Differential Diagnosis Practical Study Questions
45. A 64-year-old woman 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?
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.
7. Joint pain can be a reactive, delayed, or allergic response to: a. medications b. chemicals c. infections d. artificial sweeteners e. all the above
e. all the above
57. 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. All the above
35. pain associated with pleuropulmonary disorders can radiate to the: a. anterior neck b. UT muscle c. ipsilateral shoulder d. thoracic spine e. A and C f. all the above
f. all the above
60. 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 i. ______ Psoriatic arthritis j. ______ Systemic lupus erythematosus k. ______ HIV infection l. ______ Scleroderma m. ______ Rheumatoid arthritis n. ______ Allergic reaction o. ______ Lyme disease p. ______ Thrombocytopenia
i. ___A___ Psoriatic arthritis j. ___B___ Systemic lupus erythematosus k. __E____ HIV infection l. ___D___ Scleroderma m. __H____ Rheumatoid arthritis n. __G____ Allergic reaction o. __F____ Lyme disease p. ___C___ Thrombocytopenia
53. 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."
22. When exercising a client with known anemia, what 2 measures can be used as guidelines for frequency, intensity, and duration of the program?
(1) Client tolerance; (2) Perceived exertion levels
20. Describe 2 tests used to distinguish an iliopsoas bleed from a joint bleed
(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.
52. 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)?
63. 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.
51. 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.
32. IF a client reports that the shoulder/UT muscle pain increases with deep breathing, how can you assess whether this results from a pulmonary or musculoskeletal cause?
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.
36. What is the significance of autospliting?
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.
16. You notice a new client has an unusual (strong) breath odor. How do you assess this?
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. Chapter 5 - page 263
13. When would you consider listening for femoral bruits?
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.
68. Complete the following mnemonic: C A U T I O N S
Changes in bowel or bladder habits, A sore that does not heal within 6 weeks, Unusual bleeding or discharge, Thickening or lump in the breast or elsewhere, Indigestion or difficulty in swallowing, Obvious change in a wart or mole, Nagging cough or hoarseness, 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)
29. You are seeing an 83-year-old woman 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.
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.
12. how do you plan or modify an exercise program for a client with cancer without the benefit of blood values?
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 nailbeds, and ask about the presence of associated signs and symptoms.
46. 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 corticosteroidinduced 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?"
69. 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?)
34. 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
In accordance with our screening model, we always take a look at past medical history, risk factors, clinical presentation, and associated signs and symptoms. This patient's age, history of tobacco use, and previous history of breast cancer are red flags and risk factors for cancer recurrence and other systemic disorders. The following tests and measures can help the therapist to differentiate musculoskeletal from systemic origin of symptoms in this case: Vital signs and pulmonary auscultation, Palpation (Can symptoms be reproduced with palpation? [Bone mets are not usually painful to palpation, whereas trigger points or impaired soft tissue structures may be painful upon palpation.]). Are the intercostal spaces symmetric? Asymmetry may be noted with rib dysfunction. Active and passive spinal motion (Can symptoms be reproduced, alleviated, or changed in any way with active spinal movement? Are the accessory motions within normal limits?) Ask about the presence of other pulmonary signs and symptoms. Is the pattern of symptoms consistent with a musculoskeletal disorder? Because breast cancer can metastasize to the bone, and especially, to the thoracic spine, a neurologic screening examination may be in order, depending on the client's response to previous questions and tests.
67. 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
19. In the case of a client with hemarthrosis associated with hemophilia, what PT intervention would be contraindicated?
Local heat applied to the involved joint(s)
61. 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.
24. What should you do if a client complains of throbbing pain at the base of the neck that radiates into the inter-scapular areas and increase with exertion?
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."
23. Describe the different between myocardial ischemia, angina pectoris, and MI
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.
21. What is the significant of nadir?
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.
101. A 66-year-old woman has been referred to you by her physiatrist for preprosthetic training after an aboveknee 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.
