Differential Diagnosis Exam 3

Type 1 Diabetes Mellitus

overview T1DM is an organ-specific autoimmune disease, caused by the autoimmune response against pancreatic β cells uThe pancreatic β cells are endocrine cells that synthesize, store, and release insulin uWithout insulin, blood sugar can't get into the cells and builds up in the bloodstream uHigh blood sugar is damaging to the body and causes many of the symptoms and complications of diabetes risk factors uMay include family history and age, but are not as clearly defined as Type 2 Diabetes <30 years old ●Abrupt onset ●Insulin deficient ●β-cell destruction leading to absolute insulin deficiency ●Normal/thin BMI ●Managed: Diet, Exercise, Insulin Happening because insulin deficiency Beta cells not producing insulin Usually diagnosed younger

Type 2 Diabetes Mellitus overview and risk factors

overview uT1DM is characterized by a progressive status of chronic, low-grade inflammation that accompanies the whole trajectory of the disease, from its inception to development of complications uThe body does not use insulin efficiently and/or pancreas does not produce enough insulin risk factors uThey may include having pre-diabetes, being overweight, >45 years old, family history, physical activity <3x/week, have ever had gestational diabetes, are African American, Hispanic, Latino, American Indian, or Alaska Native. over 35 years old ●Gradual onset ●Insulin resistance, progressive insulin secretory defect ●90% incidence ●Managed: Diet, Exercise, Meds >35 years old when diagnosed most often

= < 0.5 cm, elevated, palpable, solid - warts

papule Papule- elevated wort like lesion on skin pretty small less than half cm Primary Lesions

= > 1 cm, may have irregular border

patch Patch - bigger than cm and irregular Primary Lesions

Vascular Lesions pinpoint areas of superficial bleeding into skin 1-2 mm 2degree blood extravasation - capillaries leak do not blanch sepsis, emboli, bacterial endocarditis, thrombocytopenia (↓ platelets), leukemia, blood thinners, meningiococcus

petechia (pl. petechiae) bleeding into the skin petechiae, -->purpura, -->ecchymoses Capillary leakage Low platelet count Blood thinners If you can link to history might not be concerned about it

High and Low Risk Stress Reaction Sites

photo

= > 0.5 cm, psoriasis, actinic keratosis

plaque Plaque - hard keratosis -scaley, scabby, hard, can be caused by psoriasis Primary Lesions

The likelihood that a person who has the disease test positive

positive predictive value

Positive and Negative predictive values

positive predictive value The likelihood that a person who has the disease test positive negative predictive value The likelihood that a person who does not have the disease test negative

Venous Stasis Stasis Dermatitis - signs and symptoms

prior h/o (history of) dependent edema (they don't want to sit with feet below them for long time) often have associated factors related to edema, CHF, HBP reddish-brown discoloration - hemosiderin staining dilated superficial veins medial ankle most frequently involved- watershed area - in advanced cases may encircle ankle and extend to knee - stocking erythroderma (can go from ankle to knee) brawny edema - non-pitting

Your elderly grandparent with an endocrine dysfunction frequently has these types of marks on their hands. These are called ___ and

purpura - this is likely normal given the history

= pus-filled vesicle or bulla - acne, furuncles, carbuncles

pustule Primary Lesions

Low Back Region red and yellow flags for cancer

red flag Age >50 Hx of CA (personal history of cancer) Unexplained weight loss of >10% Symptoms not changing with movement Changes in bowel-bleeding, stool consistency Night pain/sweats Pain that is unrelenting yellow flag Family history Failure of conservative treatment No mechanism of action Proximal muscle weakness -if nothing about PT is changing anything the that is red flag -no mechanism of injury -muscle weakness --> in core, one side is way more than the other or something like that

head and face region red flag for cancer

red flag Ataxia- loss of full control of bodily movements. Speech changes HA Nausea and Vomiting Altered mental status Visual changes yellow flag HINTS test (more to come) Head and face pain -any abnormality of cranial nerves is red flag Ataxia - cancer/ tumor Something is affected in one of the patients cranial nerve We will talk more about HINTs exam later- this will be a yellow flag - screen for potential brain tumors

Cervical/Shoulder Region red and yellow flags for cancer

red flag Male over 50, with hx of smoking Nagging pain along medial border of scapula or above the collar bone Burning pain down the arm Difficulty swallowing Hoarseness that does not resolve Nodules in the lymph nodes of the neck Tender Soft/ Mobil / Rubbery Enlarged yellow flag Pain does not change with position Difficulty swallowing and hoarseness that doesn't go away are major red flags - definitely refer Cervical and shoulder pain Look at their lymph nodes in neck -if you see a large lymph node - check it - if it is tender or large - rubbery - these are concerning - refer back to physician Month later- if cold is gone but lymph node is still inflamed and hoarse voice that is an issue

Age >50 Hx of CA (personal history of cancer) Unexplained weight loss of >10% Symptoms not changing with movement Changes in bowel-bleeding, stool consistency Night pain/sweats Pain that is unrelenting

red flag for cancer (low back pain)

A pt is seeing you for R jaw pain that began after an MVA. They have been cleared for PT by the ER. During testing you note the inability to converge their eyes, right facial drooping and right eye ptosis (drooping). What is your BEST course of action?

refer back to ER

Soft Tissues for x ray

s of ABCs •Muscles •Atrophy; swelling/edema of muscle and soft tissue •Fat pads and fat lines •Displacement often indicates pathology •Joint capsules •Effusion causes distension •Periosteum •Solid; laminated; spiculated/sunburst •Other soft-tissue findings(gas, calcifications, foreign bodies)

Secondary Lesions _______ = skin mark left after healing of a wound, replacement of injured tissue with connective tissue ________ = linear crack in the skin, problematic in diabetic feet (bacteria loves to climb into this= linear cleavage of the skin that extends into the dermis _______= flakes secondary to desquamated, dead epithelium, texture varies - thick, thin, psoriasis, dandruff

scar (cicatrix) = skin mark left after healing of a wound, replacement of injured tissue with connective tissue fissure = linear crack in the skin, problematic in diabetic feet (bacteria loves to climb into this= linear cleavage of the skin that extends into the dermis scales = flakes secondary to desquamated, dead epithelium, texture varies - thick, thin, psoriasis, dandruff

Diabetes and Skin microangiopathy of DM in lower extremities results in:

skin atrophy hair loss coldness of toes dystrophic nails pallor on elevation mottling on dependence Skin atrophies (thinner) Pale with elevation Mottling (get red and dark colored)

Vascular Lesions red, arteriolar lesion central body with radiating branches rare below waist associated with liver dz, pregnancy, vit. B deficiency

spider angioma Red center and spider legs around the edge Usually in upper arms

Examination - Palpation of skin

test temperature with back of hand - cellulitis = hotter, skin over lipomas = cooler normally hydrated skin should snap back into place after being pinched between thumb and finger - dehydrated skin "tents" (should snap back into place) excessively dry skin or sweating can indicate endocrine dysfunction → dryness - hypothyroid; night sweats - tuberculosis Cellulitis is the result of an infection, which is why it is hot, it can spread and these people should be referred to MD -needs to be treated with antibiotics -immune system fails them - skin gets hot and inflamed Lipomas - tumors - fat cell gets big and swollen - cold to touch

ventricular fibrillation

the rapid, irregular, and useless contractions of the ventricles

largest organ in the body normal adult has over 20 ft^2 of skin reflects internal change (ex: when you are sick- skin gets hot- skin can show systemic issues - liver issues skin has jaundice) responds to external changes (mt Everest without gloves on - frostbite) Protect underlying structures from external injury and harmful substances Insulator & homestasis (temperature) Sensory (sensation on hot/cold, sharp) Vitamin D (absorbs vit d- helps with absorbing calcium)

the skin

= > 1-2 cm, elevated, palpable, solid, do not always have sharp borders

tumor Tumor - wont have circumscribed borders Primary Lesions

Diabetes Mellitus & The Pancreas

type 1: pancreas not making enough insulin type 2: receptors not accepting insulin

u46 year-old male uReferred to PT for trochanteric bursitis (Greater Trochanter Pain Syndrome) by an orthopedic physician uTop five hypotheses? uHow would you plan to screen?

u1. Muscle/tendon: greater trochanter pain syndrome u2. Bone: stress fracture u3. Ligament/Capsule: hip mobility deficit? Capsulitis? u4. Nerve/Referred pain: Lumbar Radiculopathy? u5. Other System: History of Prostate Cancer? Other GI, history of infections, inflammatory conditions, etc.? screening uPatient Interview: long-distance runner developed sudden onset of right hip pain. uChart Review: reports no imaging, no recent lab work uSystems Review: (Patient Intake Form) history of prostate cancer 2 years ago which was treated with radiation and has been in remission for 1.5 years; indicated pain around the lateral right hip and thigh; no medications Red flag: cancer uHeel Strike Test? (is positive for this patient)--When you strike femur you should hear it - If it is cracked you wouldn't be able to hear it -no pain with palpation (greater trochanteric pain syndrome) Screening Results Red Flags: Past history of prostate cancer at 44 years Positive heel strike test (pain reproduction) Non-capsular pattern of the hip Symptoms inconsistent with referred diagnosis Recommendation: TRIAGE: contacted physician, communicated findings, recommended imaging

uPeople with Cushing's syndrome are producing ____ cortisol, leading to hypertension, cardiac hypertrophy, obesity, and poor wound healing uA) too much (hyper) uB) too little (hypo)

uA) too much (hyper)

uA patient with known T2DM presents to their follow-up PT appointment with the following symptoms: irritability, sweating, confusion, and headache. They do not have their blood glucose monitor. My next best step would be to: uA) recommend insulin or medication to lower blood glucose level uB) recommend a fast acting glucose, like juice uC) call an ambulance uD) send them home to test blood glucose and manage before returning

uB) recommend a fast acting glucose, like juice These are signs of hypoglycemia -never recommend insulin unless you know they are hyperglycemia - could kill them if hypoglycemia B) recommend a fast acting glucose, like juice

Impairments Associated with DM

uDiabetic Neuropathies uDupuytren's Contracture uShoulder Adhesive Capsulitis uAberrant integument status or wound healing issues uDecreased tissue perfusion uAutonomic dysfunction uDiabetic stiff-hand syndrome uTrigger finger uInfection uCharcot Joints uLoss of Sensation

Fractures: Major Trauma

uEmergency Room PT uUrgent Care Clinic Associated PTs uSport Team uOutpatient uAcute Care uSNF uANY SETTING uSo... how do we know that someone needs imaging? Established Clinical Guidelines for Radiography ottowa

1. Greater Trochanteric Pain Syndrome

uHallmarked by marked tenderness to deep palpation of the greater trochanter and relief of pain after peri-trochanteric injection uPatient reports he has not had an injection uPalpation by PT: no tenderness to palpation

Organ Damage Directly Associated with Endothelial Dysfunction

uHeart Disease/Attack Reduced Muscle Strength uStroke Skin Problems uHTN Cell Death uRetinopathy Amputations uKidney Disease Death uNeuropathy Peripheral Vascular Disease

Early Symptoms of DM

uIncreased thirst uFrequent urination uNocturnal urination uIncreased appetite uBlurred vision Numb or tingling hands or feet (neuropathy) Perceptions of feeling chronically exhausted Dry Skin Fatigue Slow healing wounds Frequent urination (getting up 3-4 times at night to pee)

upper quater pain - Patient Interview

uLocation uOther signs and symptoms uRule out: cervical spine, upper extremity uFrequency uTriggers (activity, positioning, stress) uObtain past medical history uTrauma - car accident, assault (acute, chronic) uHistory of cancer uPrevious treatment that has/not worked uIs the pain mechanical or non-mechanical uIs mechanical pain truly mechanical in nature?

Fractures

uMajor Trauma - obvious uMinor Trauma in those with bone density compromise uRepetitive / Stress Reaction

Upper Extremity Referred Pain

uMay Mimic Cardiac Pain uTreat or Triage... uRed Flags: Bilateral shoulder pain, shoulder pain induced by CV activity

Fractures: Repetitive Overuse/Bone Stress

uMen & Women in military, Athletes, Dancers uBony microtrauma or Fatigue-failure injuries uStress Reactions can progress to Stress Fracture to catastrophic fracture uRisk Factors: 1) involvement in high-volume repetitive physical activities with little rest, 2) sudden change in training regimen, 3) poor muscle strength and endurance, 4) white and Asian women at greater risk than African American women, 5) hypoestrogenic states in women, delayed menarche, amenorrhea, and oligomenorrhea uLocal palpatory pain may or may not be present (depends on depth of bone)

MSK trauma

uPTs are primary care providers uFractures uMajor Trauma uMinor Trauma uRepetitive Overuse uScreening Tools uHead Injuries

Non-mechanical pain

uPain that cannot be produced, changed, or reduced during your mechanical examination uPain that has an origin outside our scope of practice uCan't be recognized purely by a movement exam uCook et al., 2012 study: u1100+ patients, 66 were later found to have metastatic spine cancer uAROM uNo abnormal findings uWe must correlate the findings of the movement exam with their history and symptoms

Patient Interview - lower quarter pain

uScreening uLocation of lower extremity pain uOther signs and symptoms uRule out back, pelvis, hip knee, ankle uFrequency uTriggers (activity, positioning, stress) uObtain past medical history uTrauma - car accident, assault (acute, chronic) uPrevious treatment that has/not worked uIs the pain mechanical or non-mechanical uIs mechanical pain truly mechanical in nature? Rash leg - sign of systemic or integumentary or infection

Trauma: Head Injuries

uWas the onset of the HA associated with a traumatic event? uGlasgow Coma Scale (GCS) can be used to assess the severity of a TBI - assesses consciousness using eye, verbal, and motor responses uRed Flags (Category I): double vision, severe or worsening HA, seizure or convulsion, loss of consciousness, deteriorating consciousness, vomiting, agitation, and/or combativeness uPrimary Mechanisms by age: u0-4: falls u5-14: struck by/against object, falls u15-44: assaults, falls, MVA u45+: falls

Oncologic causes (of back pain)

uWeakness without pain or joint ROM limitation uSciatica uNon-mechanical pain uProgressive neurological deficits uSensory changes in myotome/dermatome pattern uDecreased motor function uRadiculopathy (rapid onset) uMyelopathy or Cauda Equina Syndrome uHeadache/cervical spine pain with urinary incontinence uPositive tapping test (percussion) over SP's Good to take baseline myotomes dermatomes to compare later

Secondary Lesions = skin loss extending past epidermis, necrotic tissue loss, stasis ulcer, pressure ulcer

ulcer Ulcer - wound management in PT is within our practice - pressure ulcer - bed bound not able to reposition themselves every couple of hours- heel is common area or sacrum where pressure is

= < 0.5 cm, circumscribed, elevated, palpable mass containing serous fluid - herpes simplex/zoster, chicken pox, poison ivy

vesicle Vesicle - serous fluid in it like blister - chicken pox, poison ivy Herpes zoster like shingles. Cold sores Primary Lesions

