Week 1 - PT 814

What are the steps involved in a quick screen for a patient?

1. Vitals

2. Review the pain body chart

3. Review medications and potential side effects

4. Check for red flags, risk factors, associated signs and symptoms

5. Ask broad & open-ended questions

Which vitals should be taken as part of a screen?

• Blood pressure

• Pulse

• Respirations

• Body temperature

• Pulse oximetry (O2 saturation)

Normal Adult Systolic BP

90-119 mm Hg

Normal Adult Diastolic BP

60-79 mm Hg

Pulse Strength Grades

0 = absent, not palpable

1+ = pulse diminished, barely palpable

2+ = easily palpable, normal

3+ = full pulse, increased strength

4+ = bounding, too strong to obliterate

What pulse types are considered red flags and require referral?

Pulse increases over 20 bpm lasting > 3 minutes after rest or position changes

What body temperature measurements are considered red flags and require referral?

• Persistent low-grade (or higher) fever (especially associated with constitutional symptoms e.g. sweats, unintended weight loss, malaise, nausea, vomiting)

• Any unexplained fever without other systemic symptoms (especially in the context of corticosteroids or otherwise immunosuppressed)

What are generic red flags when taking vital signs?

Unusual vitals along with:

• Pallor

• Perspiration

• Fatigue

• Palpitations

What red flag vital signs require referral outward?

• Lasting for hours (> 6 episodes per minute)

• SOB, chest pain, dizziness, lightheadedness

• + Family hx of sudden cardiac death

• Hx of heart disease

Systemic Illness Red Flags

• Gradual onset with no known cause

• Constant & intense

• BL sx (edema, pigmentation changes, clubbing, numbness, tingling)

• Constitutional sx (night sweats, fever, pallor, nausea, vomiting, diarrhea, dizziness, weight loss)

Associated Red Flag Signs & Symptoms

• Headache

• Visual changes

• Bowel/bladder changes

• Unusual vital signs

• Warning signs of cancer

• Dyspnea

• Orthostatic hypotension

Systems Review vs Review of Systems

Systems Review: brief exam of anatomic and physiologic systems (CVP, integumentary, musculoskeletal, neuromuscular, communication, learning style, cognition, attention)

Review of Systems: part of pt history to gather information that may necessitate referral outward (screening assessment)

Factors Affecting Mental Status

• Shock

• Head injury

• Stroke

• Hospitalization

• Anesthesia

• Medications

• Malnutrition

• Chemical exposure

• Hypo or hyperthermia

• Depression

• Anxiety

• Age

• Substance or alcohol use

• Education

• SES and background

Body & Breath Odors

• Fruity breath odor: diabetic ketoacidosis

• Bad breath odor: dental decay, lung abscess, throat or sinus infections, GI disturbances, bowel obstruction, or bacteria

• Body odor: incontinence (urine, ammonia, feces)

When should we perform a skin and nail bed assessment?

During every patient/client assessment

Integumentary Screening - Skin & Nail Bed Assessment

• Signs of inflammatory, infectious, and immunologic disorders

• Assess hands, arms, feet, legs

• Look for changes in texture, color, temperature, clubbing, circulation, capillary refill, edema

• Assess nail beds for changes in color, shape, thickness, texture, and presence of lesions

Abnormal Skin Texture Changes

Shiny, stiff, coarse, dry, scaly skin

ABCDEs of Skin Lesions

Asymmetry

Border

Color

Diameter

Evolution or Elevation

Musculoskeletal Screening Examination - Components

• Obvious deformities, abnormalities, disabilities, asymmetries

• Inspection and palpation of skin, muscles, soft tissues, joints

• Test “normal” side first

• Examine the joint above and below the involved joint

• Resisted isometrics are performed in open pack position

• Never force painful joint motions or painful, empty end-feels of joints

6 Major Areas of a Neurologic Screening Examination

1. Mental and emotional status

2. Cranial nerves

3. Motor function (gross and fine motor, coordination, gait, balance)

4. Sensory function (light touch, vibration, pain, pressure, temperature)

5. Reflexes

6. Neural tension

4 Physical Assessment Areas of a Regional Screening Examination

1. Head & neck

2. UEs and LEs

3. Chest & back

4. Abdomen

4 Techniques of a Regional Physical Examination

1. Inspection (texture, size, position, alignment, color)

2. Palpation

3. Percussion (determine tissue integrity, detect fluid or air in cavities)

4. Auscultation

The diaphragm side of the stethoscope is used to listen to which sounds?

