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PC 617 Exam 4

Terms in this set (40)

Describe transient carpal tunnel syndrome in pregnancy.
Carpal Tunnel Syndrome may occur in pregnancy because of the increase in fluid retention that will cause swelling within the tendon sheath around the median nerve of the hand. The syndrome usually occurs in both hands during the second or third trimester and will resolve when the swelling is gone (by 3 months postpartum). Carpal Tunnel Syndrome does tend to recur with later pregnancies. Generally, intervention is limited to splinting of the wrist at night and Tylenol for pain. It is only the severe cases (severe, debilitating pain of both hands and atrophy of the thenar area) that need to be referred (Blackburn, 2013, p. 522)
What is bursitis?
Bursitis is a pathologic inflammatory disorder of the bursae caused by varied acute or
insidious processes. A diagnosis is suspected with the common features that may include
pain at motion and at rest, regional loss of range of motion, visible swelling, esp if the
affected bursa lies close to the surface; and tenderness to palpation.
What is the most common cause of bursitis?
The most common cause of is by mechanical irritation resulting from overhead activities,
and it leads to rotator cuff tendinitis. Other processes that cause bursitis include overuse,
trauma, autoimmune diseases, crystal deposits, and infection.
Discuss the history and physical findings to confirm diagnosis of bursitis.
Hx: Pain exacerbated by overhead activities, and there may be a sleep aching that interrupts sleep at night.
Physical: Increased pain with active abduction and internal rotation of the arm plus tenderness below the acromion is demonstrated.
Weakness with internal rotation
Neer's and Hawkin's Impingement Signs
The impingement injection test (10 ml of 1% lidocaine is inj into the subacromial space; after 5-10min, the maneuver for impingement signs are repeated. If pain is reduced 50% the shoulder pain is secondary to subacromial bursitis and tendonitis.
What is the treatment for bursitis?
Periodic gentle range of motion joint activities
Avoidance of activities that exacerbate the pain
Therapeutic modalities
NSAIDS
Stronger analgesics prn esp at night
For severe cases- Corticosteroid injections (limited to 3 inj in 12 month period no fewer than 30 days apart)
PT-exercises, ultrasound, and electrical stimulation
Rotator cuff tear or rupture
Typical c/o with rotator cuff tear is shoulder pain aggravated by movement,
esp overhead activity, and radiating to the anterior aspect of the arm. Abduction is painful and weak, and tenderness may be elicited over the insertion of the greater tuberosity. On exam, the pt will be unable to abduct arm, instead producing a characteristic shoulder shrug. Passive range of motion may not be affected. The drop arm test and the empty can test assess the integrity of the rotator cuff, and results are positive with a significant tears.
What diagnostic tests are indicated for diagnosis of rotator cuff tear or rupture/
Plain X-ray films may help dx massive rotator cuff tears (ordered by NP)
MRI can help confirm a dx of rotator cuff injury and impingement.
MRI, CT scan, and ultrasound should be ordered in consultation with a specialist, particularly when there may be a need for surgical intervention.
Labs are seldom needed. But CBC, ESR, Uric Acid, and serologic test for rheumatologic diseases can be performed if indicated by H&P.
What is the recommended treatment for rotator cuff tear?
Ice packs or cold for the first few day followed by heat, and graded exercise
Physical therapy
NSAIDs, low potency opioids, and non-opioids
Intra-articular corticosteroid injection
Activity modification-avoid any activities that precipitates symptoms and esp the offending or "abusive" activity.
Immobilization (sling) is useful in some situations, only recommended when instability is apparent and never for more than 3-4 days.
ROM exercises-pendulum swing and the wall climb (2-3x/day for 5-10 min)
What is adhesive capsulitis?
The most common and worrisome complication of chronic shoulder pain is adhesive capsulitis. Adhesive capsulitis is characterized by a gradual, progressive decline in shoulder mobility, often resulting from prolonged joint immobilization after a painful episode. Diffuse aching pain and limited mobility are common. Pain is r/t the stretching
of the restricted joint capsule. Both active and passive ROM of the glenohumeral joint and scapula is limited. Patient often have difficulties with ADLs, including dressing, toileting and even feeding themselves.
Tennis Elbow AKA Lateral Epicondylitis describe history exam.
-specific activity or chain of events that brings pain on? Occupational and recreational activities? Prior elbow injury? History of other joint pain and swelling to r/o arthritis, psoriasis, crystal arthropathies, or systemic diseases.
Tennis Elbow AKA Lateral Epicondylitis, describe physical exam.
perform on both elbows-Should include wrist, shoulder and neck because pathologic conditions at these sites may cause referred pain to the elbow* Location and radiation of pain are CRITICAL for accurate assessment
Bone and soft tissue landmarks should be assessed for asymmetry, malalignment, erythema, edema, and tenderness. Also assess for medial and lateral epicondyles of the humerus and the olecranon process of the ulna
Range of motion * normal ROM r/o joint itself
Extensor tendons at the lateral epicondyle and the flexor tendons at the medial epicondyle are palpated for tenderness
Olecranon bursa inspected and palpated for edema, chronic thickening or both
Tap over the ulnar groove= pain or numbness (Tinel's sign)
How would you manage someone with tennis elbow?