= elevated mass with transient borders, often irregular, size and color varies, caused by movement of serous fluid into the dermis not free fluid in a cavity = hives, insect bites

wheal Wheal - larger elevated mass- irregular shape - color varies -hives and insect bites Primary Lesions

Skin Lesions

with DM Changes in Small Blood Vessels Diabetic Ulcers: -DM effect on immune system -Circulation -Commonly effect lower extremities Skin looks darker at feet and has spots Also darkness could be only in the shin

Neuropathy

with DM Peripheral: uWeakness uNumbness uPain uHands & Feet Autonomic: uBlood pressure uHeart rate uSweating uBowel/Bladder function uDigestion Can be peripheral or autonomic

Charcot Joints

with DM Progressive degeneration of weight bearing joints and damage to the skin around them due to loss of pain sensation (common in tabes dorsalis) Neuropathic Arthropathy Progressive degeneration: uBony destruction uBone resorption uDeformity Arches collapse - extreame end result Tone of pressure on medial arch - can lead to wounds

Adhesive Capsulitis

with DM frozen shoulder Related with diabetes Diabetes, over 55, female, menopause Once you have adhesive capsulitis once - can get it again - teach them early signs and to recognize it early

Dupuytren's Contracture

with DM uAbnormal thickening of tissues in the palm of the hand over years uThese tissues thicken into a hard lump/knots of aberrant tissue uOver time the finger(s) curl in toward the palm uTreatment: Surgery, Steroid shot, radiation therapy, enzyme injections, needle aponeurotomy, splints Surgery is really affective Will go to hand therapist Nodule in palm of hand

Family history Failure of conservative treatment No mechanism of action Proximal muscle weakness

yellow flag for cancer (low back pain)

jaundice

yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood

3D CT

•3-dimensional CT •Volume of information acquired •Reconstructed with desired threshold •Ability to pitch and rotate reconstructed image •"fly through" capability More costly than normal CT

Window Width and Window Level with CT

•Adjusting the window width and window level will change the way an image is viewed on the monitor •Wider window widths encompass greater anatomic diversity (i.e. bigger difference between densest object and least dense object), so subtle density discrimination is lost Same slices but with different filters First one on bone Second one is lung window

Contrast Resolution with CT

•Also called low-contrast detectability, or system sensitivity •CT is superior to all other modalities in its contrast resolution •In diagnostic radiography, the object must have at least 5% difference in contrast from its background to be discernable; On CT, objects with 0.5% contrast variation can be distinguished least 5% difference in contrast CT is 0.5% difference for us to be able to detect it Could be same structure but different thickeness of it CT is better than X ray for subtle soft tissue differences

Evolution of Terminology, and Generations of CT

•CAT: Computerized Axial Tomography •CTAT: Computerized Transverse Axial Tomography •CT: Computerized Tomography 5 generations of CT -have dropped the "axial"

Computed Tomography (CT)

•CT uses X-rays and computers to generate cross-sectional and/or 3-dimensional images of the body for use in diagnostic analysis •Greek: tomos (means slice or section) •Uses multiple electronic radiation detectors •X-ray beam encircles the patient •Requires a considerable amount of computer technology to assist in image creation Can get 3d info

-An important component of clinical reasoning as well -Subjective reflection of how a patient encounter went, as well as what changes you may make if you could do it over -An evidence-based form of adult learning

•Clinical Reflection

Final Takeaways for imaging

•Consider the patient condition, and the possible anatomy that may be involved/impacted •X-ray is economical and highest availability; bony anatomy well seen; not as specific if pathology is only soft-tissue-related •CT/MRI have better contrast resolution; price is higher and availability may be less •X-ray and CT utilize ionizing radiation, but visualize bony anatomy better •MRI does not use ionizing radiation, and visualizes soft tissue best •May be limitations with patient's ability to comply for imaging study •May be limitations with scan-ability based on artifacts/devices (even if not near AOI)

Image Reconstruction from Projections

•Conventional radiography •Image is reconstructed as viewed from one aspect •AP projection; AP image •Lateral projection; lateral image •Requires at least 2 views to get a "3D" perspective, since image is 2D in nature •Computed tomography •Image is reconstruction of an object as viewed from multiple perspectives, circumnavigating the object •Loaf of raisin bread concept Only shoot in one direction

-A necessary component of clinical reasoning -Objective analysis and evaluation of an issue in order to form a judgement

•Critical Thinking

•Middle aged woman •Low-speed car crash •neck pain and stiffness • •Diagnostic X-ray? MRI? CT?

•Diagnostic X-ray •Calcified fragment in right peri-odontoid tip area •CT •Nodular calcification between odontoid tip and right occipital condyle

•Middle aged adult male •Two month history of lumbar back pain with diffuse left lower limb radiation •Associated with subjective weakness and diffuse paresthesia of the left lower limb •No bowel or bladder disturbance •No focal neurological deficits • •Diagnostic X-ray? MRI? CT?

•Diagnostic X-ray •Semi-calcified thoracic disc herniation •CT •Large protrusion at T6-T7 •Mixed density calcification within disc, as well as disc protrusion close to vertebral body •Also less calcified protrusion into spinal canal posteriorly •MRI •The disc extrusion caused spinal canal stenosis with compression of spinal cord

X-ray Beam Attenuation

•Differential attenuation (absorption) •Quality versus quantity •kVp •mAs •Absorbed dose Less dense - it passes through

Contrast Media - Fluoroscopy

•Enhances soft tissue or spaces, utilizing high-density contrast media •Injection versus Ingestion (barium) Injection or ingest

•Noncancerous lumps include:

•Fibroadenomas •Lipomas •Benign Breast Disease •Mastitis = breast infection

CT Machine Components

•Gantry (donut) •Patient couch •Computer •Control console Some can go 3 revolutions per second

Red Flags - Headache of Systemic Origin

•If any are present - TRIAGE •Wakes person up at night •HA with High Blood Pressure •HA of insidious onset or new onset of HA or migraine •HA with other neuro s/s (numbess, confusion) •HA w/ constitutional symptoms (feeling sick) •Blacking out during HA We need to refer these Take their blood pressure

CT Images

•Image is determined by the amount of attenuation of the X-ray beam •Tissues with higher atomic number or higher density will appear white/light •Tissues with lower atomic number or lower density will appear darker •Contrast media can be used to enhance specific anatomy, just like diagnostic x-ray More attenuation in dense structures

Patient Safety with MRI

•Infection control •Hazards •Internal items •Intracranial aneurysm clips •Auditory implants •Pacemakers or other cardiac devices, etc. •Burns •Contrast media: GBCAs and NSF multipage screening so that they don't have anything on or in their body Basically the same thing as a microwave- can get hot

X-ray

•Ionizing radiation •Penetrates tissues •Differential absorption (due to densities or thickness) •Remnant detection •Tissue density determines appearance •Dense tissue = white on image •Less dense = black/darker Dense tissue - looks white

Magnetic Resonance Imaging (MRI)

•MRI uses strong magnets and radio wave frequencies to stimulate the atoms within the body to produce radio wave signals, which are then gathered/used to reconstruct an image •NMR / MRI / MR or MR Imaging Is noisy -nuclear too but had a bad connotation

MRI System Components

•Magnet •Receiver coils •Computer •Display

What Makes MRI Work

•Magnetic field •Earth field strength: ~0.5 Gauss (where 1T = 10,000 G) •0.00005 T •MRI field strength: 0.5 Tesla to 3.0 Tesla •Magnetic susceptibility of nuclei •8 elements suitable; hydrogen is primary •Allows for visualization of water and fat •Radiofrequency •Transmitter (gradient coils) •Antenna coil/receiver (RF coils) Lots of times water concentrations

Cauda Equina Syndrome

•Neurological deficit •Constellation of symptoms resulting from damage to the cauda equina - Lumbar and sacral spinal nerves uRapid symptoms (onset within 24 hours) (89% sens) uHistory of back pain (94% sensitivity) uUrinary retention (90% sens) (cant get urine out) uLoss of sphincter tone (80% sens) (will get fecal incontinence) uSacral sensation loss (saddle anesthesia) (85% sens) uSphincter disturbance (reduced tone) uFecal incontinence uGait disturbances uCategory I Red Flag (immediate medical attention) (saddle anesthesia) - numb in groin and the area that would be in the saddle

Equipment Hazards with MRI

•Non-MRI safe equipment If you work in MRI zone - make sure you know what is going on - need to be screened appropriately

Breast Cancer-Yellow Flag

•Noncancerous lumps CANNOT be distinguished from breast cancer on physical exam! •Noncancerous lumps include: •Fibroadenomas •Lipomas •Benign Breast Disease •Mastitis = breast infection •The Good News: ~ 8 out of 10 lumps found on palpation are benign -do mammographs, self exams Lumps in breast lots of time are not cancerous The lump needs to be screened if find it -men can get breast cancer too

Cardiovascular Causes of neck & back pain

•Pain pattern: - Rapid onset - Severe - Radiating to chest - Non-mechanical MI, AAA, Angina Pain in the upper and midthoracic spine, radiating symptoms down left shoulder/arm, TMJ/Jaw, neck Differentiate from: muscle strain, DDD, stenosis, rib syndromes, TOS, trigger points, psychogenic, scoliosis, Scheuermann's disease, scapular dyskinesias, cervical radiculopathy Acute chest pain with dyspnea - Immediate medical attention (e.g. PE, MI, AAA) Sudden change in typical angina pain - unstable angina - immediate medical attention Angina - chest pain, nitroglycerin is medicine - stable and unstable - we can treat with stable - if symptoms present have them take more medicine and wait a few min

Reasons to Order Fluoroscopy

•Physiology over anatomy (when compared to Dx radiographs) •Systems: •GI and urinary systems, primarily •Spinal cord/column (less utilization now with other advanced modalities) Bottom of esophasgus with scarring due to reflux

Fluoroscopy

•Provides dynamic imaging, displayed in real time •Purpose is not only to study anatomical structures, but also function through movement of contrast media in vessels and/or organs •Image intensifier (II) or flat-panel digital (FPD) detector, coupled to video camera •Converts image from output screen of II or FPD to video signal Basically a movie Dynamic imaging •Can acquire cine images and static/spot images too

Hounsfield Units

•Quantify the degree of beam attenuation •Also referred to as CT numbers, or density values HUs Tissues and their atomic densities Fat is darker than water and air is the darkest

Relaxation and Receiving MRI Signal

•RF applied in short pulses •Flips the direction of the nuclei •Puts nuclei in a particular phase •Following shutoff of the RF pulse •Relaxation of nuclei, from "out of phase" back to "in phase" •Emission of energy in the form of a resonating signal, which produces electric signal in receiver coil Magic All of the electrons align

•Young adult with 3-mo history of right thigh pain after running a marathon •Seasoned amateur long-distance runner •Physical exam revealed free ROM of both hips and knee joints •Non-specific pain in the right thigh could be provoked by forced passive ROM testing of hip •No localized tenderness or swelling were evident •L spine and SI joints were clinically normal • •Diagnostic X-ray? MRI? CT?

•Radiographs first, and were unremarkable •MRI follow-up •Bone marrow edema •MRI #2, 6 weeks later •Edema continued •MRI #3, 8 weeks later •Edema continued •CT 3-months post-presentation •Transverse and coronal planes reveal stress fracture with callus formation in diaphysis

Measurement of Signal for MRI

•Receiver coils •Specific coils for different parts of body

Systemic Clinical Reasoning in Physical Therapy (Baker et al., 2017) SCRIPT

•SCRIPT utilizes a method of pro-active planning that makes explicit the connections between thinking and future actions. •Suggests listing all structures that could be possible sources of the patient's symptoms: -joints and bony structures -muscles, tendons, and soft tissue -structures that could refer to the area -other structures or conditions that must be considered or ruled out •visceral pathology, infections, space-occupying lesions, and systemic non-musculoskeletal pathology. Still 'outside resources of base knowledge" 5 things method Be proactive in your planning When very novice this is a great idea to use The first focus in the script method is on correct diagnosis. Then the priority focuses on choosing intervention strategies that the patient will tolerate and will work. What to do if they come back and are better or worse What will be tolerated and what are the patients goals

•50% of all Cancer risk factors are modifiable such as...

•Smoking •Alcohol use •Sunlight exposure •Poor diet and obesity

CT Comparison to Other Modalities

•Strengths •Acquires images in only 1 plane, but can reconstruct/reformat others •Best modality for evaluation of loose bodies in a joint •Best for identifying subtle fractures and/or complex fractures •Best for evaluation of degenerative changes such as spinal arthritic changes •Weaknesses •Depending on type of machine, and on protocol, the exposure/dose can be much higher than diagnostic radiographs •Cost is more compared to diagnostic or fluoroscopic exams •

X-ray Comparison to Other Modalities

•Strengths •Cheap •Fast •Readily available •Weaknesses •Soft-tissue visualization limitations •Superimposition of structures Need to look at it form 2 different views to make sense

Fluoroscopy Comparison to Other Modalities

•Strengths •Dynamic/function capabilities (over and above anatomic structure visualization) •Widely available •Weaknesses •Patient preparation requirements •Higher radiation exposure than diagnostic radiography; cost is generally more than diagnostic radiography as well Sometimes need to stop meds for a little bit to do this and you have to prepare the patient for it Higher radiation

MRI Comparison to Other Modalities

•Strengths •Non-ionizing (uses magnetic frequencies) •Multiplanar (like CT) •Very sensitive for detecting changes and variation in bone marrow •Excels in the display of soft-tissue detail •MRI is replacing invasive diagnostic procedures such as arthroscopy •Best modality for differential diagnosis of disc herniations and/or nerve root impingements •Can stage neoplasms in bone and soft tissue •Weaknesses •Often higher cost than CT or radiographs •Bone resolution is not ideal •Exams take longer Costs $2500-3000 Takes 45 min

Reasons to Order CT

•Systems: •Skeletal system and bony anatomy, where X-ray is too limited •Subtle/complex fx; bone proximity to other bone •Soft tissues where overlap may impede diagnosis •GI system with barium-based contrast •Vascular items (and anything fed by vasculature, such as tumors)

Reasons to Order an MRI

•Systems: •Soft tissue visualization, similar to CT (over Dx X-ray) •Joint spaces and complex layering of muscles and surrounding soft tissues •May provide physiologic information, in addition to anatomic •Although it can visualize bone, it excels at the joint and soft tissue visualization

Pulse Sequences for MRI

•T1: measurement of longitudinal relaxation •Typically identifies/visualizes normal anatomy - fat is bright, water is dark •T2: measurement of nuclei as they become out of phase •Typically identifies pathology - water is bright(edema) •Spin density: measurement of quantity of H nuclei in the area which were influence by RF pulse (fluid, cartilage and fibrocartilage) •FLAIR: pulse sequence used to suppress liquid signals •STIR: pulse sequence used to suppress fat signals The noises you hear change depends on this T1 - fat is bright, water is dark T2 - water is bright

Causes of Type 1 DM

•The pathophysiological causes of T1DM have yet to be fully discerned •The causes of T1DM have been identified primarily through correlative studies and not yet through a thorough understanding of pancreatic dysfunction Pancreas isn't producing insulin as it should

Causes of Type 2 DM

•This chronic condition results in excessive glucose circulating in the bloodstream •In T2DM, there are primarily two inter-related problems at work. •1. the pancreas does not produce enough insulin •2. cells respond poorly to insulin and facilitate movement across the cell wall Modifiable risk factors for type 2

Spine Pain: Treat or Triage?