High-pitched sounds (i.e. normal heart sounds, bowel sounds, friction rubs)

The bell side of the stethoscope is used to listen to which sounds?

Low-pitched sounds (i.e. heart murmurs and BP)

Hematologic System

Composed of blood, blood vessels, and the organs that produce blood

What are the components of blood?

• Erythrocytes: RBCs (carry oxygen and remove CO2 from tissues)

• Leukocytes: WBCs (inflammatory and immune response)

• Plasma: pale yellow or green fluid where platelets are suspended (carry antibodies and nutrients to tissues, remove waste)

• Platelets: thrombocytes (control blood clotting)

Signs & Symptoms of Hematologic Disorders

CVP: dyspnea, chest pain, palpitations, severe weakness, fatigue, decreased diastolic BP

Nervous system: headaches, drowsiness, dizziness, syncope, polyneuropathy

Integumentary: pallor, easy bruising, bleeding (skin, gums, hands, face, fingernail beds, mucous membranes)

GI: blood in stools

Musculoskeletal: severe swelling and pain in joints & muscles

Anemia - Description

Reduction in the oxygen-carrying capacity of the blood as a result of an abnormality in the quantity or quality of erythrocyte

• Iron deficiency

• Chronic disease

• Neurologic conditions

• Infectious disease

Anemia - Clinical Signs & Symptoms

• Skin pallor or yellow-tinged skin (fingernail beds, hands)

• Fatigue

• Lightheadedness

• DOE with heart palpitations and rapid pulse

• Chest pain with minimal exertion

• Decreased diastolic BP

• Nervous system manifestations

True or False: It is normal for the systolic BP to change in patients with anemia.

False (systolic BP is unaffected but diastolic BP is lower than normal)

Can anemia be diagnosed used a pulse oximeter?

No (patients will have a normal SpO2 reading, likely lower systolic/diastolic BP and increased HR)

Sickle Cell Disease - Description

A group of inherited disorders characterized by the presence of an abnormal form of hemoglobin

• Altered sickle or curved shape of cells

• Cells cannot get through vessels

• Vessels become deprived of blood supply

Autosomal recessive disorder

More common with African descent

Sickle Cell Disease - Clinical Signs & Symptoms

• Pain

• Bone and joint episodes

• Vascular complications

• Pulmonary episodes

• Neurologic manifestations

• Hand-foot syndrome

• Splenic sequestration episodes

• Renal complications

Leukopenia

Reduction in the number of leukocytes in the blood

High risk of infection if the patient is immunosuppressed

Check for constitutional symptoms (fever, chills, sweats) and immediately refer if present

Thrombocytopenia - Description

Decrease in the number of platelets (< 150,000/mm³)

Thrombocytopenia - Clinical Signs & Symptoms

• Bleeding after minor trauma

• Spontaneous bleeding

• Petechia (small red dots)

• Ecchymoses (bruises)

• Purpura spots (bleeding under skin)

• Epistaxis (nosebleeds)

• Menorrhagia (excessive menstruation)

• Gingival bleeding

• Melena (dark, tarry stools)

Example Causes of Thrombocytopenia

• Bone marrow failure

• NSAIDs

• Chemotherapy

• RA medications

• Blood thinners

Hemophilia - Description

Hereditary blood-clotting disorder caused by an abnormality of functional plasma-clotting proteins

X-linked recessive disorder

Hemophilia - Clinical Signs & Symptoms

• Hemarthrosis (bleeding into joint spaces)

• Muscle hemorrhage

• GI involvement

Primary Polycythemia

Increase in RBC concentration (commonly associated with sleep apnea, smoking, chronic CVP conditions, high altitudes, smoking)

Blood becomes thickened = increased risk of clotting

Why is soft tissue mobilization contraindicated for individuals with thrombocytopenia?