26. When are palpitations clinically significant?
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.
27. A 48-year old woman with TMJ syndrome has been referred to you by her dentist? How do you screen for the possibility of medical (specifically cardiac) disease?
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.
66. Name three predisposing factors to cancer that the therapist must watch for during the interview process as red flags
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)
58. What are the most common musculoskeletal symptoms associated with endocrine disorders?
Proximal muscle weakness, myalgia, carpal tunnel syndrome, periarthritis, adhesive capsulitis (shoulder)
79. A 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.
28. A 55-year old male grocery store manager reports that he becomes extremely weak and breathless when he is stocking groceries on OH shelves. What is the possible significant of this complaint?
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.
25. What are the 3P's? what is significant for each one?
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).
37. Which symptoms has greater significants: dyspnea at rest or exertional dyspnea?
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.
70. 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.
17. under what circumstances would you consider asking a client about a recent change in altitude or elevation?
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])
15. A 76-year old man was referred to PT after a THR. The goal is to increase functional mobility. Is a health assessment needed since 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 good candidate for THR?.
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 subclinically 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.
56. Which glycosylated hemoglobin (A1C) value is within the recommended range? a. 6% b. 8% c. 10% d. 12%
a. 6%
76. 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. Fever, muscle weakness, weight loss
89. 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. Is younger than 20 or older than 50
2. 52-year-old woman 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.
a. Minimal distractions heighten a person's awareness of musculoskeletal discomfort.
93. 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
88. 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. Past medical history, risk factors, clinical presentation, and associated signs and symptoms
98. 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.
48. decreased level of consciousness, impaired function of peripheral nerves, and asterixis (flapping tremor) would probably indicate an increase in the level of: a. AST b. alkaline phosphate c. serum bilirubin d. serum ammonia
d. serum ammonia
106. 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. She is sexually active, and her period is late
105. 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 side lying when it is pulmonary b. Symptoms get worse when lying supine but better when right side lying when it is musculoskeletal
a. Symptoms get worse when lying supine but better when right side lying when it is pulmonary
80. Skin pain over T9 to T12 can occur with kidney disease as a result of multisegmented 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
a. True
75. 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-thecounter 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. Yes; age, bilateral symptoms, progression of symptoms, report of GI distress
30. What are the primary signs and sx of CHF? a. fatigue, dyspnea, edema, nocturia b. fatigue, dyspnea, varicose veins c. fatigue, dyspnea, tinnitus, nocturia d. fatigue, dyspnea, headache, night sweats
a. fatigue, dyspnea, edema, nocturia
41. What is the significance of Kehr's sign a. gas, air, or blood in abdominal cavity b. infection of the peritoneum (peritonitis, appendicitis) c. esophageal d. thoracic disk herniation masquerading as chest or anterior neck pain
a. gas, air, or blood in abdominal cavity
8. Bone pain associated with neoplasm is characterized by: a. increases with weight bearing b. negative heel strike c. relieved by turns or other antacid in women d. goes away after eating
a. increases with weight bearing
3. Referred pain patterns associated with impairment of the spleen can produce musculoskeletal symptoms in: a. left shoulder b. right shoulder c. mid-back or upper back, scapular, and right shoulder areas d. thorax, scapulae, right shoulder, or left shoulder
a. left shoulder
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
a. neoplasm
4. Associated signs and symptoms are a major red flag for pain of a systemic or visceral origin compared to musculoskeletal pain. a. true b. false
a. true
94. 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
95. 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
72. 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. Notched edges
64. 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. Purple-red blotches or bumps on the trunk and head
86. 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. Sacral pain is relieved when the client passes gas or has a bowel movement.
90. 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. Squat test, hop test, translational/rotational tests
85. A 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. The client should be screened for systemic disease even if you have already included screening during the initial evaluation.
65. 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. Vocal hoarseness, sneezing, and chest tightness
74. 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. You can't. This requires a medical evaluation.