•Triage •Red Flags •Systemic Origin •Cauda Equina •Cancer Rule (the 4) •Treat •Mechanical Pain •MSK Origin

treat vs triage with headache

•Triage •Red Flags •Unexplainable onset/cause •Treat •Mechanical Headaches •Associated with Neck Pain

X-Ray Image

•Two-dimensional representation of tissue density •Bones and higher density tissues are seen best •4 general densities seen •Gas • Fat •Water •Bone / mineral / calcification

Multiplanar Reconstructions - CT

•Volume of information used to display the anatomy in any standard or oblique plane •Information normally obtained in axial plane

•Young adult male; injury during soccer game •Foot planted, he was side-tackled, and foot was forced to twist •Sat out remainder of game •Minor soft tissue swelling •Visited emergency room afterwards • •Diagnostic X-ray? MRI? CT?

•X-ray •5th metatarsal fx •Surgical intervention •Lag screw* •Cast •PT

Image Usefulness Concepts

•X-ray •Most economical; quickest •Bony anatomy injuries •CT •Bony anatomy •Artifacts can impede image quality, but maybe less so than MRI image quality •Higher contrast resolution than X-ray •MRI •Similar high contrast resolution, but soft tissue involvement best visualized •May be highest cost; may be limited availability •Patient contraindications (and/or artifacts and image quality) •e.g. Joint space near prosthesis

PT & Diabetes Management

●Blood Glucose Testing (patients in outpatient should always bring their own) ●Fast-acting glucose source (glucose tablets, glucose gels, non-diet soda, fruit juice) ●Long-acting glucose source (graham crackers, etc.) ●Know how to recognize hypoglycemia - if unsure, administer fruit juice or honey (won't harm hyperglycemic patient, but may save hypoglycemic patient)

Overview of Diabetes

●Diabetes Mellitus is a chronic heterogenous metabolic/autoimmune disorder with complex pathogenesis ●Hyperglycemia serves as the primary biomarker for the diagnosis of diabetes ●Hyperglycemia results from abnormalities in insulin secretion, insulin action, or both ●Long-term hyperglycemia often leads to various microvascular and macrovascular diabetic complications directly related to the hyperglycemia effects on vascular endothelial cells ○These complications are responsible for diabetes-associated morbidity and mortality Prediabetes people probably don't know they have it

Osteoporosis & Exercise

●Exercise + Diet and Pharmacology ●Delay osteoporosis ●Manage pain ●Weight-bearing, resistive, aerobic ●Strength, balance, reduce risk of falls/fractures ●Wait 30 minutes after ingestion of biophosphonates before exercising CPG Recommendations: ●Smoking Cessation ●Limit Alcohol Intake ●Weight-bearing and light resistance exercise ●Pharmacology ●Diet Adequate calcium intake, consider bioavailability of supplements, should combine with D These patients may have early discomfort with exercise and need extra encouragement Reduce risk of falls

Supplies and Technology for diabetes

●Glucometer, Lancets, and Test Strips ●Insulin - Oral v Subcutaneous, short acting and long acting ●Insulin Delivery - Syringes, Pump ●Continuous Glucomes Monitoring System ●Insulin Pump Closed loop system with CGM (implanted device) Diabetes supplies Metformin is for diabetes

Insulin Costs

●People who require insulin will use 2-10 units per dose, 3-10 times per day (1 unit for every 10 grams of carbs, or 1 unit to drop your blood sugar 30-50 mg/dL) ●As of 3/22/23 ●1 unit of Humilin N Kwikpen (commonly used, lower cost product) = $0.39/unit ○Up to $1170/month!!! ●Insulin Rationing (where people will wait a little longer and use a little less- will lead to more complications)

What is an outcome measure?

"A set of items that are used to create scores that are "intended to quantify a patient's performance or health status based on standardized evaluation protocols or close ended questions."

history of skin Questions are usually prompted by observation of something atypical (a mole, skin color changes, rashes, etc.)

"Are you experiencing any current skin problems?" such as rashes, dryness, oiliness, drainage, bruising, swelling, or color changes? See an unusual looking mole? Ask: "Has this mole changed size or begun bleeding?" -have to be SPECIFIC with questions -Always ask about moles because of concern about cancer - in terms of differential relatively uncommon but serious consequence of missed dx -How long have you had the mole

___________ is the term introduced by Alvan R. Feinstein in the early 1980s to indicate a domain concerned with indexes, rating scales and other expressions that are used to describe or measure symptoms, physical signs and other clinical phenomena. _____________ has a set of rules that govern the structure of indexes, the choice of component variables, the evaluation of consistency, validity and responsiveness."

"Clinimetrics'

Clinimetrics

"Clinimetrics' is the term introduced by Alvan R. Feinstein in the early 1980s to indicate a domain concerned with indexes, rating scales and other expressions that are used to describe or measure symptoms, physical signs and other clinical phenomena. Clinimetrics has a set of rules that govern the structure of indexes, the choice of component variables, the evaluation of consistency, validity and responsiveness."

What does the literature say about red and yellow flags for cancer with low back pain.

"While a positive response to a red flag question may indicate the presence of serious disease, a negative response to 1 or 2 red flag questions does not meaningfully decrease the likelihood of a red flag diagnosis. Clinicians should use caution when utilizing red flag questions as screening tools." 64% of patients with spinal malignancy had no associated red flags prior to diagnosis. Cluster signs and symptoms helps you to determine if you should continue to treat or refer. You can refer after a few sessions. Don't get stuck, you are ALWAYS using Differential Diagnosis skills. Screening isn't perfect Look at a cluster of things History of cancer and other signs History of cancer with no other signs less likely History of cancer with yellow flag is possibly time to refer Refer when things don't add up

Non-pitting or Brawny edema

"woody" - cannot be easily indented by compression Woody edema - looks big and swollen and no indentation occurs - skin is very hard

CPG: When managing patients with headaches associated with neck pain, clinicians should...

(a) rule out major structural or other pathologies, or migraine (b) classify headaches associated with neck pain as tension‐type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c-h): interventions and plan of care (i) reassess the patient at each visit to assess outcomes and determine whether a referral is indicated PTs don't treat migraines Reassess at each visit

Second cancers

(new cancer unrelated to the first) are not uncommon. About 1 in every 6 people diagnosed with cancer has had a different type of cancer in the past. •Time to secondary cancer after Radiation treatment : •2-5 years for leukemia •3-10 for solid tumors

The Canadian C-Spine Rules

*Age >65 *Trauma mechanism *Cannot assume sitting or standing position *Unwilling to move neck more than 45 degrees either direction *Mid-line neck tenderness *Needs support for neck (usually with hands) Need to know this Dangerous mechanism Cant rotate neck 45 degrees The Canadian C-Spine Rules 100% sensitivity, 43% specificity for identifying important cervical spine injuries

- skin darkening 1st palmar creases, soles, scars, mouth, gums (skin is darker especially in creases)

- Addison's disease (adrenal destruction)

type 1 vs type 2 diabetes

- Type 1: insulin dependent, 5-10% of cases; autoimmune, genetic, environ. factors - Type 2: non-insulin dependent, 90-95% of cases; older age, obesity, family hx, prior hx of gestational diabetes, impaired glucose tol., phys. inactivity, race/ethnicity

hemosiderosis, hemochromatosis

- iron overload - skin turns slate gray

The Process of Clinical Reasoning •Theoretical Components of CR:

-1. Base Knowledge Fact that you have learned stuff in school, anatomy, neuro, lower ortho, upper ortho, you've been told things, now apply info and assess again -2. Analyzing and Reanalyzing -Reflecting in "Real Time" -Reflection is a part of a process of self-monitoring called Meta-Cognition Or thinking about your thinking -3. Rationalizing or justifying -You may be rationalizing to yourself, to your patient, to their referring physician, to the insurance company, or all of the above Take all info, do all special tests and now you have the pt diagnosis explaining what you found and what you are going to do about it -4. Combining Knowledge -Putting it all together -- Patient, interview, exam and your experience and putting all the knowledge together and how to diagnosis the person and how to help them -5. Problem solving and pattern building -This, is a really important step in the process. Because solving the problem, and seeing the pattern that happened with a particular patient is now going to be filed away and you will have that now in your base knowledge. Next time you see it, you'll recognize it sooner, do fewer tests and measures, and select interventions that were well-received by previous patients.

•Clinical Reasoning

-A thinking and decision-making process used by practitioners (PT, OT, physicians - anyone taking info form patient and making a decision) -Uses objective and subjective knowledge

Alcohol use -Moderate Alcohol Consumption= -Heavy = -Binge =

-Moderate Alcohol Consumption= 1 drink daily for women; 2 for men (red wine reduce the risk of cancer) -Heavy = 4+ in a day or 8 per week women/ 5+ in a day or 15 per week men, increased cancer risk -Binge = 4+ in 2 hour period women/ 5+ men Back to modifiable risk factors for cancer Moderate alcohol is not concerning Heavy and binge drinking increase chances for cancer

Lymphedema

-Swelling that generally occurs in one of your arms or legs, sometimes occurs bilaterally -Most common after removal or damage to lymph nodes (post cancer treatment) -Presents with restricted ROM, aching, recurring infections, hardening and thickening of skin -Certified Lymphedema Specialists (PT or OTs) have additional training in compression and lymphedema management Caused by lymphatic system (damage or it was removed) Fluid builds up in limbs - limits ability to move and is painful - skin begins to breakdown - infections and hardening

A physical therapist examines an ice hockey player with mid-back pain that occurred 2 weeks ago for no apparent reason. To hypothesize regarding potential benefit from PT, the therapist should conduct a screening, which consists of

-gather info from diagnostic imaging and clinical labs -systems review -patient history

Clustering of tests

-make sure to do test clusters -use multiple tests -gives us more confidence

history and physical --for skin

-most skin disorders are diagnosed by appearance and history -special techniques used to confirm dx e.g. biopsies, scrapings, cultures Consider Age + Skin - changes throughout the lifespan: baby skin is different than adolescent, which is different than adult and of the older adult At dermatologist- they look you over your entire body -look at it and ask questions about it Baby skin is softer and hasn't been exposed to environment Older adult - skin is thinner and fragile

The Skin- Structure name 3 layers

1. Epidermis -Protection, immune response (hives if touch something you are allergic to) -Sweat, excretion, hair ,etc 2. Dermis -Collagen, histamine response, inflammation 3. Subcutaneous -fat

I think my patient needs a radiograph... now what?

1. implementation of protective mechanisms: splinting, change weight-bearing status and provide appropriate gait device, neck brace 2. Transport to radiology Stabilize, implement protective mechanisms

•Patient is a 45 year old male presenting to PT outpatient clinic with complaint of acute left shoulder pain.

1.Base knowledge -possible causes that could cause acute shoulder pain Broke humerus/clavicle -impingement -labral tear -neural issues -rotator cuff -ligament -cardiovascualr 1.Do you have any pre-existing medical conditions, like cancer, diabetes, or heart issues? 2. Do you take any medications regularly? 3.When did the shoulder pain start? 4. Was there an injury? 5. Aggravating or alleviating factors? 6. How would you rate and describe your pain? 7. Does it radiate anywhere? 2.Acute left shoulder pain - you should screen for cardiovascular system Benign medical history -nothing much - nothing concerning •Acute history of left shoulder pain, he was at work when the shoulder pain began. •Since that time it mostly only bothers him when he's exercising or doing repetitive movements at work. •Denies radiating pain, numbness/tingling Bothers him when exercising -probably cardiac 2.Analyzing and Reanalyzing Did that information help you narrow down your initial list of hypotheses? Did it raise new questions? Has it changed your top hypothesis? 3. Rationalizing or justifying This is your Justification (step 3!) for taking vitals! What if his BP is 190/85? 150/95? 130/75? What would you recommend to them? Why? •Don't worry, his blood pressure was 123/72. •You have justified your reasoning for continuing the exam. •So, what's next? •What does your list of Working Hypotheses look like? •Rank them from most to least likely. Could be impingement - repetitive pain overhead He does crossfit We think it's rotator cuff impingement. But we want to include special testing that could disprove that. We did not ONLY include tests for impingement, but 1-2 that rule out other possible hypotheses - shoulder instability (apprehension testing), and subscapularis injury (its part of the rotator cuff); previously we cleared the C-spine as well. 4. Combining knowledge Do you have enough information to make a decision? A diagnosis? What's the justification of your diagnosis? 5. Problem solving or pattern building Remember to reflect after this experience! Go back and ask yourself those questions. What went well? What could have gone better? All of this info will help to pattern build and add to bank

LE: Systems Review

1.Cardiac Heart disease 2.Pulmonary Vascular disease 3.Gastrointestinal Crohn's Disease (joint pain at times, knee pain) 4.Renal/Urologic UTIs Kidney stones 5.Gynecologic Pelvic Inflammatory Disease 6.Male reproductive Testicular Prostate 7.Neurologic Referred pain from the spine Reflex Sympathetic Dystrophy (RSD)

Neurologic or Vascular Causes of LE

1.Vascular claudication (blood flow) 2.Neurogenic claudication (stenosis) 3.Peripheral Neuropathy Motor Sensory Mixed (motor and sensory) Well's CPR for DVT in LE: Low Probability = 0 or < Intermediate = 1-2 High = 3 +

Consider the scenario Setting: outpatient physical therapy Referral/Dx: Eval & Treat for post op knee replacement Med Hx: hypertension, insulin-dependent diabetes mellitus Your patient making progress since the knee replacement and you decide to get them on the bike for aerobic exercise & ROM. Prior to beginning her session, you asked if they checked their blood glucose level today and it was 110 mg/dL about 30 minutes ago. Vitals on arrival were BP 136/70 and HR 84 bpm. After cycling for 10 minutes, they becomes diaphoretic(sweaty) and you notice they slow down significantly. You discontinue cycling and repeat testing shows her HR at 115 bpm, BP 149/78, and glucose 82 mg/dL. uWhat is the most appropriate next step?

110 à its okay (70-100 is normal) Blood pressure is elevated but not a red flag -could give them a snack -continue PT

American College of Sports Medicine and the CDC Guidelines-Exercise for Disease Prevention

150 min of moderate-intensity aerobic activity every week 2x per week - muscle strengthening activities on 2 or more days a week that work all major muscle groups Activity helps decrease risk of cancer -long-term activity for overall health is important 150 min per week Weight-lifting at least 2 times a week

As PTs, we have the opportunity to educate patients about modifiable risk factors of cancer. What % of risk factors for cancer are modifiable, and what are they?

