PTE 731: exam 1

pathophysiology module 1: chapters 1-4

why must physical therapists perform a screening for referral?

1. treat as specifically as possible by determining the most appropriate plan of care and intervention strategy for each patient

2. recognize the need for medical referral

what 4 factors empowers a physical therapist for proper decision making processes?

to other health care professions, PTs can:

1. refer

2. consult

3. retain (direct/supervise)

4. co-manage

list the 7 reasons for screening per the text.

1. direct therapy access

2. quicker and sicker patient base

3. signed prescription

4. medical specialization

5. disease progression

6. patient disclosure

7. presence of 1 or more yellow or red flags

T or F: a physical therapist shall consult with an approved health care provider after ten visits or 30 days, whichever comes first, before continuing PT if a patient’s condition has improved and the therapist believes that continued PT is reasonable and necessary.

T

health

state of complete and physical, mental, and social well-being and not merely the absence of disease

disease

state of impaired physical, mental, or social functioning

_______ is the study of the transition from “normal” to “abnormal”.

pathophysiology

recovery involves treatments. what are some examples of treatments discussed in class?

• diet

• active rest

• protected physical activity

• medications

• emotional support

what are the 3 types of prevention?

1. primary: stop/avoid disease or illness prior to clinical onset

2. secondary: early disease detection to limit damage; not clinical apparent

3. tertiary: improve outcomes in those with disease

what are the elements of patient management?

• examination: hx, review of systems, tests and measures

• evaluation: assessment of data

• diagnosis: determined within scope of practice

• intervention: coordination, communication, and documentation of plan

• outcomes: actual results of plan

methodological screening chart

what is possible in the event of incongruence between a patient’s history and a therapist’s working diagnosis?

red or yellow flags

what is considered the number one red flag?

patient has a history of the disease/condition

what characteristics of the patient’s disease are we looking for?

1. type

2. onset

3. intensity

4. location

5. duration

6. progression

7. modifying factors

what are constitutional symptoms?

a general, systemic indicator of illness that affects a person's overall well-being, rather than a specific organ or localized problem

list the constitutional symptoms.

• fever

• diaphoresis

• episodic sweats

• nausea

• vomiting

• diarrhea

• pallor

• dizziness/syncope

• fatigue

• weight loss

what screening list do we perform while collecting subjective information according to Dr. Joe?

1. chief complaint

2. history of present illness

3. past medical and surgical history

4. medications/ allergies

5. social history

6. family medical history

chief complaint

statement of why patient is here

• in their own words

• give them time to answer

• open posture and attitude

history of present illness

pertinent information on the patient’s disease and dis-ease

• search for red and yellow flags

• include if patient has had this before; if so, what was done and what were the outcomes

past medical history

gathering of historical health info that is seemingly not related to the present illness

past surgical history

any prior surgeries and their outcomes/complications

• if it pertains to chief complaint, obtain detailed info

medications/ allergies

any and all current medications (rx, OTC, herbs/spices)

• include any allergies- intolerances and reactions

social history

interactions with surroundings and society

• think socioeconomic factors

family medical history

similar to past medical history but for family

• first degree: mom, dad, brother, sister

• second degree: grandparents, uncles, aunts

what are the big 4 medical historical events that are important to obtain during the subjective?

1. ASCVD (MI/stroke)

2. hypertension

3. diabetes

4. cancer

pain referral patterns

what are the two instances where a therapist will need to refer a patient?

1. “when no apparent movement dysfunction, causative factors, or syndrome can be identified, and/or the findings are not consistent with the NMS dysfunction.”

2. reached the limits of your medical knowledge

patient evaluation and referral flow chart

how can a therapist improve his or her nonverbal communication skills when collecting subjective info?

declutter area, sit down, present with an open posture, affirm patient, and maintain neutral expressions

what are the three common errors exhibited by the therapist while collecting the subjective info?

1. control of conversation

2. understanding (lack of?)

3. over assumption

what factors frame an individual’s communication style?

• age

• gender

• ethnic identity

• education

• religion

what are the therapist traits needed for a good collection of subjective info?

• unhurried

• empathetic

• patient

• inviting and accepting

• guiding

• encouraging

• educational

• adaptable

what’s the difference between open-ended and close-ended questions according to Dr. Joe?

open-ended: absence of bias; allows patient to state his/her perceived response with out forcefully fitting it to therapist’s agenda (inviting)

close-ended: leading and limits patient’s response (restrictive)

what is the purpose of paraphrasing a patient’s response back to him or her?

it shows/provides validation, clarification, and enhancement

tools/reviews of systems provide these 4 factors to the therapist’s decision making process:

1. standardization

2. completeness

3. relevance

4. reproducibility

what does the CAGE questionnaire stand for?

pertains to questions related to alcohol use

• cut down

• annoyed by criticism

• guilty about

• eye-opener

____ is the most common primary risk factor for disease, illness, and comorbidities.

age

what does CH2OPD2 stand for?

community

home, hobbies

occupation

personal habits

diet, drugs

what factors constitute a fall risk assessment?

