8-3, and Obturator Muscle Test, Fig. 8-7).

9. What is the significance of nadir?

9. Nadir, or the lowest point the white blood count reaches, usually occurs 7 to 14 days after chemotherapy or radiation therapy. At that time, the client is extremely susceptible to infection; the therapist must follow all universal precautions, especially those pertaining to good handwashing.

9. A 52-year-old male with low back pain and sciatica on the left side has been referred to you by his family physician. He has had a discectomy and laminectomy on two separate occasions about 5 to 7 years ago. No imaging studies have been performed (e.g., X-ray examination or MRI) since that time. What follow-up questions should you ask to screen for medical disease?

9. The first question should always be, "Did you actually see your physician?" Then ask questions directed at assessing for the presence of constitutional symptoms. For example, after paraphrasing what the client has told you, ask, "Are you having any other symptoms of any kind in your body that you haven't mentioned?" If no, ask more specifically about the presence of associated signs and symptoms, including naming constitutional symptoms one by one. Follow up with Special Questions for Male (see Appendix B-21).