50% smoking, sunlight, obesity, alcohol, diet

25% of all new CA(cancer) diagnosis occur in those over ____

66

What does the literature say about signs of cancer?

9,940 patients with LBP -159 (1.6%) had malignancy -58% of total sample (9,940) said "Pain awakens from sleep" -64% of patients with spinal malignancy (159) had NO associated red flags! -Specific (Sp) for malignancy: Unexplained weight loss (95.6% ), cancer history (95.6%), fever/chills/sweat (93.2%) 1.6% had cancer 64% had no red flags Think about clustering symptoms but you might miss it because cancer signs aren't always present

erythema

= redness (drew a line around the redness to see if size changes) caused by capillary dilation Blanches(turns white) with pressure then reforms

Paget's disease

A disease of unknown origin that is characterized by extensive breakdown of bone tissue followed by abnormal bone formation. Chronic Bone Disorder Excessive breakdown and regrowth of bone Deformities, Fractures, Pain More susceptible of fractures

Alignment for x ray

A of ABCs •General skeletal architecture •Size, number (too many; too little), congenital aspects; developmental deformities •General contour of bone •cortical outlines, discontinuity of cortices, bony trabeculations •Alignment of bones relative to adjacent bones •Fracture, dislocation, subluxation

Metabolic Syndrome

A syndrome marked by the presence of usually three or more of a group of factors (as high blood pressure, abdominal obesity, high triglyceride levels, low HDL levels, and high fasting levels of blood sugar) that are linked to increased risk of cardiovascular disease and Type 2 diabetes. Cluster of Conditions that increase risk of heart disease, stroke, and Diabetes. Hypertension, hyperglycemia, excess body fat around waist, and hypercholesterolemia Someone who is obese This combo of symptoms

When should you use an outcome measure? A.Pre-intervention B.During intervention C.Post intervention

A.Pre-intervention B.During intervention C.Post intervention all of them

What type of outcome measure is the DASH? A.Self-report measures B.Performance-based measures C.Observer-reported measures D.Clinician-reported measures

A.Self-report measures Disabilities of arm shoulder and hands Self report What is the tool and who does it?

Skin cancer screening ABCDE

A=Asymmetrical B=Border C=Color D=Diameter E=Evolution (growth) Some people have a skin check annually but not everyone does that If mole looks unusual - make patient aware of it If something doesn't look right - point it out to the patient Top row is normal, bottom row is abnormal

Reasons to order Diagnostic Radiographs

ABCs •A: alignment •B: bone density •C: cartilage spaces •S: soft tissues

outcome measures and ICF TUG, 6-minute walk, 30 second chair stand, Bayley

Activity

_____ is the most important risk factor of cancer.

Advancing age

When to consider Spine Cancer

Age >50 Previous history of cancer Failure to improve in 1 month of PT Constitutional Symptoms (fever, headache, unexplained weightloss, hyperhidrosis, fatigue, dyspnea, malaise) Need to have ALL FOUR before you should seriously consider Spine Cancer: If a patient is <50, no history of cancer, no unexplained weight loss, and has not failed conservative treatment, the sensitivity is 1.00 and the specificity is 0.6 40% chance of false positives, but virtually no false negatives TOO many positives, but can feel pretty confident about a negative. Insidious onset Night pain Need to have all 4 of these symptoms Virtually no false negatives This is extremely important to know

Red Flags - Back Pain of Systemic Origin

Age: < 20 years > 50 years History of Cancer Injection drug use Constitutional symptoms Recent UTI, blood in urine, or pain with urination Pain: Unremitting, Non-mechanical, >6weeks oProgressive neurologic deficit Cauda Equina Syndrome oHistory of falls oMorning stiffness oSkin rash

Why do people get Fatigue with cancer?

Anemia Inflammation (increase immune system activity) Immune system activity Altered muscle metabolism Neurotransmitter dysregulation (axons within nerve aren't sending signals correctly) Anemia - low red blood cells Most common cause is having anemia

Proximity of Viscera to Spine

Any dysfunction of musculature can alter relationship of the viscera Organ pathology (inflammation or infection) -> compression or tension on spinal structures

Fracture Screening Tools

Auscultation with bony percussion - not looking to provoke pain, looking to see if the sound transmits through the shaft of the bone. If there is a fracture, the sound/energy would not conduct. Can be used for the long bones. Tuning Fork for Pain Provocation - use if palpation did not provoke pain but you're still suspicious; sensitivity -0.75, specificity 0.67

Bone Density for x ray

B of ABCs •General bone density •Sufficient radiographic contrast between bone and soft tissue •Sufficient contrast within bone itself (cortical outlines to bony trabeculations) •Texture abnormalities •Bony trabeculations may be described as thin, delicate, coarsened, smudged, etc. •Local density changes •Sclerosis (healed fx, etc.)

What type of outcome measure is the Timed Up and Go? A.Self-report measures B.Performance-based measures C.Observer-reported measures D.Clinician-reported measures

B.Performance-based measures TUG test What is the test and who does it? The person has to get up and walk and it is timed, fixed distance

•Patient presents with symptoms -Therapist comes up with a working hypothesis -Selects special tests and data to be gathered in attempt to support this hypothesis -A great method for novice therapists -Con: is more time consuming potentially, if first one or two hypotheses prove to be incorrect

Backward Reasoning Patient comes with symptoms and you come up with a hypothesis -they come with shoulder problems - you make a hypothesis that they have impingement- what special tests should I do -great method for novice therapists - more time consuming Have to start over if hypothesis is incorrect

Examination - Nails beaus lines

Beau's lines occur after acute illness and eventually grow out (they were probably really sick and are doing better now - ask about health history

________ tumors remain in the site of origin and do not invade surrounding tissues. _________ tumors invades surrounding tissues and metastases.

Benign tumors remain in the site of origin and do not invade surrounding tissues. Malignant tumors invades surrounding tissues and metastases. Benign stays in origin Malignant - invades other layers of skin - other parts of body

outcome measures and ICF MMT, AROM, PROM, Reflex testing

Body structure and function

How to choose an outcome measure

Body structure and function MMT, AROM, PROM, Reflex testing Activity TUG, 6-minute walk, 30 second chair stand, Bayley Participation SF-36 Activity- ability to perform tasks Participation - person is telling you they cant do what they want to do but you aren't picking that up in your body structure and function tests SF-36 does a good job with participation

What ICF domain is MMT? What type of outcome measure is MMT? Body structure and self-report Body structure and performance based Activity and self-report Activity and performance based

Body structure and performance based

leading types of cancer

Breast, Prostate, Lung, Colorectal

Cartilage Spaces for x ray

C of ABCs •Joint space width •Normal space versus decreased joint space •Subchondral bone •Increased sclerosis versus erosions •Epiphyseal plates •Position, size, borders, uniformity

There are several possible complications of Gestational Diabetes. For the baby, this includes pre-term birth, excessive birth weight, obesity later in life, type 2 DM later in life, stillbirth, and ______ uA) skin problems uB) retinopathy uC) respiratory distress syndrome uD) peripheral vascular disease

C) respiratory distress syndrome If born early- their lungs might not be developed yet

CAUTION signs of cancer

C-Changes in bowel or bladder (low back) A-A lesion that does not heal (any region) U-Unusual bleeding or discharge (any region) T-Thickening or lump (neck) I-Indigestion or difficulty swallowing (neck) O-Obvious changes in moles/warts (any region) N-Nagging cough or Hoarseness (head/neck) CAUTION Potential for cancer Lesion - scab than isn't healing - older people this is harder to figure out- these would be more open and not healing

A patient presents in clinic for a right shoulder injury. You notice when they smile it droops on the left. You ask the patient to raise their eyebrows and only the right eyebrow raises. Which CN is most likely involved?

CN7

Calcific Tendonitis

Calcium Deposits Pressure, friction, chemical irritation Rotator Cuff commonly Insertion of rotator cuff Less responsive to typical treatment Ultrasound could help Want to break it down - friction, steroids from physician, rehab, take it slower it is irritable

Universal Cancer Sign

Cancer-Related Fatigue = "A distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning" Number 1 sign of cancer is fatigue Being tired and fatigue are different Fatigue - unrelenting , sleep all day but still be exhausted, sleeping 10-12 hours a day and still tired Her mom walks 10,000 a day and when it flairs up she is tired after 1,000 steps Extreme fatigue is related to cancer But be careful about people saying they are exhausted - if sleeping 12 hr days and still exhausted that is issue Only sleeping 6 hours and tired less concerning

Examination - Nails capillary refill

Capillary refill - press on nail until bed blanches(turns white), release and observe for color return pink should return in < 3 sec -capillary refill › 3 sec is consistent with hypoxia (someone with COPD, cystic fibrosis, emphysema - their refill is slower) -can be affected by room and body temperature, vasoconstriction from smoking or peripheral edema (if cold it will go slower) Just show them on yourself Squeeze until turns white and release looking for pink/red

Headaches of Systemic Origin

Cardiovascular--Migraine, Ischemia, stroke, CVT, HTN Pulmonary--Obstructive Sleep Apnea, anxiety Renal/Urologic--Kidney failure; renal insufficiency Gynecologic--Pregnancy; dysmenorrhea Neurologic--Post-seizure; brain abscess Other--Side effect of a drug or other condition; Cancer

1.Approach in a way to systematically rule in/out musculoskeletal pain versus systemic origin.

Careful assessment of all signs and symptoms combined should direct the physical therapy plan. 1.Non-mechanical pain should always be approached as systemic in origin. 2.When in doubt, refer out.

- pale yellow skin from carotene overload due to eating too many carrots or vitamin A - sclera not yellow

Carotenemia Carotenemia - really rare - too much vitamin A eating too much carrots - your sclera does not turn yellow - not common

A 77-year-old man was referred for physical therapy by his primary care physician (PCP) with diagnoses of lumbar spine and left hip osteoarthritis and possible trochanteric bursitis. Examination: -Family hx of CA (yellow) -50 year hx of smoking 2 packs a day (red flag) -Pain severity 10/10, using wheelchair for mobility due to pain (red flag) -Positive "sign of the buttock," and empty end feels of all hip joint motions -all motions empty and pain (red flag) -Noncapsular pattern of joint restriction of the hips (red flag) ----> at this point still treat

Case Continued visit 3 -Pt was seen by PT for 2 additional visits. -Pt continued to use a wheelchair due to pain. -Pain 10/10. -Pt reported not sleeping due to pain. See two more times Pain was not getting better Now is time to refer result The patient was diagnosed with primary lung adenocarcinoma with widespread metastases. A computerized tomography scan of the left hip revealed a metastatic lesion at the left proximal femur. Had primary lung cancer that metastasized to hip Better to refer and be wrong then not refer - just don't refer everyone back -document when you contact dr have conversations with the patient about your thoughts and the physician

_________ occur when a score exceeds a threshold to detect progress. For example, a patient's pre-rehab score may be in-range at the initial evaluation, but the patient's ability exceeds the measure's highest score over time. Therefore, it is unable to accurately assess progress as the patient improves.

Ceiling effects

This type of edema is the result of an infection that can spread and potentially be life threatening. If you suspect this is the case, this patient should be triaged/referred out for immediate care. celluitis brawny edema lymphedema

Cellulitis - is the answer - infection causes it - it can spread throughout body and potentially be life threatening - doesn't spread from person to person Brawny edema- don't get indentation, older people with congestive heart failure, chronic venous insuffientcy - build up of fluids in lower extremity normally - caused by circulation issue - veins get thick Lymphedema - caused by having damaged lymph system - lymph nodes removed or just failing on its own - waste is not getting out of their tissues and swells - NOT caused by infection

red flag Male over 50, with hx of smoking Nagging pain along medial border of scapula or above the collar bone Burning pain down the arm Difficulty swallowing Hoarseness that does not resolve Nodules in the lymph nodes of the neck Tender Soft/ Mobil / Rubbery Enlarged yellow flag Pain does not change with position

Cervical/Shoulder Region red and yellow flags for cancer

Challenges and Opportunities for our Patients with diabetes

Challenges ●No cap on insulin prices (except Medicare) ●Out of pocket costs for technology that provides the best control ●Insulin dependent diabetics have fewer options ●Inconvenience of frequent blood sugar checks Opportunities ●Noninsulin dependent DM - diet and exercise! ●Always having something at your facility to facilitate correcting hypoglycemia ○Glucose tablets - no expiration date!! ●Be aware of the signs and symptoms of low and high blood sugar and what the safest next steps are

Skin Lesions: Burns

Chemical or actual (heat) Skin layers are destroyed Partial to full thickness of skin susceptible to infection Pain and disfigurement Can be life threatening

- fixation on something early in the interview or chart review; fixation on first impressions, etc. (get stuck on #1 hypothesis first)

Clinical Reasoning Errors •Anchoring bias

ageism, stereotyping

Clinical Reasoning Errors •Ascertainment bias -

only looking at the special tests that were positive that confirmed your diagnosis and ignoring special tests that disprove your hypothesis

Clinical Reasoning Errors •Confirmation bias -

tendency to end the decision making process before it was fully verified, did not consider alternatives (didn't think of everything)

Clinical Reasoning Errors •Premature closure -

inclination to hold back from making a rare diagnosis due to lack of confidence, despite supporting evidence; reluctance to try a rare intervention for the same reason

Clinical Reasoning Errors •Zebra retreat -

Clinician reported measures

Clinician-reported measures are measurements that are completed by a health care professional. Professional uses clinical judgement and reports on patient behaviors or signs that are observed by the professional. UPDRS Unified Parkinson's Disease Rating Scale PT, OT, physician The clinician fills it out Professional fills it out exclusively

Risks: Overweight, sedentary, diet with red/processed meat, smoking, immunodeficiency disease, inflammatory bowel disease/ polyps, personal cancer hx (esp. prostate/testicular), diabetes type 2 No symptoms in early stages! Red Flags in Advanced stages -Rectal bleeding -Blood in stool (Hematochezia) -Change in bowel habits -Iron deficiency anemia -Abdominal pain

Colorectal Cancer Related to many modifiable risk factors Inflammatory bowel disease IBD (crones disease) which is different from IBS Not a lot of early signs for this type of cancer Anemia from blood in stools Iron deficiency and fatigue

Trauma: Concussion

Considered a mild TBI Most common symptoms is headache followed by dizziness uBe vigilant of more serious constitutional signs and symptoms uImportant physical exam components if someone is referred for concussion or with s/s: uVital signs uCranial nerve testing uUpper motor neuron testing (Babinski and Hoffman) uMyotomes and Dermatomes uDTRs uRoutine and tandem gait uCoordination ubalance

Recognize Presence of Skin Conditions -contact dermatitis -scarlett fever - Systemic Lupus Erythematosus -rocky mountain spotted fever

Contact Dermatitis- came in contact with something they are allergic to - new detergent - rash exactly where their shirt was - present in spot where they touched Scarlett fever - patchy bright red areas - need to see physician -needs meds - contagious Systemic Lupus Erythematosus - butterfly look Rocky Mtn. Spotted Fever - spending lots of time outside - tick bite

What could limit clinical use of a standardized outcome measure? 6 things

Cost of Instrument (could be free could be expensive) Training Required (could be extra training) Time to administer (self reported could be either super fast or very slow - other tests could be long or fast) Burden of measure: -To the clinician -To the patient (could be painful) Resources required? - Clinical space and equipment (not space to do 6 min walk or don't have a treadmill) - Instrument-specific requirements Organizational constraints (sometimes clinics have outcome measures they want you to use)

MRI Artifacts

Crescent shapes are from motion of the patient Try to eliminate blinking Wraps around incorrectly Metal artifacts - titanium aneruysm clip - total hip replacement If they have metal in them MRI might not be the best

designates a positive or negative test outcome.