• impaired balance and/or vision

• slower reaction times

• decreased strength

• limited range of motion

• medications/polypharmacy

• comorbidities

• fear of falling

adverse drug events (ADE)

any harm or injury resulting from the use of a medication

what information is important to gather from a hospitalized patient’s medical record?

• age

• medical diagnosis

• surgery report

• physician/nursing notes

• associated or additional problems

• medications

• current precautions or restrictions

• lab results

• vital signs

what is pain?

an unpleasant sensory and emotional experience associated with, or resembling that of, actual or potential tissue damage

• not a vital sign

• clinicians should asses pain’s impact on function, context, and patient goals

how are pain and nociception different?

pain is a perception whereas nociception is a “true” neurological experience

what are the three characteristics of pain?

1. perceptional

2. personal

3. learned

pain is a sum of what three functions?

1. biological

2. social

3. psychological

what is the purpose of pain?

to patient: acts as a protective warning system for body

to therapist: an indicator and guide for treatment plan

how is pain perceived?

via a loop response within the body between receptors, neurons, and the cortex

• pathway follows along sympathetic pathways

T or F: chronic pain is a learned response

T

nociceptive pain

pain related to damage of somatic or visceral tissue as a result of trauma or inflammation

what are three examples of nociceptive pain cases?

• RA and OA

• tendonitis/ bursitis

• neck and back pain with structural pathology

neuropathic pain

pain related to damage of peripheral or central nerves; an irritated or dying nerve

• this type of pain indicates an abnormality of transmission

what are three examples of neuropathic pain cases?

• lumbar or cervical radiculopathy

• stenosis

• PHN

central sensitization

pain without identifiable nerve or tissue damage thought to result form persistent neuronal dysregulation (CNS amplification)

• aka nociplastic

what are three examples of central sensitization pain cases?

• fibromyalgia

• IBS

• chronic fatigue syndrome

if a patient presents with mixed pain conditions with multiple pain pathophysiologies (like chronic back pain) what should a therapist do?

identify the predominate type of pain to address first

what are the five sources of pain?

1. cutaneous

2. somatic

3. visceral

4. neuropathic

5. referred

T or F: somatic and visceral pain from a deeper source are usually poorly localized.

T

visceral pain patterns are usually experienced in a _______ pattern because the central nervous system has trouble interpreting the input.

dermatomal

what is referred pain?

pain that is perceived at a location different from the actual source of the pain stimulus

list five places referred pain is most likely to be experienced?

1. chest

2. back

3. shoulder

4. scapula

5. pelvis

a patient presents with middle and lower back pain. he claims a gradual onset and that his pain does not change when he tries different positions. what source do you suppose his pain is originating from?

visceral diagnosis of abdomen and pelvis area

a patient presents with shoulder pain. she is a collegiate volleyball player, yet the therapist cannot reproduce her pain during testing. what source do you suppose her pain is originating from?

visceral diagnosis of thorax area

the lower thorax and the upper abdomen are visceral pain sources that are hard to differentiate and require careful examination. what are the referral areas associated with each one?

visceral diagnosis of lower thorax: shoulder, mid/upper back, upper abdomen

visceral diagnosis of upper abdomen: lower chest, mid back, shoulder

what are the three mechanisms of referred visceral pain?

1. embryologic development

2. multisegmental innervation

3. direct pressure and shared pathways

how does embryological development play a role in referred pain?

the referred pain pattern is based on the development of tissues and organs from the same embryonic origin

referred pain via ______ _______ describes how viscera (organs) share overlapping spinal segments with somatic structures.

multisegmental innervation

define “pain equivalences”

(painful) symptoms associated with activity while experiencing an underlying visceral issue

• example: cardiac issues leads to painful sensations like shortness of breath, fatigue, and nausea

the innervation levels of ______ explain why patients with cardiac issues experience referred pain in various UE and upper trunk regions.

C3 - T4

how do direct pressure and shared pathways play a role in referred pain?

direct pressure: irritation, inflammation, obstruction, or distention of an organ brings it into contact with another, uninvolved organ

shared pathways: nerve signals from the irritated organ travel through ganglions nad nerve plexuses that connect different neural systems and provide local control to organs

describe visceral-organ cross-sensitization

ganglions from each neural system gather and share info through the spinal cord to the plexus

• aka pain in one organ results in pain in another, because 2nd order neurons in the CNA have convergent inputs

visceral organs are innervated by the _____ nervous system.

autonomic

visceral pain patterns

what characteristics of the patient’s pain are we looking for?