STM can cause bruising resulting in increased risk of bleeding (low platelet count at baseline poses higher risk of bleeding)

Clinical Presentation of Immunologic Diseases

• Pain

• Swelling

• Stiffness

• Generalized weakness

• Nail bed changes

Fibromyalgia - Description

Chronic systemic condition with widespread pain and fatigue

Women > men impacted

Hypersensitive CNS

Fibromyalgia - Clinical Signs & Symptoms

• Myalgia

• Fatigue

• Sleep disturbances

• Restless leg syndrome

• Tender points on palpation

• Chest wall pain

• Tendinitis, bursitis

• Temperature dysregulation

• Dyspnea, dizziness, syncope

• Morning stiffness (> 15 min)

• Paresthesia

• Mechanical LBP with radiation

• Subjective swelling

• IBS syndrome

• Urinary urgency

• Dry eyes & mouth

• Cognitive difficulties

• PMS

• Weight gain

• Depression/anxiety

Rheumatoid Arthritis (RA) - Description

Chronic autoimmune disorder attacking the lining of the joints

RA - Signs & Symptoms

• Swelling in one or more joints

• Early morning stiffness

• Inability to move a joint normally

• Obvious redness and warmth in joints

• Unexplained weight loss, fever, or weakness combined with joint pain

• Nodules

Ankylosing Spondylitis - Description

Inflammatory arthritis primarily affecting the spine

Ankylosing Spondylitis - Signs & Symptoms

• Intermittent LBP

• Sacroiliitis

• Spasms of paravertebral muscles

• Loss of normal lumbar lordosis

• Intermittent, low-grade fever

• Fatigue

• Anorexia

• Anemia

• Painful limitation of cervical joint motion

Lyme Disease - Description

Bacterial infection transmitted through the bite of an infected tic commonly affecting the knees, shoulders, and elbows

Lyme Disease - Signs & Symptoms

• Red rash

• Flu-like symptoms

• Migratory MSK pain

• Neurological symptoms (severe headaches, numbness, pain, weakness in extremities, poor motor coordination, cognitive dysfunction)

• Arthritis

• Encephalopathy

• Neurocognitive dysfunction

• Peripheral neuropathy

*Area of involvement can shift

Guillain-Barre Syndrome - Description

Rare neurological disorder where the body's immune system mistakenly attacks the peripheral nerves

Guillain-Barre Syndrome - Signs & Symptoms

• Muscle weakness (ascending)

• Diminished DTRs

• Paresthesia

• Fever, malaise

• Nausea

• Oculomotor dysfunction

• Ataxia

• Areflexia

Myasthenia Gravis - Description

Chronic autoimmune neuromuscular disease that causes fluctuating weakness of voluntary muscles

Myasthenia Gravis - Signs & Symptoms

• Muscle fatiguability and proximal muscle weakness (worse with exertion)

• Respiratory failure

• Ptosis

• Diplopia

• Dysarthria

• Bulbar involvement

• Alteration in voice quality

• Dysphagia

• Nasal regurgitation

• Choking

• Pain

*Hallmark signs

How can we differentiate between GBS and Myasthenia Gravis?

GBS: ascending weakness (LEs then UEs)

Myasthenia Gravis: descending weakness (UEs then LEs)

What is the goal of the endocrine system?

Maintain homeostasis and coordinate activity of the whole body

What are common signs and symptoms of endocrine disorders?

• Proximal muscle weakness

• Myalgia

• Cramps

• Fatigue

• BL carpal tunnel syndrome

• Periarthritis and calcific tendinitis

• Chondrocalcinosis

• Spondyloarthropathy and OA

• Hand stiffness and pain

DM - Description & Symptoms

Description: body does not produce enough or respond normally to insulin, causing abnormally high blood glucose levels

Symptoms: excessive thirst, hunger, frequent urination, vision changes, delayed wound healing, unexplained weight loss

Hyperparathyroidism - Description & Symptoms

Description: excess parathyroid hormone resulting in too much calcium released into the blood

Symptoms: osteoporosis, kidney stones, heart disease

Hypogonadism - Description & Symptoms

Description: decreased estrogen or testosterone

Symptoms: infertility, lack of secondary sex characteristics

Acromegaly - Description & Symptoms

Description: pituitary gland overproduces growth hormone (results in overgrowth)

Symptoms: abnormally large hands, feet, nose, lips, altered facial structure, joint pains, thick skin, sexual dysfunction

Addison’s Disease - Description & Symptoms

Description: insufficient adrenal gland action resulting in not enough cortisol or aldosterone

Symptoms: anorexia, vomiting, nausea, muscle weakness, personality changes, hyperpigmentation, cardiac insufficiency

Cushing’s Disease - Description & Symptoms

Description: excess cortisol (associated with corticosteroid use or adrenal or pituitary tumors)

Symptoms: osteoporosis, buffalo hump, emotional instability, acne, moon face, truncal obesity, easy brusing, muscle wasting, DM