Cut-Off Scores:

Cut-off Score

Cut-Off Scores: A cut-off score designates a positive or negative test outcome. The cut-off score for being a fall risk is 13 seconds. A person scoring >13 seconds is a fall risk a person scoring <13 seconds is not a fall risk. Designated a pos or neg outcome For TUG test: 13 sec is cut off score for fall risk -17 sec or 20 sec means they are a fall risk (probably want a gait belt on them and hands on them if 13 sec is higher) -if below 13 seconds - they are not a fall risk

________ are often used to create clinical prediction rules. OR Prediction of disease

Cutoff scores

Cutoff Scores

Cutoff scores are often used to create clinical prediction rules. OR Prediction of disease Receiver operations curves (ROC) can be used to help determine cutoff scores. Think about where the clinical prediction rules come from ROCs - receiver operation curves can help determine cutoff scores

If test has 100% Sn and 30% Sp.... A.A person that tests negative, does not have the condition. B.A person that tests positive has a 30% chance of having the condition. C.A person that tests positive has a 70% chance of not having the condition. D.All are true.

D.All are true.

Examination - Nails dark lines

Dark lines beneath the nail should be checked ASAP - can be melanoma (this one is more of a true red flag)

Examination - lesions primary lesions vs secondary lesions

Description --size, shape, color, texture, position primary lesions = original lesions produced by trauma or other stimuli (ex: you stepped on tac or cut finger while cutting) secondary lesions = result from some alteration, usually traumatic, to the primary lesion. (ex: they evolve from primary lesion - incision on knee from surgeon then you get an allergic reaction and scratch it and you get secondary lesions - can cause infection) Secondary lesions may evolve from primary lesions, or may be caused by external forces such as scratching, trauma, infection, or the healing process. The distinction between a primary and secondary lesion is not always clear Size - measure the size with tape measure

Generalized Endothelial Dysfunction

Diabetes Related Complications uSystemic effect of prolonged hyperglycemia uPrecedes the development of atherosclerosis uWhen endothelium is exposed to hyperglycemia, an array of intracellular events promotes endothelial dysfunction uEndothelium becomes "sticky" - attracting platelets, leukocytes and red blood cells > leads to vascular narrowing uHypertrophy of the smooth muscle subcutaneous to the arterial endothelium > leads to further stenosis uInflammatory cascade > Leads to scarring uIncreased concentrations of blood sugar promote the accelerated release of acetylcholine which results in paradoxical constriction instead of vasodilations > more narrowing (vasoconstriction)! Vision, neuropathy, poor blood flow in the feet Blood flows less readily and easily

Intake cont.. (for cancer) Beyond information about personal and family history of cancer, lifestyle:

Diet Obesity Exercise Tobacco use Alcohol use -Moderate Alcohol Consumption= 1 drink daily for women; 2 for men (red wine reduce the risk of cancer) -Heavy = 4+ in a day or 8 per week women/ 5+ in a day or 15 per week men, increased cancer risk -Binge = 4+ in 2 hour period women/ 5+ men Back to modifiable risk factors Moderate alcohol is not concerning Heavy and binge drinking increase chances for cancer

Direct Access for PTs

Direct Access varies state to state In Oklahoma we can see a patient for 30 days without a referral from an MD. Except Medicare, you can complete an evaluation and then you must obtain the referral. This why Differential Diagnosis is so important. Could have a patient from off the street - could be caner -need to be able to screen for it -refer or treat? -continually screening them every time -story: night sweats, pain, exhausted - the man had pancreatic cancer - took her 3 times to figure it out - it is ongoing

The Skin-Dysfunction

Direct contact (cut yourself) Reaction to medication (itchy, hives - could be reaction to pain meds- reach out to dr about it) Trauma (hit by something, scratched) Genetics (predisposition to having eczema or scars, keloids) Allergy Radiation (from sun or from working in a plant) Systemic conditions (liver dysfunctions) Burns Cancer (skin cancer) Do they work with chemicals? Physical explanation of environment - high wind? Environmental Factors: Mechanical Chemical Physical Biologic

Examination - Lesions ---skin

Distribution of lesion ---light exposed areas -----seborrheic dermatitis(cradle cap), acne vulgaris generalized -drug induced, infectious -Reaction to illness/meds -erythema multiforme -palms/soles Where is it? Cradle cap - lesions on scalp of baby in first couple of weeks - yellow patches or nonyellow scaly - normally on scalp- can last months - special shampoos can help - deals with oil production and changing environments Acne - oily parts of skin

Pathology / Artifacts with x ray

Don't have as good of quality with these

In the early stages many cancers have NO signs or symptoms. What do you look for?

Early normally have no symptoms - this is how they get very advanced or metastasized because people don't know they have it

vascular lesions purpura larger than 1.0 cm round or irregular macular lesion color varies and changes: black, yellow, green associated with bleeding tendencies, not caused by trauma

Ecchymosis (pl. ecchymoses) Huge purpura Associated with bleeding tendency - not necessarily caused by trauma but can be caused by trauma The ankle one was because they sprained their ankle

Physical Therapy and Diabetes

Examination and Evaluation: ●Discussing DM diagnosis and current self-management ●Monofilament - sensation testing ●Proprioception testing ●Motor and Reflexes ●Wound care ●Prognosis Interventions: ●Improve endurance and lower blood glucose through exercise ●Safe, customized exercise routine (incl. strength training) ●Foot care education ●Proper footwear ●Walking programs Warn them about insulin rationing Have them check their feet everyday- wounds can lead to amputations which can shorten life

General Exercise Recommendations with DM

Exercise as a method to control Blood Glucose If starting new routine - monitor BEFORE, DURING, and AFTER Before: 100-250 mg/dL ok to exercise; below 100, eat a snack; above 250 - CAUTION, exercise could cause ketoacidosis (avoid exercise) During: Check blood sugar levels every hour, if drops below 70-stop and eat a snack After: learn how your diabetes is affected by exercise Glucose levels may drop for up to 24 hours after a workout, patient should continue to monitor at their regular intervals over the next day If starting new routine - monitor BEFORE, DURING, and AFTER - ask them to bring their test strips with them next time

Malignant Melanoma: Risks

Fair skin, blonde or red hair, blue eyes, freckles Brief, intense sun exposure Immunosuppressive therapy Tanning (incl. indoor) Flight Crew Hx of melanoma -fair skin, blond, intense sun exposure -several severe sun burns History of skin cancer

Intake Either on your intake form or during your initial evaluation you should ask about: (for cancer)

Family history cancer Personal history of cancer HOWEVER....Most people diagnosed with cancer don't have a family history of the disease. Only about 5% to 10% of all cases of cancer are inherited. ---Sometimes, people in the same family get cancer because they share behaviors that raise their risk. Not because they share genes. Behaviors that increase risk of cancer include smoking, diet, exercise Second cancers (new cancer unrelated to the first) are not uncommon. About 1 in every 6 people diagnosed with cancer has had a different type of cancer in the past. •Time to secondary cancer after Radiation treatment : •2-5 years for leukemia •3-10 for solid tumors Personal history of cancer is more predictable of getting cancer again Personal risk is more important than family history Second cancer - her mom had breast cancer , it went away, now she has leukemia

Universal Cancer sign Fever... without _____ with ______

Fever.... -Without infection -With night sweats Fever is another big one Without infection and with night sweats Women in menopause will have night sweats too Night sweats with fever is issue

Floor and Ceiling Effect

Floor Effect --Floor effects occur when there is an artificial lower limit, below which data levels can't be measured. --For example a measure that assesses caregiver depression may not be sensitive enough to assess low or intermittent levels of depression among caregivers. Ceiling Effect --Ceiling effects occur when a score exceeds a threshold to detect progress. -- For example, a patient's pre-rehab score may be in-range at the initial evaluation, but the patient's ability exceeds the measure's highest score over time. Therefore, it is unable to accurately assess progress as the patient improves. Ceiling effect occurs when a score exceeds a threshold to detect progress. -can be a problem sometimes floor: example the depression doesn't pick up the low levels of depression Ceiling - looks like you hit a plateau but cant measure any more improvements

_________ occur when there is an artificial lower limit, below which data levels can't be measured. For example a measure that assesses caregiver depression may not be sensitive enough to assess low or intermittent levels of depression among caregivers.

Floor effects

CPR (clinical prediction rule) of the L-spine

Flynn and colleagues developed a clinical prediction rule (CPR) to identify patients with LBP who were likely to respond favorably to a specific lumbosacral spinal manipulation technique. Five variables were identified as predictors and together formed the CPR. The variables were: 1) Duration of symptoms less than 16 days 2) At least one hip with greater than 35 degrees of internal rotation, 3) Hypomobility with lumbar spring testing in one or more segments 4) A score of less than 19 on a sub-scale of the Fear-Avoidance Beliefs Questionnaire (FABQ) 5) No symptoms distal to the knee. Who will respond positively to manipulation - clustered results

Gout

Form of arthritis characterized by pain, redness, & joint tenderness Uric Acid crystalization & deposits Med: Colchicine Diet, exercise, and decreased alcohol intake Most commonly in feet but can be in hands Normally great toe

•Patient presents with symptoms -Therapist hones in on correct hypothesis more quickly through the use of pattern recognition and experience -Fewer special tests are performed -Utilized by expert therapists -Information collected from patient interview is invaluable -However, when faced with a complex case, these therapists revert to using Backward Reasoning

Forward Reasoning Want to move towards forward reasoning Expert therapists do this Therapist immediately hones in on the correct hypothesis - they've seen patterns -they use fewer special tests Pretty much know what it is Experts do this Complicated cases - resort back to backwards reasoning

_______ is an emerging and immediate public health concern given the growing aging population. The condition of _______ is characterized by a reduction in physiologic reserve, which places _______ older adults at considerable risk for further functional decline, hospitalization, institutionalization, and death. Recent research suggests that _______ may be reversible, which could result in significant improvement in public health. Thus, a strong impetus exists to develop strategies for _______ older adults that achieve the Triple Aim through better promotion of population health, optimization of patient experiences, and delivery of high-quality care at minimal cost. Physical therapists often treat _______ older adults, yet how physical therapists can contribute to preventing or reversing _______ in healthcare settings has not been described, and may potentially influence patient outcomes and healthcare spending. Therefore, the purpose of this publication is to outline the potential role of physical therapists in achieving the Triple Aim for the_______ older adult population

Frailty

Metabolic System Functions & Disorders

Functions: ●Fluid Balance ●Potassium Management Disorders: ●Metabolic Syndrome ●Metabolic Ankylosis or Acidosis ●Gout ●Osteoporosis (bones) ●Paget's (bones) ●Osteomalacia (bones)

Hepatic Causes of back pain

Gallbladder: - "Tucked" under the liver - C/o pain or nausea after eating Liver: -Primary complaint is back pain -May be able to palpate liver distension.

skin Examination

General inspection followed by a detailed examination (if warranted) Try to examine in a well lighted area to gain maximum information Scan skin, look for lesions, note position and symmetry Relies almost entirely on careful inspection and meticulous descriptive terminology Observe area you are treating With back pain - look at back With knee pain - look at knee Want to be in well lighted area- compare each side -looking for redness, swelling -if you refer to dermatologist use the correct terms

Examination - Skin Color Jaundice

Generalized changes in skin color occur in jaundice, iron overload, endocrine disorders, albinism Jaundice - yellow tinge includes sclera ulongstanding deep obstructive jaundice is yellow-green Jaundice is iron overload - issue with liver - liver is filter - will get too much iron in blood and it goes to the skin, eyes and makes it yellow Yellow in eye sclera- longstanding liver disorder if eyes are yellow

You are evaluating a 73-year-old female patient who fell and fractured her proximal humerus. She has not had surgery, she was placed in a sling for 10 weeks and is now referred to you for ROM and strengthening as tolerated. Her PMH includes: type 2 diabetes (non-insulin dependent), high cholesterol (takes a statin). Vitals today: 112/68, normal HR and RR. She mentions that since she has been in the sling for "so long" her neck has become stiff and painful as well. At this comment, you ask her to turn her head and she is only able to rotate her head 10-15 degrees to each side.

Get radiograph rotate her head 10-15 degrees to each side. age treat the shoulder, refer out for imaging of the cervical spine uContinue to consider the "top 5" hypotheses (SCRIPT method) uUse what you know from this course to rule out systemic causes uWhen trauma is involved, think through "worst case scenarios" and how you would rule out fractures and when you would recommend imaging

Diabetes Mellitus and Skin

Glucose attaches to protein and affects structure and function Crosslinking of collagen may account for fact that skin in people with DM is thicker (skin appears and feels thicker) Advanced glycosalation endproducts are probably responsible for yellowing of skin and nails Microvascular effects of DM cause structural changes - thickened capillary walls and functional changes - ↑'d blood viscosity that result in dilated capillary loops (circulation issues-ankle problems, get wounds that wont heal)

Clinical Prediction Rules (CPR)

Goal of CPR is to cluster tests to help in making diagnostic decisions. Ottawa ankle rule -Sn 95-100% -Negative likelihood ratio 0.8 -Pretest probability 15% -1.5% risk of fracture in those with negative test Goal of ottowa ankle rules - goal is to determine if someone needs an x ray of their ankle - do they need an x ray Sen is strong - if neg rule out knee of x ray Neg likelihood ratio is close to what we want 98.5% change that someone with neg test does not have ankle fracture -goal is to cluster info together to help with diagnostic decisions

Likelihood ratios examples hawkins kennedy speeds horn blowers empty can

Hawkins kennedy - 92% 10% -- snout is good spin is bad, pos likelihood is only 3 not super confident, neg confident ration want less than .1 --> strong snout but likelihood confidence is mod-poor --> not overwhelmingly confident in any diagnosis - this test is very general any ways

Pulmonary Causes of neck and spine pain

History of Cancer Recurrent history of URI, pneumonia Pneumothorax (google this) Risk factors Smoking Trauma Immobility Dehydration (travel) Chronic diseases Recent surgery/illness Pain pattern Sharp Sudden onset Aggravated by breathing movements Non-mechanical Possible associated SOB Auto-splinting eases the pain (lying on affected side) Shoulder and/or trunk ROM does not reproduce symptoms

Likelihood ratio

How good is the test as a diagnostic tool? Sn and Sp are used to determine Likelihood ratios. It follows that a positive or negative result don't always rule in or out disease: They change the probability of disease. Likelihood ratios provide a numerical measure of the effect of a result on probability. All about calculating probability- what is likelihood they actually have that disease

Blood Sugar Levels - hyperglycemia

Hyperglycemia Causes: Improper management of DM Symptoms: ●Extreme thirst, dry mouth, headache, frequent urination (high output), blurry vision, nausea, confusion, SOB Bloodwork may show __ketones____ present, _low___ hematocrit, & _low___ pH Ketones are chemicals from your liver that you produce when you don't have enough insulin in your body to convert sugar to energy. Your body uses fat instead, turns it into ketones. the story of the man driving in to the ditch

Blood Sugar Levels - hypoglycemia

Hypoglycemia (below 70) Causes: Medications that lower glucose (insulin, steroids, some antibiotics) - or haven't eaten when they were suppose to Symptoms: ●Hunger, irritability, trouble concentrating, fatigue, sweating, confusion, fast heart rate, shaking, headache

Validity of a test

Is the test measuring what it is suppose to measure? What is assessed is indeed what is intended to be assessed Make sure you are using the right tool to capture it

Screening for Skin Cancer: Age-related Skin Changes Keratoses -Seborrheic keratosis = ________ -Actinic keratosis = ____________ Lentigines -_________________

Keratoses -Seborrheic keratosis = benign -Actinic keratosis = pre-malignant Lentigines -Liver spots

history -- skin ask about leisure activities

Leisure activities - gardening, model building, carpentry, photo developing, hiking, foreign travel, insect exposure Ask about topical treatments being used as these may alter skin lesion appearance and make assessment and diagnosis more difficult other examples - itchy rash + sore tongue = yeast infection - Candida albicans seen with use of broad spectrum antibiotics photosensitive rash - rash in sun exposed areas but without strong sunburn → SLE, porphyria, some drugs itching or pruritis without rash → underlying systemic disorder Photosensitivity - Phototoxic - usually see skin change in minutes to hours - occurs with some antibiotics - tetracyclines, fluoroquinolones (ciprofloxicillin); NSAIDs; diuretics (furosimide); statins; St. John's wort - photoallergic - see response 1-3 days after agent is in contact with skin

Diagnostic values of the test.

