Exam 1 Content

why do we need a solid understanding of differential diagnosis

• may systemic diseases mimic common musculoskeletal conditions

• therapists are entry point to healthcare

responsibilities of PT

• understand anatomy, physiology, kineisology, kinesiopathology

• perform tests and measurements

• interpret tests and measurements

• plan initial and subsequent treatments

• administer treatments

• communicate with other healthcare professions

what is differential diagnosis

comparison of symptoms of similar diseases so that a correct assessment can be made

what is a diagnosis

collections of relevant signs and symptoms to identify disease

what are signs

measurable and observable findings

what are symptoms

unobservable but reportable indications of disease perceived by patient

examples of signs

fever, swelling, cough

examples of symptoms

pain, dizziness, nausea, numbness

what differentiates a medical diagnosis from a PT diagnosis

medical diagnoses only describe the site of an injury, while PT diagnoses encompass a cluster of signs and symptoms

what is the purpose fo a PT clinical diagnosis

• determine prognosis

• guide PT in determining most appropriate intervention

• consider risk factors along with treatment

steps of PT clinical diagnosis

1. examination

2. evaluation

3. diagnosis

what happens in examination stage of PT clinical diagnosis

collection of data

what happens in evaluation stage of PT clinical diagnosis

organization and interpretation of data

what happens in diagnosis stage of PT clinical diagnosis

application of evaluation to determine most appropriate intervention

APTA standards for screening exams

• describe etiology and clinical manifestations of disorders that mimic dysfunction

• describe clinical signs and symptoms of the more common disorders of organ systems other than neuromuscular

example of relating neuromuscular signs and symptoms with other organ systems

shoulder pain could indicate a heart attack

what is etiology

the study of the causes, origins, or reasons behind a disease, condition, or phenomenon

why is subjective examination important

to look for possible risk factors

what types of date can be generated from subjective examination

• general demographics

• functional status and activity level

• medications

• other tests and measures

• past history of current condition

• past medical or surgical history

• family history

• health status

• social habits

• history of current condition

• living environment

• growth and development

• employment

• social history

why do we need information on medications to develop diagnoses

different medications can produce certain side effects, some combinations of medications can cause synergistic or antagonistic effects

what is important to consider when interviewing a patient

awareness of cultural uniqueness

what is the typical clinical interview process

1. one or two open-ended questions

2. close-ended questions

3. end with final “anything else” open-ended question

purpose of body chart

• localize symptoms

• chart pain, numbness, tingling, etc

• identify referred or radiating pain

• a visual to review with clients

what is the importance of patient history

• clarify history of present illness

• reveal past medical history

why do we need to know a patient’s past medical history

some diagnoses can affect/spread other areas/systems

what important questions can be asked to aid with diganoses

• medications

• imaging

• recent surgery

• weight change

• bowel or bladder dysfunction

• contraindications

• stressors

what are some signs that can indicate cancer

abnormal weight change, bowel or bladder dysfunction

what are contraindications

signs that may interfere with PT intervention

what is beneficial about knowing history of symptoms

• identifying factors that either relieve or aggravate symptoms

• identify type of symptom: acute, subacute, chronic

key fact to understand pain

pain is subjective, but it is quantifiable

characteristics of pain

• neuromuscular location

• description

• pattern (to identify potential risk factors)

• frequency

• duration

• intensity (pain scale)

• associated symptoms

identify the standardized pain assessment tools and describe which one is basic or complex

• Visual Analog Scale (basic)

• McGill Pain Questionnaire (complex)

list the sources of pain

• cutaneous pain

• deep somatic pain

• visceral pain

• neuropathic pain

• referred pain

what is cutaneous pain

pain from skin and/or subcutaneous tissue

cutaneous pain is also known as

superficial somatic pain

describe localization of cutaneous pain

well localized, easy for client to point out

common mixup between cutaneous and deep somatic pain

tenderness may occur in one or both

what is deep somatic pain

pain arising from bone/periosteum, nerve, muscle, tendon, ligament, joint, blood vessel

what could pain in bone/periosteum indicate

arthritis

what could pain in nerve indicate

impingement

describe localization for deep somatic pain

key characteristics of deep somatic pain

• dull, aching, expanding pressure

• associated with nausea, faintness, dizziness

what is visceral pain

pain originating from internal organs and heart muscles

describe localization of visceral pain

not well localized

how do cutaneous pain and visceral pain get confused

visceral pain can produce referred pain

what is neuropathic pain

pain as a result from damage/pathology of PNS or CNS

key characteristic of neuropathic pain

• it is not elicited by nociceptors (pain receptors), but a maladaptation in nerves system

• sharp, shooting, burning, tingling sensation

• non-noxious stimuli (touch, cold, etc)

describe maladaptation in nervous system

CNS gets messed up and reorganizes to function abnormally

what is referred pain

pain that is felt at a site distant from its cause

describe localization of referred pain

well localized but occurs in remote areas

why does referred pain happen

certain areas of the body have same/similar sensory innervations due to embryologic development

examples of referred pain

• shoulder with heart

• shoulder and waist with gallbladder

list the types of pain

• muscular/myofascial pain

• joint pain

• inflammation of arteries/pleura

• heart pain

• GI pain

• radicular pain

characteristics of muscular pain

• worsens with muscle contraction or stretch

• pain can come from ischemia

• use of muscle, bone, tendon, bursa increase pain

• rest brings relief

characteristics of myofascial pain

• considered muscular pain

• pain from active myofascial trigger point with associated dysfunction

what is a trigger point

hyperirritable spot in skeletal muscle or fascia that is tender on palpation and gives rise to referred pain