Hashimoto’s Disease - Description & Symptoms

Description: underactive thyroid gland (hypothyroidism)

Symptoms: Cold intolerance, heart failure, bradycardia, muscle weakness, loss of hair, coarse and brittle hair, edema in extremities

Grave’s Disease - Description & Symptoms

Description: hyperthyroid syndrome (overproduction of thyroid gland)

Symptoms: Weight loss, warm skin, hyperreflexia, diarrhea, pre-tibial edema, heart failure, tachycardia, thin hair, exophthalmos (eye protrusion)

Dehydration & Fluid Loss - Symptoms

Thirst, weight loss, poor skin turgor, dryness of mouth, throat, and face, absence of sweat, increased body temperature, low urine output, postural hypotension, dizziness when standing, confusion, increased hematocrit

Potassium Depletion - Signs & Symptoms

Muscle weakness, fatigue, cardiac arrhythmia, abdominal distention, nausea and vomiting

Gout - Signs & Symptoms

Tophi (lumps under skin, eruptions through the skin, chalky urate crystals), joint pain and swelling, fever and chills, malaise, redness

What are some common risk factors for gout?

Diet (red meat, shellfish, alcohol), obesity, hypertension, DM, family history, sex (men)

What are some common signs and symptoms of GI disorders?

Abdominal pain, dysphagia, odynophagia, GI bleeding, epigastric pain with radiation to the back, early satiety, weight loss, constipation, diarrhea, arthralgia, fecal incontinence, referred shoulder pain, psoas abcess, tenderness over McBurney’s point, neuropathy, symptoms affected by food

Abscess of the Obturator Psoas Muscle - Signs & Symptoms

• Fever (hectic, up and down pattern)

• Night sweats

• Abdominal pain

• Loss of appetite or other GI upset

• Back, pelvic, abdominal, hip and/or knee pain

• Antalgic gait

• Palatable tender mass

Gastroesophageal Reflux Disease (GERD)

AKA acid reflux; a disorder of the lower esophageal sphincter where the sphincter doesn’t work correctly and stomach acids flow backwards into the esophagus

Symptoms: heartburn, regurgitation with bitter taste in mouth, belching, chest pain, sensation of a lump in throat, difficulty swallowing, sore throat, asthma, weight loss, anemia, wheezing, coughing, hoarseness

Heartburn

AKA acid indigestion; a symptom of GERD involving burning, pain or discomfort in the chest, sour or bitter taste in the throat and mouth

Peptic Ulcer - Signs & Symptoms

Heartburn, night main, radiating back pain, stomach pain, right shoulder pain, lightheadedness, nausea, vomiting, anorexia, weight loss, blood stools, black tarry stools

NSAID-Induced Disease

• Asymptomatic

• Stomach upset and stomach pain

• Indigestion, heartburn

• New-onset back or shoulder pain

• Melena

• Tinnitus

• CNS changes (headache, depression, confusion, memory loss, mood changes)

• Renal involvement (muscle weakness, unusual fatigue, restless leg syndrome, polyuria, nocturia, pruritus)

Diverticulitis - Signs & Symptoms

Generalized abdominal pain, loss of appetite, nausea, abdominal bloating, left lower quadrant pain, decreased or absent bowel sounds, palpable abdominal mass, flatulence, bloody stools, constipation or irregular bowel movements, urinary urgency and frequency, low-grade fever

Appendicitis - Signs & Symptoms

Periumbilical and/or epigastric pain, right lower quadrant or flank pain, right thigh, groin, or testicular pain, abdominal involuntary muscular guarding and rigidity, (+) McBurney’s point, (+) pinch test, rebound tenderness, positive hop test, nausea and vomiting, anorexia, dysuria, low-grade fever, coated tongue and bad breath

Where is McBurney’s point located?

Halfway between the ASIS and the umbilicus (right quadrant of the abdomen)

Pancreatitis - Signs & Symptoms

Epigastric pain radiating to the back, nausea, vomiting, anorexia, abdominal distention and pain, tachycardia, malaise, weakness, bluish discoloration or abdomen or flanks, jaundice, upper L lumbar regional pain, weight loss, oily or fatty stools, clay-colored or pale stools

(Acute vs chronic)

Ulcerative Colitis & Crohn’s Disease - Signs & Symptoms

Diarrhea, constipation, fever, abdominal pain, rectal bleeding, night sweats, decreased appetite, nausea, weight loss, skin lesions, uveitis, arthritis, migratory arthralgias, hip pain (iliopsoas)