Likelihood + / -

How good is the test as a diagnostic tool? Sn and Sp are used to determine

Likelihood ratios.

Screening questions for spine pain

Location of back or neck pain Other signs and symptoms Frequency Triggers (activity, positioning, stress) Obtain past medical history -Trauma - car accident (acute, chronic) -History of cancer Previous treatment that has/not worked Is the pain mechanical or non-mechanical? Kidney and back pain --> change in urinary habits, worse after peeing?

Back Pain Lower Limb Pain Lumbar Stenosis? OR Back Pain Lower Limb Pain Cardiovascular System?

Lumbar stenosis - canal narrows and encroaches on spinal cord - can cause bilateral leg and foot pain - when they rest it gets better perform the bike test -Assesses underlying cause of intermittent claudication Intermittent Claudication: pain affecting the calf, and sometimes the thigh and buttock that is induced by exercise and relieved by rest. Occurs as a result of muscle ischemia during exercise, caused by an obstruction to arterial flow. It is associated with a significantly increased risk of death from CVD. -Bike Test - allows you to stress the LE vascular system without diagnoses like stenosis interfering If they don't get flared up - stenosis If they do get flared up - more cardiovascular Stenosis- up and about, spine narrows, sitting exercise shouldn't bother them

Risks: -Smoking (>1/2 ppd, starting as a teen, secondhand), other enviro exposures, prior lung disease, genetic factors --Pack Years = packs per day X yrs Red flags: -Persistent cough, dyspnea, wt. loss, fatigue, hemoptysis, poorly localized chest pain, dysphagia, voice changes, bronchitis/ pneumonia, wheezing Most Commonly Diagnosed by -Routine chest films, Anemia

Lung Cancer-Red Flags Smoking - especially if start young and smoke a lot If persistent cough - x ray - or if anemia they can find it

Screening for the Leading Causes of Cancer (Breast, Prostate, Lung, Colorectal)

Men - prostate most common Women -breast most common Lung then colorectal next common Lung cancer has higher death rate Die from lung cancer more

Osteoporosis-related fractures

Men >65, Women >75 with sudden onset of severe back pain - spinal fracture needs to be considered Roman Clinical Prediction Rule: 1) age >52, 2) no leg pain, 3) BMI < 22, 4) does not exercise regularly, 5) female gender. A finding of 2 or less of these has sensitivity of 0.95 and a negative likelihood ratio of 0.16. A finding of 4+ yielded a positive likelihood ratio of 9.6 Osteoporosis related fractures most commonly occur in the thoracic/lumbar spine, femoral neck, and radius Spine: worse with trunk flexion activities, transitioning from sit <> stand Femoral neck: groin pain, greater troch pain, deep buttock pain, worse with WB'ing activities (LE ER is more comfortable) Distal Radius: Associated with FOOSH, may or may not have deformity (depends on displacement)

__________ is a published value of change in an instrument that indicates the minimum amount of change required for your patient to feel a difference in the variable you are measuring.

Minimal Clinical Important Difference (MCID) The MCID

_________ is the minimum amount of change in a patient's score that ensures the change isn't the result of measurement error.

Minimal Detectable Change (MDC) The MDC

MDC and MCID

Minimal Detectable Change (MDC) -The MDC is the minimum amount of change in a patient's score that ensures the change isn't the result of measurement error. Minimal Clinical Important Difference (MCID) -The MCID is a published value of change in an instrument that indicates the minimum amount of change required for your patient to feel a difference in the variable you are measuring. Mean two different things MDC: you measure shoulder flexion Monday and Tuesday there is a difference of 3 degrees- is this real or a result or error --> for shoulder flexion it is 8 degrees - could be because of error with the measuring of goni or their shirt is different --> more than 8 degrees means there is an actual change in the patients ROM MCID: does the 8 degrees matter to the patient - meaure mon to tues see a 8 degree difference - they did gain Rom but the patient says it feels the same - (usually more than the MDC)

Musculoskeletal Complaints

Most common reason for PT visits MSK pain can be referred from local, referred, or visceral origin PTs need to identify the source of the pain/symptoms, determine if appropriate for therapy, treat v refer Do this by SCREENING Examine if appropriate, to continue screening

Later Symptoms of DM

Multiple Organ Dysfunction Syndrome uRenal uCardiac uCentral Nervous system uPeripheral Nervous system uReproductive uGastro-Intestinal uUrinary uVisual uIntegumentary uImmunological It can effect multiple systems at once

Does a measure have to be both valid and reliable in order to use it? yes no

NO - but you should try to only use tests that are both reliable and valid The answer is No Can have something that is valid but it is not reliable Or can have a test that is reliable but not valid for what you are testing MMT is very reliable but can you use it with infants? No - not valid but it is reliable It doesn't have to but not sure if you should use it if it isn't both

Diabetes and Skin __________ begin as 1-3 mm well circumscribed papules or nodules that expand to become waxy, atrophic, round plaques (hard) initially red-brown but become progressively more yellow usually on shins 40% of cases in non-DM (not exclusive to diabetes) 3x's more common in women collagen degeneration may be due to microangiopathy

Necrobiosis Lipoidica

Clinical Lab Results for Diabetes Mellitus

Non-Fasting: Normal: ___70-100___ mg/dL Hypoglycemia: <_70__ mg/dLHyperglycemia: >_200__ mg/dL 2-Hour Oral Glucose Tolerance Tests: Normal: <139 mg/dL Pre-diabetes: 140-199 mg/dL Diabetes: ≥ 200 mg/dL Fasting Plasma Glucose Tests: Normal: ___90-130_____ mg/dL Pre-diabetes: 100-125 mg/dL Diabetes: >_126__ mg/dL

Non-modifiable and modifiable risk factors of cancer Non-modifiable Modifiable

Non-modifiable -Advancing age is the most important risk factor of cancer. -25% of all new CA diagnosis occur in those over 66 Modifiable -Alcohol consumption -Smoking -Diet -Obesity -Sunlight

Examination - Nails clubbing and spoon nails

Normally thicker in older persons and dark skinned persons Normal angle between nail base and skin is 160degrees; normal concave nail bases create a small diamond-shaped space between opposing index finger nail beds clubbing → angle ≥ 180degrees, occurs with chronic tissue hypoxia (not enough oxygen for a long time - body sacrifices fingernails) spoon nails (concave) may be present with iron deficient anemia Thin in babies Usually not perfect flat 180 - normally slightly concave Clubbing - angle is greater than 180

Normative value

Normative Data: Normative data represent scores pulled from published literature. -Normative data provides "normal" values for specific variables within a population. -This data can provide approximate guidelines. -Example-6-minute walk test -Distance walk based on age. A person that is 65 year of age should be able to walk 1000 feet. If your patient walks 900 they are below the norm. You can NOT apply the norm across health condition. A person that is 65 with Parkinson's' disease may have a different normative value. Goni, ROM , the normal Shoulder goes 0-180 normative values for population (ages or genders could have different)

Mary is now a pediatric therapist working with an infant and their mother. She collects data from the mother about the infant's ability to roll, hold a bottle, etc. This type of measure is an ___. Self-Report Measure Performance-Based Measure Observer-Reported Measure Clinician-Reported Measure

Observer-Reported Measure

Observer reported measures

Observer-reported measures are measurements completed by a parent, caregiver or someone who regularly observes the patient on a daily basis. Disability rating scale Filled out by parent, caregiver, Pediatric measures use this a lot PT and patient do not fill this out- it is a caregiver

Established Clinical Guidelines for Radiography ottowa ankle and foot

Ottawa Ankle Rules 100% sensitive, 40% specific -pain at malleolar zone and 1- ttp at tip of lateral or medial mall 2- inability to bear weight Ottawa Foot Rules 100% sensitive, 40% specific -pain at midfoot and 1- ttp at base of 5th met OR navicular 2- inability to bear weight

Established Clinical Guidelines for Radiography ottowa knee

Ottawa Knee Rules Exclusion Criteria: •Age <18 years •Isolated superficial skin injuries •Injuries older than 7 days •Recent injuries being reevaluated •Paraplegia or multiple injuries 97% sensitive, 27% specific for knee fractures

Classification of Function and Disability ICF model and standardized outcome measures

Outcome measures typically have 1 or more Domain listed Make sure you don't neglect any part of ICF measure The tools tend to forget about participation They tend to focus on one aspect normally A patient might have strength and ability to walk but they still cant participate in their social life

PT-Cancer Prevention and Screening PT-Prevention -Educate patients on ___________ -Educate patients on ___________ and ___________ for participation in life. PT-Screening -Recognize ___________ and ___________ associated with cancer

PT-Prevention -Educate patients on modifiable risk factors. -Educate patients on exercise and activity for participation in life. PT-Screening -Recognize signs and symptoms associated with cancer

Renal Causes of back pain

Pain pattern (T9 to L1 area; pelvic, flank, LBP) Past medical history UTI Kidney stones Trauma Clinical presentation Constitutional symptoms Blood in urine Testicular pain Kidney causes for back pain Flank pain

Universal Cancer Sign pain clustered with ..

Pain--Independently these may not indicate cancer -Unrelenting -Does not change with position -No relief with bed rest, lasting >1 month Clustered with: (When added to these the likelihood of cancer increases) -Unintentional weight loss -Cancer history Pain alone isn't red flag But unrelenting pain without change of position is concerning Pain in low back should change with how they are moving - if not red flag for cancer Clustering together increases One on its own less likely

outcome measures and ICF SF-36

Participation

Gastrointestinal Causes of neck/back pain

Past medical history Crohn's disease Cancer Risk factors Long-term or chronic NSAID use Ant. neck or back pain with any of the following: Immediate referral •Esophageal pain •Epigastric pain -> radiating into the back •Fecal incontinence •Blood in the toilet •Loss of appetite

Fractures: Minor Trauma

Pathologic Fractures Osteoporosis (primary or secondary), malignant bony tumors Minor trauma: a slip with no fall, lifting groceries from the trunk of the car, a big cough or sneeze - most of the time we may not even call these "trauma" Sometimes trauma could be a sneeze and fracture vertebral body

Woman (mid 60s) referred with dx of SCIATICA from PCP Symptoms: Bilateral LE Weakness, pain at left SIJ and left buttock, numbness in Left Leg after walking, sensations of heat and cold during walking, cramps in right calf, no reports of leg Pain Intake Form: extensive history of family heart disease; Vitals: 138/79 and takes an ACE inhibitor (hypertension/BP) What is the appropriate course of action for the therapist?

Patients with sciatica can have all these things At this point continue -----> Clinician did ROM screening of lumbar spine, slump test, and myotomes, dermatomes, and DTRs which were WNL, clonus and Babinski were WNL as well; due to cramping and lower leg sensation changes as well as medical history, clinician checked LE pulse sites and found diminished dorsalis pedis pulse on left side -Bike Test - Reproduced symptoms of weakness in legs and temporarily abolished dorsalis pedis pulse completely What should we do now? More concerned now --> refer because more cardiovascular

Self-report vs Performance based how do they relate?

Performance-based measures and patient reported measures both capture a current status. These measures do not typically equate with each other.