1. type

2. onset

3. duration

4. location

5. intensity

6. pattern/behavior

7. associated signs and symptoms

a patient describes her pain as “aching, sore, and deep.” what source of pain did she just describe?

musculoskeletal

a patient reports “throbbing and sometimes pulsing” pain in his left LE. what source of pain did he just describe?

vascular

a patient “sharp, itching, tingling, and shooting” pain down her right UE. what source of pain did she just describe?

neurogenic

studying for the pathophysiology exam brings on “frightful, agonizing, exhausting, and annoying” pain. what source of pain are you feeling?

emotional :)

T or F: during the screening process, therapists are more interested in separating the musculoskeletal from the non-MSK causes of pain in order to properly identify and refer patients.

T

T or F: cyclical pain is not considered a red flag because it is a natural, reoccurring pain pattern that the patient can deal with.

F; cyclical pain = red flag!

what is the purpose of the physical assessment screen tool?

gather info on the physical condition of the patient in order to identify those who are and are not appropriate for therapy and to arrange appropriate triage in a timely manner for those who are at risk

T or F: a full head to toe physical assessment is always needed.

F; not always needed! if the screening tests are congruent, move on with interventions

what are the four parts of the general survey?

1. mental status: delirium

2. nutritional status

3. odors

4. vital signs: pulse, temp, RR, SaO2, BP

what are the three parts of the mental status exam?

1. LOC: awake, aware, responsive

2. orientation x4: person, place, time, situation

3. communication: congruent words, actions, and affect

what is delirium?

a temporary often reversible change in mental status that commonly occurs in older patients, especially ~24 hours after hospitalization for serious illness or surgery with general anesthesia

what can lead to a state of delirium?

injury, infection, hypoglycemia, hypoxia, hypotension, and/or medications

the BMI is not the end all, be all for checking nutritional status, but it can still provide healthcare providers with helpful info. what can a classification of over-nutrition and under-nutrition show providers?

over-nutrition: patient may have or be at an increase risk of diabetes, hypertension, MI, stroke, cancer, or dylipidemia

under-nutrition: patient may have or be at an increase risk of poor intake, malabsorption, or hypermetabolic

a patient presents to the clinic with constant fatigue and neck pain/headaches. the therapist notices after a couple weeks that the patient appears more gaunt with noticeable bruising, bagger clothing, and seems disinterested in therapy. what may explain this change?

patient is undernourished

what three smells are common in a patient with diabetes who is not taking care of himself?

• pseudomonas

• yeasty small

• acetone smell

what are considered the primary vital signs according to Dr. Joe?

BP, HR, RR, core temp, and SaO2 (oxygen saturation)

what are considered the secondary vital signs according to Dr. Joe?

pain rating, skin temp, capillary refill, and walking speed

what’s the difference between respiration and ventilation?

respiration: breathing, the physical act of taking in oxygen and expelling carbon dioxide

ventilation: process of bringing fresh, outdoor air into a space while removing stale, indoor air.

normal respiratory rates chart

patients with what diseases may experience a low respiratory drive?

TBI, stroke, drug users, and NMD (neuromuscular disease)

where in the cortex is the respiratory drive center located?

pons and medulla oblongata

what is the purpose of the cardiovascular system?

• deliver oxygen/nutrients

• remove waste

• circulate hormones/immune cells

• regulate temp, fluid balances, and pH

what is the protocol for measuring an accurate reading of a patient’s blood pressure?

• empty bladder

• no eating, drinking, or smoking for 30 mins prior

• feet flat on floor in quiet environment for 5 mins prior

• proper sized cuff

• proper patient posture: sitting upright in chair, legs and feet uncrossed, arm resting at heart level, and cuff right above elbow on bare skin

blood pressure chart

if a blood pressure reading is whack, what should the health care provider do?

1. wait 5 mins and measure it again (while following proper protocol)

2. measure it on opposite arm

3. call/refer out if still whack

a resting SBP > 180 and/or a DBP > 120 are considered a hypertensive crisis, but what’s difference between a hypertensive urgency and emergency?

hypertensive urgency: without signs of organ failure

hypertensive emergency: with signs of organ failure, stroke, heart attack, or dyspnea

a patient who is on vacation in Colorado (high altitude) walked in to a clinic after encountering a bear on a hike. she presents with high stress/anxiety from the incident and states her heart rate hasn’t slowed even after meeting her family for lunch. the health care provider should expect her blood pressure to be ____ than normal.

higher