Colorectal Cancer - Signs & Symptoms

Rectal bleeding, hemorrhoids, abdominal, pelvic, back, or sacral pain, back pain that radiates down the legs, changes in bowel patterns, constipation progressing to obstruction, diarrhea with copious amounts of mucus, nausea, vomiting, abdominal distention, weight loss, fatigue, dyspnea, fever

Early Stages vs Advanced Stages

Liver - Function

• Regulates chemical levels in the blood

• Produces bile (waste)

• Balances nutrients and metabolizes drugs

Liver - Disorder Signs & Symptoms

Jaundice, bruising, fatigue, edema, nausea, R upper quadrant pain

Gallbladder - Function

Stores bile needed for digestion

Gallbladder - Disorder Signs & Symptoms

R upper abdominal pain (positive Murphy’s sign), sudden excruciating pain in the mid epigastrium, referred pain to the back and right shoulder, anterior rib pain

Explain the Different Hepatitis Viruses

HAV: present in feces of infected persons most often transmitted through consumption of contaminated water or food

HBV: transmitted through exposure of infective blood, semen, and other bodily fluids; vaccines are available

HCV: mostly transmitted through infected blood; no vaccine available

HEV: mostly transmitted through consumption of contaminated water or food; vaccines are somewhat available

Where does the liver refer pain to?

Thoracic spine (midline - R), R upper trapezius and shoulder

Where does the gallbladder refer pain to?

R upper quadrant, R scapula/axilla, mid back

What are the functions of the kidney?

• Regulates composition and pH of body fluids through reabsorption and elimination

• Eliminates metabolic wastes

• Assists in blood pressure regulation

• Contributes to bone metabolic function

• Controls production of RBCs in the bone marrow

Renal Failure - Description & Symptoms

Description: sudden or progressive loss of renal function and impaired ability to eliminate metabolic waste from the blood

Symptoms: swelling, confusion, lack of urine output, abnormal measures of kidney function

Urinary Tract Infection (UTI) - Description & Symptoms

Description: infection of the urinary tract with microorganisms

Symptoms: pain and frequency of urination, fever, chills, back or groin pain, pain over costovertebral angle (Murphy’s sign), confusion (older adults)

Kidney Stones or Benign Prostate Hypertrophy - Description & Symptoms

Description: pressure build-up backward from site of obstruction due to the inability of urine to flow

Symptoms: flank pain, back pain, hip or upper thigh pain, hypersensitivity over dermatomes T10-L1, fever, chills, hematuria

Renal Cancer - Description & Symptoms

Description: cancer of the kidney

Symptoms: flank pain, hematuria, fatigue, unexplained weight loss

What are the associated signs and symptoms of psudorenal pain?

None; Murphy’s point is negative, reports of bowel and bladder changes are unlikely

Transient Ischemic Attack (TIA)

Stroke presentation lasting <24 hours

Individuals may present with slurred speech, difficulty understanding others, sudden confusion, loss of memory, LOC, temporary blindness, dizziness, severe headache, paralysis or extreme weakness, LOB, impaired coordination, and difficulty walking

Symptoms are usually brief (5-20 min)

Orthostatic Hypotension

A fall in systolic BP >20 mmHg or a drop in diastolic BP >10 mmHg with an increase in HR

Caused by normal aging, medication side effects, neurologic origins, venous pooling

Associated with lightheadedness

Symptoms are worse in the AM and aggravated by heat, humidity, heavy metals, exercise

What are some sample risk factors for PE and DVT?

Family or previous hx, congestive heart failure (CHF), age > 50 years, oral contraceptive use, immobilization or inactivity, OBGYN conditions, neoplasm, pacemakers, trauma, blood disorders, hx of infection, DM

What are the clinical signs of a DVT?

Unilateral tenderness or leg pain, swelling, warmth, discoloration (redness)

Abdominal Aortic Aneurysms (AAA)

Abnormal dilations in weak or diseased arterial walls causing a sac-like protrusion

Associated risk factors: smoking, heart disease, surgery, recent infection, CAD, genetic conditions, weight-lifting in older adults, anticoagulant therapy

Patients present with chest pain, palpable pulsating masses, dull ache in mid-abdominal region, hip, groin, buttock, and/or leg pain and weakness or paralysis of legs

Cyanosis

Bluish or purplish discoloration of the skin, lips, or fingernail beds caused by a lack of oxygen in the blood