Self-report vs Performance based

Performance-based measures and patient reported measures both capture a current status. These measures do not typically equate with each other. Does time to complete the nine-hole peg = patient's perception of hand function? (maybe or maybe not) Performance-based measures tend to bring to light physiologic factors. Patient reported outcome measures may capture a patient's perception, beliefs, social factors and/or health factors. This is where they are today They don't exactly line up Physiological factors - during 6 min walk they get very out of breath

Performance based measures

Performance-based measures require the patient to perform a set of movements or tasks. Scores for performance-based measures can be based: -Objective measurement (e.g., time to complete a task, muscle testing) -Qualitative assessment that is assigned a score (WNL, WFL) MMT, ask them to do 6 min walk They are doing an activity, task, movement and assign it a score Can be WNL or WFL - or assigning grades

Diabetes Adverse effects on end organs

Peripheral Neuropathy sensory and autonomic loss of protective sensation loss of intrinsic muscle function collapse of foot architecture alteration in weight bearing Eyes, sensation, can cause peripheral neuropathy Affects ability to sweat and grow hair and autonomic nervous system

history --- skin

Permits evaluation of precipitating factors Social conditions - overcrowding, close physical contact - scabies, impetigo Occupational or domestic toxins or chemicals Use of new soaps, deodorants, cosmetics? Recent change in medications? Remember systemic disorders can present skin symptoms e.g. SLE, Crohn's Infectious diseases often present skin rashes, lesions - sore throat? (consider staph or scarlet fever) - especially in kids Is the problem seasonal? allergies, insects (mosquito/spider bite) Ask questions about recent changes Scabies - from Latin scabere 'to scratch' - also known as the 7 year itch - sarcoptic mange in dogs Impetigo = gram + bacteria - highly contagious, topical antibiotics mupirocin, - blister-like sores, honey colored crust SLE = auto immune dz (lupis) - skin symptoms in 3/4s of people with SLE - ½ of these are photosensitive rashes - discoid lesions - if in scalp can cause hair loss - typical butterfly or racoon rash Crohn's dz - also auto immune - pyoderma gangrenosum - deep ulcer with a well defined border, which is usually violet or blue. - ulcer edge is often undermined (worn and damaged) and the surrounding skin is erythematous and indurated - ulcer often starts as a small papule or collection of papules, which break down to form small ulcers with a "cat's paw" appearance. T - these coalesce and the central area then undergoes necrosis to form a single ulcer. Seasonal - spider activity - brown recluse - spring tick exposure mosquito

Examination - Nails pitted or ridged nails

Pitted or ridged nails can be early indicators of psoriasis or inflammatory arthritis

You are measuring tissue return time for a patient with pitting edema in a skilled nursing facility. You note that it takes 80 seconds for your patient's tissue to return to normal. You should document this as:

Pitting - easily compressed 1+ barely detectable 2+ <15 seconds to refill 3+ 15-30 seconds to refill 4+ >30 seconds to refill +4

Examination - Palpation pitting edema scale

Pitting - easily compressed 1+ barely detectable 2+ <15 seconds to refill 3+ 15-30 seconds to refill 4+ >30 seconds to refill Pitting edema is either caused by a localized problem with veins in the affected area, or a systemic problem with your heart, kidneys, or liver function. Edema without pitting is more likely to be caused by issues with your thyroid or lymphatic system Pitting edema scale- has to do with circulation - leaves a finger print in the skin - graded on how fast it refills

Mary (a PT) is using a clinical test that has a high reported positive predictive value. If her patient tests ____, this means that it is very likely that the patient actually has the disease/disorder. Positive Negative

Positive

Positive and negative predictive values

Possible meniscus tear They have jt line tenderness - pos predictive value is bad - but if they don't have it feel a little bit more confidence Mcmurrys is more confident Joint the pieces of info together

Cauda Equina Syndrome potential causes

Potential causes: 1.Cancerous tumor 1.Inflammation or infection 2.Herniated Nucleus Pulpous (HNP) 3.Vertebral fracture

Influenced by prevalence to determine the value of a test

Predictive + / -

Reflects the diagnostic values of the test. Influenced by prevalence of disease to determine the value of a test. Should not use outside that population.

Predictive value

Clues to Endocrine Dysfunction Recognition

Previous Diagnosis (patient intake form) Bilateral Carpal Tunnel Syndrome Medications: Long-term use of Cortico-Steroids, Diuretics (& signs of potassium depletion), Hormone replacements Bilateral Arthralgias + endocrine signs Bilateral Carpal Tunnel Syndrome -- >hepatic issue or endocrine issue Arthralgias - joint pain

Considering Red and Yellow Flags for cancer Proceed with caution. One red flag ______ warrant a referral back to the PCP. Clustering red flags _____ warrant referral back to the PCP.

Proceed with caution. One red flag may not warrant a referral back to the PCP. Clustering red flags may warrant referral back to the PCP. One red flag does not warrant back to physician Lots of red flags do

No symptoms in early disease! Weak/ interrupted flow of urine; Difficulty starting/stopping flow Frequent or urgent urination Blood in urine Pain/ burning with urination Hip, spine, rib, pelvic pain (mets) 5-Year Survival: 99-100%*

Prostate Cancer-Red Flags Not many early signs Pain in hip spine rib pelvic pain Survival rate is very high Lung cancer has increased risk of death associated

Vascular Lesions larger areas of bleeding into the skin - 0.3 - 1 cm do not blanch to pressure 'senile purpura' = areas in older persons on backs of hands and forearms due to vasculitis, longterm use of steroids, vit. C deficiency (scurvy), meningitis, septicemia

Purpura Common in elderly Big purple red where bleeding under the skin occurred Wont turn white Backs of hands or forearms where they bumped something Could be because they are on blood thinners Arteries and veins just not very healthy -if can link to history

Types of Reliability

Rater Reliability --Inter/Intra-Rater Reliability Test-Retest Reliability MMT - one PT doing it today and tomorrow - will she be consistent (intra) MMT - one PT doing it today and a different PT does it tomorrow - will she be consistent (inter)

What is our responsibility as PTs with integumentary?

Recognize integumentary changes that are expected vs. not, when to refer and when to continue to treat EXAMPLES: -Patient with known end-stage liver disease - you observe jaundice - ask if it's changed, likely it has not - document and continue to treat -Patient with Diabetes, you observe loss of sensation in the feet, they have not been diagnosed with Diabetic Peripheral Neuropathy -Document, continue to treat, refer to physician for evaluation Rash or flaky on head is expected sometimes - cradle cap Rash on babies head is not expected and needs to be referred back

Metabolic System Dysfunctions & Referrals

Red Flags: ●Uncontrolled DM (confused, lethargic, sweating at rest, hypoglycemia signs) ●Signs of potassium depletion (muscle weakness & cramping with simple exercise, arrhythmias, nausea) ●Thyroid Storm - fever, tachycardia, HTN, neurological or GI abnormalities (refer to emergency room) Otherwise: Refer back to physician (but continue to treat): ●If a cluster of symptoms is noted ●Your patient has a personal and family history that are consistent with your suspicion ●Lab values ●Generalized signs and symptoms

Predictive value

Reflects the diagnostic values of the test. Influenced by prevalence of disease to determine the value of a test. Should not use outside that population. Hyperglycemia can be used to predict likelihood of developing diabetes or having diabetes Don't use it outside of the population

Head Pain/Headaches

Screening: patient interview, systems review, chart review (imaging, labs) Patient interview: Location, Frequency, Triggers, PMH (Trauma? Acute V Chronic; cancer?), Previous Treatments Systems Review: patient intake form, medications, any systemic s/s or conditions that can cause HA? Chart Review: referral notes, head imaging, lab values How often are your headaches? Are you triggered by light or sounds?

= flakes secondary to desquamated, dead epithelium, texture varies - thick, thin, psoriasis, dandruff

Secondary Lesions scales

= thin, dry, transparent appearance of epidermis; loss of surface markings; secondary to loss of collagen and elastin; aged skin, arterial insufficiency - skin has started to thin- loss of collagen and elastin - arterial insufficiency if younger

Secondary Lesions atrophy

= dried reside of serum, blood or pus on skin surface, large adherent crust is a scab, residue after a vesicle rupture → herpes, eczema -needs to be cleaned and managed and the cause needs to be managed

Secondary Lesions crust

Secondary Lesions ____= loss of superficial epidermis, does not extend to dermis, depressed moist area, ruptured vesicle, scratch, aphthous ulcer ____ = mechanical removal of epidermis, exposes dermis ____ = skin loss extending past epidermis, necrotic tissue loss, stasis ulcer, pressure ulcer

Secondary Lesions erosion = loss of superficial epidermis, does not extend to dermis, depressed moist area, ruptured vesicle, scratch, aphthous ulcer excoriation = mechanical removal of epidermis, exposes dermis ulcer = skin loss extending past epidermis, necrotic tissue loss, stasis ulcer, pressure ulcer

= linear crack in the skin, problematic in diabetic feet (bacteria loves to climb into this= linear cleavage of the skin that extends into the dermis

Secondary Lesions fissure

= hypertrophied scar tissue; secondary to excessive collagen formation during healing; elevated, irregular, red; greater incidence in African Americans; can be internal or external -higher melanin - big thick scar- if you've had one - more prone to have another - goes below surface of skin - big thick scarring attachment

Secondary Lesions keloid

= thickening and roughening of the skin; secondary to repeated rubbing, irritation, scratching; contact dermatitis

Secondary Lesions lichenification

= skin mark left after healing of a wound, replacement of injured tissue with connective tissue

Secondary Lesions scar (cicatrix)

Types of Standardized Outcome Measures name 4

Self-report measures Performance-based measures Observer-reported measures Clinician-reported measures

Self-report measures

Self-report measures are typically captured in the form of a questionnaire. Patient-reported outcomes are questionnaires where the patient reports on their perception of the their health or physical function. Self-report measures seem subjective in nature, HOWEVER self-report measures objectify a patient's perception. The LEFS is a self-report measure. It is important to get their perception so that you are on the same page Make sure you both are seeing the same issues Ex: LESF: lower extremity functional scale - hand them a questionnaire and they fill it out

Vinne L. has been using the Hawkins Kennedy test to help him determine if his patients' symptoms are caused by impingment. He wants to know the rate of false positives for this special test. In order do the math and calculate the false negative rate of this test, he needs to look up the test's reported ____. Specificity Sensitivity Likelihood Ratio Positive Predictive Value

Sensitivity (i think)

looks at the presence and absence of disease.

Sensitivity and Specificity

Measures of Validity examples

Sensitivity and Specificity - what is chance of true or false neg or pos Likelihood + / - -- how confident that the pos test is actually pos Predictive + / - --- how strongly can I predict if someone will develop a disease- hyperglycemia - person may develop diabetes but not right now- they may develop diabetes

Sensitivity (Snout) and Specificity (Spin)

Sensitivity helps to rule out when the test is truly negative --Ability of the test to find (+) results for someone who has the disorder --False negative = 1- Sn Specificity helps to rule in when the test is truly positive. --ability of the test to find (-) results for someone who does not have that disorder --False positive = 1- Sp Sen - no false negs Spin - no false negs

Measures of Validity

Sensitivity, Specificity Likelihood ratio positive and negative Predictive value positive and negative Does anyone know the difference?

UE pain -Systems Review

Shoulder and diaphragm both innervated by C3-C5 spinal nerves Rule out: 1.Heart 2.Lungs 3.Respiratory system 4.Gallbladder 5.Spleen 6.Upper Extremity Pain in general

intro to the skin

Skin protects the rest of the body and keeps poisons out - skin has lots of jobs and important jobs Why should PTs care about skin? Patient example - veteran with spinal stenosis in lumbar region resulting in quadraparesis - multiple co-morbidities - skin issues 1. h/o venous stasis - exacerbated by decreased muscle tone and pump 2. trauma to skin on L/Es from transferring due to decreased sensation 3. sacral decubitus or pressure ulcer 4. mysterious lesion on L scapula - not a place you would usually look turned out to be ringworm (tinea capitis) - vet had cats and not great hygiene - fungal infection often carried by cats, transmitted by contact In its active form as calcitriol, vitamin D contributes to skin cell growth, repair, and metabolism. It optimizes the skin's immune system and helps destroy free radicals that can cause premature aging. While the body can produce vitamin D on its own through sun exposure, too much sun accelerates skin aging.

Osteomalacia

Softening of Bones Severe Vitamin D Deficiency & Calcium absorption Bowed legs and fractures Can happen in kids

Examination - Nails split or cracked nails

Split or cracked nails can signal thyroid disease

Venous Stasis

Stasis Dermatitis inflammatory skin disease in L/Es as a result of chronic venous insufficiency fibrinogen leaks out of capillaries into surrounding tissue → forms fibrin cuff around the capillaries → decreases O2 diffusion → leads to hypoxia and cell damage → dermal fibrosis leukocytes become trapped in the cuffs and release inflammatory mediators → contribute to inflammation and fibrosis Pretty common Venous system isn't doing its job of bringing the blood back to heart because the capillaries fail first Stains the skin Need PCP to check it out

A 62 year old male presents to the PT clinic with complaints of mid back pain. You begin your screening process with the interview and he states that he has been taking statin drugs for many years, but otherwise has been healthy and is an active person. He also reveals that sometimes he has lower leg pain when he tries to exercise, which has been a limitation to exercise for him. His patient intake form provides no other information.

Statins - cholesterol meds Lower leg pain Need to screen for DVT Screen cardiovascular disease These are three necessary vitals for cardiovascular screen cardiovascualr , assess vitals (HR, BP, RR), observe for lower limb edema and assess BMI

Treat or Refer/Triage

Synthesize information on patient as a whole Does this person need immediate triage, or should I continue my examination & screening? Focus on the location of pain and symptoms Determine your hypothesis regarding origin of their symptoms Is it a: -Medical Problem/Disease: Triage -Referred pain: treat or triage -Injury: Treat or triage

Your patient injured their knee playing soccer. You perform a Lachman's test, and find it to be positive. You refer them for imaging. Which type of imaging is most likely to reveal the suspected injured anatomy?

T2 MRI

When is "Night Pain" a systemic concern?

Tell me about your symptoms at night. Can you lie on that side? For how long? Does it wake you up if you roll onto that side? How are you feeling in general when you wake up?Do you have any other symptoms when you wake up? What makes it better/worse? What happens to your pain when you sit up? Upright posture reduces venous return to the heart. Decreased pain may indicated cardiopulmonary cause. How does eating/drinking affect your symptoms? Does taking an antacid affect your symptoms? Inability to change/improve symptoms or fall back asleep with repositioning at night is highly suspicious Night pain is associated with cancer

You are using a test used to identify ACL tears in the knee, the "Anterior Drawer" test. The test has a reported sensitivity of 41% and specificity of 86%. Please choose the best answer regarding the reported clinimetrics of the "Anterior Drawer" test. The Anterior Drawer test will be positive 86% of the time that the patient has an ACL tear. The Anterior Drawer test will be positive 41% of the time that the patient has an ACL tear. The Anterior Drawer test will be negative 86% of the time that the patient does not have an ACL tear.

The Anterior Drawer test will be positive 86% of the time that the patient has an ACL tear. Snout 41 Spin 86%

CPR of L-spine continued

The CPR demonstrated: -Positive likelihood ratio of 24, indicating that individuals who were positive for at least four of the five variables increased their likelihood of a successful outcome with manipulation from -45% (pre-test probability) to 95% (post-test probability). -Successful outcome was defined as a 50% or greater reduction in Oswestry Disability Index (ODI) scores. The ODI is a valid measure of disability for individuals with LBP. This CPR was later validated in two subsequent randomized controlled trials Pos ratio of 24 --> 10 or above is what we are looking for so this is awesome

Reliability of a test

The consistency of a measurement. Free from error. Reproducible and dependable. Without reliability we can not have confidence in our data. 50 +/- 2 vs +/- 20 No change in scores really If it isn't reliable then we shouldn't be talking about that data

CPR patient likely to benefit from CT-spine manipulation to decrease shoulder pain.

The following five criteria are considered predictors of improved short term shoulder pain prognosis following cervicothoracic manipulation: [1] 1.Pain-free shoulder flexion < 120˚ 2.Shoulder internal rotation < 53˚ @ 90˚ of abduction 3.Negative Neer's Test 4.Not taking medications for their shoulder pain 5.Symptoms < 90 days Cluster talking about which tests are included

If a test has 100% Sn and 30 % Sp and person is negative...

They do not have COVID

If a test has 100% Sn and person is negative...

They do not have COVID.

If the test has 100% Sp and the person is positive...

They have COVID

If the test has 100% Sn and 30% Sp the person is positive...

They have a 30% chance of having COVID

If a test has 100% Sp and person is negative...