43. Name 2 of the most common meds taken by clients seen in a PT practice likely to induce GI bleeding a. corticosteroids b. antibiotics and anti-inflammatories c. statins d. none
b. antibiotics and anti-inflammatories
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
b. crushing, shooting, pricking
39. 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
b. decrease
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 the pain right now? c. does the pain wake you up at night after you have fallen asleep? d. Is there anything that makes the better better or worse?
b. do you have the pain right now?
47. An inpatient who has had a THR with 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. hepatic encephalopathy
40. bleeding in the GI tract can be manifested as: a. dysphagia b. melena c. psoas abscess d. tenderness of McBurney's point
b. melena
18. 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 results from AIDs d. all the above
b. pernicious anemia resulting from vitamin b12 deficiency
84. 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. A lack of objective findings
62. 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. Ankylosing spondylitis
92. Vascular diseases that may cause referred hip pain include: a. Coronary artery disease b. Intermittent claudication c. Aortic aneurysm
c. Aortic aneurysm
97. 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.
59. Fibromyalgia syndrome is a: a. Musculoskeletal disorder b. Psychosomatic disorder c. Neurosomatic disorder d. Noninflammatory rheumatic disorder
c. Neurosomatic disorder
49. 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. Prolonged coagulation times
103. 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. The mid or upper back, scapular, and right shoulder areas
104. 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
11. 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
c. a normal finding
31. When would you advice a client in PT to take his/her nitroglycerin? a. 45 minutes before exercise b. when sx of chest pain do not subside with 10-15 minutes of rest c. as soon as chest pain begins d. none of the above e. all of the above
c. as soon as chest pain begins
33. Neurologic sx such as muscle weakness or muscle atrophy may be first indication of: a. cystic fibrosis b. bronchiectasis c. neoplasm d. deep vein thrombosis
c. neoplasm
10. Pulse strength graded as 1 means: a. easily palpable, normal b. present occasionally c. pulse diminished, barely palpable d. within normal limtis
c. pulse diminished, barely palpable
102. 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. All of the above
73. 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. All of the above
77. 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. All of the above
82. 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. All of the above
91. 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. All of the above
96. 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. All of the above a. is most likely though
87. 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. Diagnostic imaging is the only way to know for sure
71. 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. Fever, chills, sweating
54. 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 with decreased muscle strength
55. 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. Hypertension, slow wound healing, easy bruising
81. 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. Medical referral is advised
50. 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. Requires medical referral
78. 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. Throbbing, "tired"
100. 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
83. 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. Vascular pattern of ischemia
99. 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
d. all of the above
42. 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
d. large intestine and colon dysfunction
14. A 23-year-old female presents with new onset of skin rash and joint pain followed by 2 weeks later by GI sx of abdominal pain, nausea, and diarrhea. She has previous hx of Crohn's disease, but this condition has been stable for several years. She does not think her current sx are related to her 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 examination, and abdominal auscultation d. no further assessment is needed, there are enough red flags to advise this client to seek medical attention
d. no further assessment is needed, there are enough red flags to advise this client to seek medical attention
9. A 48 year old man presented LBP of unknown cause. He works as a carpenter and says he is very active, has work related mishaps, and engage 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 exam, 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 tissues 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.
d. obstruction, irritation, or inflammation of the body of the pancreas distends the pancreas, thus applying pressure on the central respiratory diaphragm.
38. Common sx 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 lightheadness c. hyperventilation with changes in level of consciousness d. onset of sleepiness, confusion, and decreased ventilation
d. onset of sleepiness, confusion, and decreased ventilation
44. A 65-year 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 osteomyeltis b. GI bleeding causing hemorrhoids and rectal fissures c. Crohn's disease manifesting as sacroilitis d. pressure on sacral nerves from stored fecal content in the constipated client taking narcotics
d. pressure on sacral nerves from stored fecal content in the constipated client taking narcotics