characteristics of joint pain

• described as sharp pain

• improves with rest and aggravates with activity

characteristics of arterial pain

• due to artery inflammation

• increased pain from increased systolic BP

• described as throbbing pain

characteristics of pleural pain

• correlates with respiratory movement

• sharp pain associated with breathing, coughing, laughing

• sounds like rubbing sandpaper with a stethoscope

what is a pleura

lining between lungs and thoracic cavity

characteristics of heart pain

• pain increase from increased demand on heart

• decreases with rest

• as symptoms progress pain may be present without increase in activity

what increases demand on the heart

exercise, stress

characteristics of GI pain

• increase with ingestion or peristalsis

• decrease with fasting, bowel movement, vomitting

• distended organs

• body positions and movements may increase pain

• supportive positions may decrease pain

• pain not well localized

characteristics of radicular plain

• direct irritation or involvement of a spinal nerve

• pain caused in dermatome, sclerotome, myotome

what can cause pain at rest

• ischemia from vascular disease

• ischemia from tumor growth pressing on nerve endings

• neoplasm

describe neoplasm

pain that worsens in the evening, interrupting sleep

how to identify acute arterial occlusion

disproportionate pain, pallor, pulselessness, paresthesia, paralysis

describe an embolism

group of blood cells lodged as vessel narrows, blocking blood flow

describe vascular pain due to activity

• cramping pain from intermittent claudication

• artery narrowed by plaque and gets pushed more with movement

• present during movement and decreases with rest

what acronym is used for cardinal cancer warning signs

CAUTION

what are the cardinal cancer warning signs

• changes in bowel/bladder

• a sore that does not heal

• unusual bleeding or discharge

• thickening or lump in breast or elsewhere

• indigestion or difficulty swallowing

• obvious change in wart or mole

• nagging cough or hoarseness

characteristics of systemic pain

• recent, sudden

• deep aching, throbbing, cutting

• unilateral or bilateral

• relatively constant

• have associated signs and symptoms

describe general musculoskeletal pain

• gradual onset

• stiff, cramping, achy, local tenderness

• unilateral

• position changes and movement alter pain intensity

factors to consider during pain assessment

• anxiety

• depression

• panic

• fear avoidance behaviors

tips to accurately interpret patient history

• identify noncontributory information

• identify chief and secondary problems

• identify information that is inconsistent with presenting complaint

• generate working hypothesis regarding possible causes

• determine whether referral is indicated

red flags to consider when interviewing a patient

• history of cancer, recent infection, recurrent flu/cold, recent trauma, immunosuppression

• risk factors

• clinical presentation (unknown etiology, insidious onset, failed PT intervention, progressive symptoms)

• pain pattern

• associated symptoms and signs

when do PTs give referrals

• physical therapy is contraindicated

• treatment of condition is outside scope of knowledge

• medical diagnosis required but not established

who should PTs refer patients to

• patient’s PCP

• provide list of recommendations for physicians

define pharmacology

study of drugs

define drug

any substance that may modify one or more of its functions

why is understanding pharmacology important

can utilize knowledge of pharmacology to create therapeutical alliance with patients

define pharmacotherapeutics

use of drugs to prevent, treat, or diagnose disease

define pharmacokinetics

how body absorbs, distributes, or eliminates drugs

define pharmacodynamics

effect drug has on body systemically and cellularly

pharmacokinetics and pharmacodynamics are aspects of what

pharmacotherapeutics

why might some people use substitutes of generic drugs

they are less expensive and reduce cost of healthcare

criteria for generic substitution of drugs

• same type and amount of active ingredients

• same administration route

• same pharmacokinetic profile

• same therapeutic effects

list the phases of drug approval process and how long each phase takes

• preclinical trials (1-2 years)

• clinical trial phase 1 (less than 1 year)

• clinical trial phase 2 (2 years)

• clinical trial phase 3 (3 years)

• clinical trial phase 4

describe preclinical trial stage of drug approval

research of drug and testing on animals

describe clinical trial phase 1 of drug approval

drug is tested on healthy person and a patient

describe clinical trial phase 2 of drug approval

drug is tested on small patient sample

describe clinical trial phase 3 of drug approval

drug is tested on larger patient sample

describe clinical trial phase 4 of drug approval

drug is approved for marketing and post-marketing surveillance takes place

what are orphan drugs

drugs that treat rare diseases

characteristics of orphan drugs

• not super profitable

• did not pass clinical trial phase 3 or 4

• small population effect

define off-label processing

use of drug to treat conditions other than those that drug was originally approved to treat

how did off-label prescribing come about

additional clinical observation and research, serendipitous discovery (happy accident)

characteristics of off-label prescribing

• FDA cannot dictate how they are prescribed

• physicians must justify the need for them

• insurance companies can deny payment for these drugs

• clinical practice guidelines (CPG) has potential to reduce these types of drugs

list some examples of off-label prescribing drugs and their use

• metformin for diabetes, blood thinning, and PCOS

• viagra for vasodilation from vasoconstriction of angina, erectile dysfunction

• platelet rich plasma (PRP) for meniscal tear, tendonitis, muscle strain

• ACE inhibitors for BP regulation, decrease thyrosis, arthritic fibrosis, decrease scar tissue

define prescription drugs

must be ordered or dispensed by authorized provider