They may or may not have COVID

If the test has 100% Sn and the person is positive...

They may or may not have COVID

Referred Pain with LE

To the hip - Lumbar spine Sacral area From the hip - uLumbar Spine uSIJ uSacral area uGroin uAnterior thigh uKnee uAnkle

Self-report measures Performance-based measures Observer-reported measures Clinician-reported measures

Types of Standardized Outcome Measures

What is cancer? Uncontrolled cell _______ Typically cells undergo ________ (cell death) In cancer cells do not die, rather continue to _______ and then ________ at an uncontrolled rate.

Uncontrolled cell growth. Typically cells undergo apoptosis (cell death) In cancer cells do not die, rather continue to mutate and then multiply at an uncontrolled rate. Cancer is when the cells continue to divide - don't get to apoptosis

Venous Stasis Ulcers

Venous Stasis Ulcers -usually non-painful -but underlying fat necrosis or lipodermatosclerosis is very painful - makes it difficult to distinguish from erythema nodosum Secondary infection by bacteria → honey colored crusting Secondary infection by candidiasis → pustules Longstanding → inverted champagne bottle Can get infected very easily

Visceral Referred Pain

Visceral pain results from stimulation of visceral organ receptors Felt as vague aching, gnawing, burning Activated by tissue stretching, ischemia, chemicals, muscle spasms

Osteoporosis

Weak & Brittle Bones New bone creation not keeping up with breakdown Signs/Symptoms -TTP spinous processes -loss of height, possible rib/spinal deformity, possible pain with deep breathing/coughing, aggravated by prolonged sitting Many times, asymptomatic until compression fracture has occurred Use romans clinical prediction rule

Why is clinimetrics important?

When considering test and measures, you need to understand clinimetrics. Is this test Sn or SP? Is this test valid and reliable? Measuring is important because it quantifiable. It can help with goal setting. It can help with measuring progress. It can help with prognosis. We have to quantify everything for insurance companies- need to see objectively that making improvements - need to show patients the numbers that they are improving Quantifiable Important for payers, patients, employers

CT Artifacts

With metal we get streaking sometimes D is a detector issue Radiograph à $100+ reading fee CT à $2,000+ reading fee CT 3d à depends on the structures + reading fee Fluoroscopy à $250-1000 + reading fee

Endocrine System Functions

Works with the CNS to ●Regulate metabolism ●Water and salt balance ●Blood pressure ●Response to stress ●Sexual reproduction

Addison's disease

a condition that occurs when the adrenal glands do not produce enough cortisol or aldosterone Adrenal Insufficiency uCortisol uAldosterone uBlood volume & Blood pressure Not enough cortisol or aldesertone Low blood volume or pressure Creases have become dark Vertical lines in nailbed Low blood pressure

Gestational Diabetes

a form of diabetes mellitus that occurs during some pregnancies Risks: (For Baby):Respiratory Distress Syndrome Pre-term Birth Excessive Birth Weight Obesity and Type 2 DM later in life Stillbirth (For Mom): Preeclampsia (excessively high blood pressure) C-Section Future Diabetes

Acromegaly

abnormal enlargement of the extremities Acromegaly - pituitary gland issue , too much growth hormone, can affect face Pituitary Gland: uGrowth hormone uBones uMiddle-Aged adults

= linear streak of dark skin on light skinned people on back of neck indicative of diabetes

acanthosis nigrans

A PT examines a pregnant female who presents w/ a dx of bil CTS, and has a past medical history including sleep apnea, HTN, and type 2 DM. You observe that she has larger than avg hands, feet, and facial features. Which condition might you suspect?

acromegaly

Examination - Nails Pale color point to

anemia, CHF, liver disease, malnutrition (ask questions about their health -keep in back of your mind)

My patient comes in to the clinic with neck pain after bungee jumping. They deny paresthesias in the extremities. You do note, tenderness along the spinous processes of C3-4. Using the Canadian C-Spine Rules, what should be your next step?

ask patient to actively rotate neck

Secondary Lesions _______= thin, dry, transparent appearance of epidermis; loss of surface markings; secondary to loss of collagen and elastin; aged skin, arterial insufficiency - skin has started to thin- loss of collagen and elastin - arterial insufficiency if younger _______= thickening and roughening of the skin; secondary to repeated rubbing, irritation, scratching; contact dermatitis

atrophy = thin, dry, transparent appearance of epidermis; loss of surface markings; secondary to loss of collagen and elastin; aged skin, arterial insufficiency - skin has started to thin- loss of collagen and elastin - arterial insufficiency if younger lichenification = thickening and roughening of the skin; secondary to repeated rubbing, irritation, scratching; contact dermatitis

= >0.5 cm, circumscribed, elevated, palpable mass containing serous fluid - bigger blister, bullous impetigo (newborn-bacterial infection) --Can spread quickly, triage to urgent care or other same day appointment

bulla Bulla will happen with diseases like chicken pox, but can spread quickly and should be triaged to urgent care or the pediatrician urgently Bulla - red flag - urgent care -young infant with blister looking - infection bacterial - antibiotics - if on newborn sudden rash need to take them to urgent care today Primary Lesions

Primary Lesions ________ = >0.5 cm, circumscribed, elevated, palpable mass containing serous fluid - bigger blister, bullous impetigo (newborn-bacterial infection) --Can spread quickly, triage to urgent care or other same day appointment _____ = elevated mass with transient borders, often irregular, size and color varies, caused by movement of serous fluid into the dermis not free fluid in a cavity = hives, insect bites

bulla = >0.5 cm, circumscribed, elevated, palpable mass containing serous fluid - bigger blister, bullous impetigo (newborn-bacterial infection) --Can spread quickly, triage to urgent care or other same day appointment wheal = elevated mass with transient borders, often irregular, size and color varies, caused by movement of serous fluid into the dermis not free fluid in a cavity = hives, insect bites Primary Lesions

A physical therapist examines a middle-aged male who presents with a diagnosis of bilateral carpal tunnel syndrome and has a past medical history including obesity, hypertension, and osteoporosis. During the exam, you note that your patient has a round face, thin skin on the hands, and purpura. Which of the following conditions should the therapist suspect? a) Addison's Disease -low cortisol, low blood pressure b) Acromegaly - growth hromone c) Cushing's Disease d) Paget's Disease -- fractures, weak bones

c) Cushing's Disease Cushings disease Bilateral carpal tunnel - liver, diabetes, carpal tunnel

Mr. Peterson, was successfully treated for lung cancer 6 months ago. You are now seeing him, in the acute care setting, after a total knee replacement. His surgery was yesterday. As he transfers from supine to sitting, he is breathing rapidly. You assess his vitals and his heart rate is 113. You quickly assess the Well's Criteria and his score is 4.5. What is your best course of action?

call for help - code

Diabetes and Skin Increased prevalence of cutaneous infections

candida - yeast --glans, vulva --hands, feet -----erythema, swelling and separation of the lateral nail fold from the lateral margin of the nail -----usually 3rd-4th, 4th-5th web spaces of toes - white patch of skin with central peeling

Cushing's syndrome

caused by prolonged exposure to high levels of cortisol Hypercortisolism -Exogenous -Endogenous -Adrenal Gland hypofunction -Pituitary Too much cortisol -it will look like they have trunk obesity - buffalo hump, moon face, frail skin, purpura

vascular lesions round and papular red or purple normal age-related skin alteration not clinically significant may blanch with pressure

cherry angioma

Diabetes and Skin Spontaneous appearance of Bullae (big blisters- don't want it to pop)

clear, sterile blisters on tips of toes, fingers not the result of trauma or infection usually spontaneously heal in 2-5 weeks Have a harder time healing

You are working Home Health. A patient who is post-op TKA is commonly taking Warfarin (anti-coagulant). At his nursing/labs appointment yesterday, INR levels were checked and reported 4.3ug/dl. Your best option is to

complete a PT eval and treatment with light exercise only 4-5 light exercise 5-6 eval only 6 contraindicated

Secondary Lesions _______ = dried reside of serum, blood or pus on skin surface, large adherent crust is a scab, residue after a vesicle rupture → herpes, eczema _______ = hypertrophied scar tissue; secondary to excessive collagen formation during healing; elevated, irregular, red; greater incidence in African Americans; can be internal or external

crust = dried reside of serum, blood or pus on skin surface, large adherent crust is a scab, residue after a vesicle rupture → herpes, eczema -needs to be cleaned and managed and the cause needs to be managed keloid = hypertrophied scar tissue; secondary to excessive collagen formation during healing; elevated, irregular, red; greater incidence in African Americans; can be internal or external -higher melanin - big thick scar- if you've had one - more prone to have another - goes below surface of skin - big thick scarring attachment

cyanosis = central vs peripherial

cyanosis = bluish tinge central cyanosis (in the mouth) - oral mucosa → cardiopulmonary (lack of o2) peripheral cyanosis(could be caused by environment) - venous stasis hemosiderin staining - darkening of skin in legs with chronic venous stasis

= encapsulated fluid-filled or semisolid mass, in the subcutaneous tissue or dermis - sebaceous cyst, epidermoid cyst

cyst semisolid Primary Lesions

Primary Lesions ______ = encapsulated fluid-filled or semisolid mass, in the subcutaneous tissue or dermis - sebaceous cyst, epidermoid cyst ______ = pus-filled vesicle or bulla - acne, furuncles, carbuncles

cyst = encapsulated fluid-filled or semisolid mass, in the subcutaneous tissue or dermis - sebaceous cyst, epidermoid cyst pustule = pus-filled vesicle or bulla - acne, furuncles, carbuncles

Cellulitis

diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling -hot red flag

degeneration or abnormal formation of the skin. often used to refer to nail diseases. (nails are smaller- short)

dystrophy Other Secondary Changes

Other Secondary Changes ___ degeneration or abnormal formation of the skin. often used to refer to nail diseases. (nails are smaller- short) _____ refers to a large malignant tumor that is erupting like a mushroom or fungus. _____ hard plaque covering an ulcer implying extensive tissue necrosis, infarcts, deep burns, or gangrene (burn ward most often)

dystrophy degeneration or abnormal formation of the skin. often used to refer to nail diseases. (nails are smaller- short) fungating refers to a large malignant tumor that is erupting like a mushroom or fungus. eschar hard plaque covering an ulcer implying extensive tissue necrosis, infarcts, deep burns, or gangrene (burn ward most often)

Secondary Lesions = loss of superficial epidermis, does not extend to dermis, depressed moist area, ruptured vesicle, scratch, aphthous ulcer

erosion Erosion - top layer of skin eroded off - if blister has come off

hard plaque covering an ulcer implying extensive tissue necrosis, infarcts, deep burns, or gangrene (burn ward most often)

eschar Other Secondary Changes

Secondary Lesions = mechanical removal of epidermis, exposes dermis

excoriation Excoriation - procedure done in dermatologist office

Normative scores can be applied across populations? true false

false You can NOT apply the norm across health condition. Normative score - 6 min walk test , age 65 1000 feet is normative score but we know younger people can walk further - can we apply to 1000 feet to other population? No the answer is false

Likelihood ratios for positive we want _______ for negative we want ________

for positive we want more than 10 for negative we want less than zero Top row is strongest Pos ratio over 10 is very good Negative likelihood ratio less than zero feel really confident As you go down the table it shifts your confidence

Examination - Nails Yellow discoloration is seen in

fungal infections psoriasis, thyroid dz, lung dz, DM (ask follow up questions)

refers to a large malignant tumor that is erupting like a mushroom or fungus.

fungating Other Secondary Changes

A patient is using a Beta Blocker for high blood pressure. Due to this your patient is at risk of__.

having a suppressed heart rate and blood pressure to exercise

Vascular Lesions localized collection of blood creating an elevated ecchymosis associated with trauma

hematoma

You develop a new test for labral tears of the hip. Your newly developed test is named "L-Tear" and it has Sensitivity of 100% and a Specificity of 40%. Please choose the BEST answer regarding the reported clinimetrics of L-tear

if a patient tests neg with the L tear they most likely do not have a labral tear based on the sensitivity

Examination - Nails Whiter than expected nails esp. with darker rims are suggestive of

liver problems Liver dz esp if co-occurs with jaundice

= < 1 cm, flat, circumscribed with color change - seen in rubella, scarlet fever

macule Macule - flat, circular change in color in skin, scarlet fever looks like this but lots of them - round fat color change Primary Lesions

Primary Lesions ___ = < 1 cm, flat, circumscribed with color change - seen in rubella, scarlet fever _____ = > 1 cm, may have irregular border _____ = > 0.5 cm, psoriasis, actinic keratosis ______ = < 0.5 cm, elevated, palpable, solid - warts

macule = < 1 cm, flat, circumscribed with color change - seen in rubella, scarlet fever patch = > 1 cm, may have irregular border plaque = > 0.5 cm, psoriasis, actinic keratosis papule = < 0.5 cm, elevated, palpable, solid - warts

Multiple Myeloma

malignant tumor of bone marrow cells Most common malignancy of the spine Diffuse osteoporosis Pain: With movement Not relieved in recumbent position

MCID

minimal clinically important difference

MDC

minimal detectable change

Diabetes and Skin Diabetic Dermopathy

multiple, hyperpigmented macules on legs like age spots occur in skin that has been injured or traumatized classified as vascular disorder because histology shows red blood cell extravasation and capillary basement membrane thickening Treatment-usually none Little spots Round flat lesions

The likelihood that a person who does not have the disease test negative

negative predictive value

= 0.5 - 2.0 cm, circumscribed, elevated, palpable, solid, extends deeper into dermis than a papule - lipoma, squamous cell carcinoma

nodule nodule = raised solid lesion more than 1 cm. and may be in the epidermis, dermis, or subcutaneous tissue. - medium to large size- elevated like a bump - extends down into the dermis Primary Lesions

Primary Lesions ____ = 0.5 - 2.0 cm, circumscribed, elevated, palpable, solid, extends deeper into dermis than a papule - lipoma, squamous cell carcinoma _______ = > 1-2 cm, elevated, palpable, solid, do not always have sharp borders ______ = < 0.5 cm, circumscribed, elevated, palpable mass containing serous fluid - herpes simplex/zoster, chicken pox, poison ivy

nodule = 0.5 - 2.0 cm, circumscribed, elevated, palpable, solid, extends deeper into dermis than a papule - lipoma, squamous cell carcinoma tumor = > 1-2 cm, elevated, palpable, solid, do not always have sharp borders vesicle = < 0.5 cm, circumscribed, elevated, palpable mass containing serous fluid - herpes simplex/zoster, chicken pox, poison ivy

A physical therapist examines a patient who exhibits weakness bilaterally in the hip flexors, hip abductors, and gluteals, constant pain in the low back, hips, and legs, and fatigue. These are signs and symptoms that are

non mechanical and may reflect systemic involvement

"A set of items that are used to create scores that are "intended to quantify a patient's performance or health status based on standardized evaluation protocols or close ended questions."

outcome measure Quantify performance or heath status -fixed number of responses -close ended questions -how well can they function based on this tool