Usually a self-limited injury but may take several months for full recovery
Conservative therapy: NSAIDS, splint, "palms- up" lifting, toning exercises of wrist extensors. Steroid injections if prior treatment not helpful
4.Under what conditions would you refer Mari to an orthopedist?
Refer for surgical evaluation if conservative treatment fails
What is lumbar radiculopathy?
radiculopathy typically refers to involvement of the spinal nerve root with resultant neurologic symptoms, such as pain, weakness, numbness, tingling, and change in reflexes involving a specific dermatomal or myotomal distribution associated with an affected lumbar spinal nerve root.
2 Describe how the straight leg raise is done and what a positive straight leg raise would mean
Performed with the pt in the supine position, and the examiner raises the leg to approx 70-90 degrees of hip flexion. If the pts typical pain is reproduced at any point when the leg is in 20-70 degrees of hip flexion, this indicates a positive test.
This maneuver identifies irritation of the lower lumbar nerve roots, L5 and S1.
What does radiculopathy mean?
The consequence of nerve root damage
What is the typical presentation with Osteoarthritis?
Insidious, progressive pain or stiffness of one or more joints
Sx worse on arising and after a prolonged activity. Relieved w/rest.
Pain/stiffness worse with weight-bearing activities (stairs, changing positions/activity, walking, prolonged standing)
Crepitus (grinding), swelling, joint deformity and gradual loss of motion
If OA involves the cervical or lumbar spine patient may report neuropathy (nerve pain) and rediculopathy (nerve root pain) as nerves are compressed.
OA in the hip presents w/groin or buttock pain, may radiate to the knee. patient may favor the hip causing muscles weakness. Known as Trendelenburg's gait.
OA of knee may lead to joint deformity, pain on palpation and joint effusions, also atrophy of the quadriceps muscle. 70% of knee OA affects medial joint.
What will you include in the physical exam of a patient suspected of osteoarthritis?
Range of motion, pain on palpation, crepitus, swelling, deformity (mostly covered in above question)
Most diagnostic testing is used to rule out other disease processes.
Bone scan may show increased metabolic activity; x-ray may show lost joint space as disease progresses.
Joint fluid may be aspirated to rule out crystalline, infectious or inflammatory conditions.
What type of deformities are most often seen on hands with someone who has osteoarthritis?
Heberden's nodes: deformity of the distal interphalangeal joints
Bouchard's nodes: deformity of the proximal interphalangeal joints
What is the typical medical management of care for a patient with osteoarthritis?
Tylenol 1g 3x daily (max daily dose 3g/24 hours) mainstay for initial treatment
Tramadol (not an NSAID but a non-opioid pain reliever). Synergistic effect w/tylenol or NSAIDs.
NSAIDs~ use cautiously in patients at risk for cardiac toxicity, or renal & liver dysfx
Hyaluronans: intra-articular injections act as lubricant and improves fluid viscosity within the joint. Injected 1x week for 3-5 weeks. Benefits last for >6 months.
Kenalog and Depo-Medrol: corticosteroid intra-articular injections. After initial increase in pain, warmth and redness, most patients have significant pain relief. Cannot be done more often than every 3-4 months. Cautious w/patients taking oral prednisone or diabetics.
Other medications: opiates, neurontin, SSRIs, tricyclic antidepressants, OTC rubs and patches, lidocaine patches, topical NSAID gel (diclofenac)
Non pharmacologic management: : EXERCISE, PT and OT (strengthens structure, improves ROM, decreases pain, improves CV conditioning, weight reduction). Also stretching programs, supportive footwear, assistive devices, heat, ice. Weight reduction is a big factor in symptom improvement.
Complamentary: acupuncture, glucosamine with or w/o chondroiton (1500mg daily for 6 months - if no improvement, discontinue)
Also: omega-3, bromelain, dimethyl sulfoxide, ginger, MSM, SAM-e
Surgery (total joint replacement) if none of the above work.
What are common complications with OA?
Pain and immobility
Decreased quality of life (well-being and mood), less exercise, inability to control weight
Increased risk of falls DT pain and weakness
Meniscus tear
...
Ankle sprain, what is the difference between grade 1,2 and 3?
Grade 1 :due to overstretching there is a microscopic tear in the ligament
Grade 2: an incomplete tear of the ligament causing some functional impairment
Grade 3 : a complete tear or the ligament, with loss of ligament integrity ( LE sprains result in weight bearing difficulty)
What does RICE stand for?
RICE: Rest- Ice (at 20 minute intervals) - if spasms occur switch to heat Compression
Elevation -for the initial 24hrs the ankle should be elevated above the level of the heart ( to reduce swelling)
What are possible complications of ankle sprain?
Compartment syndrome is complication of any muscular injury caused by a decreased blood flow to the compartment resulting in ischemia and necrosis. Compartment syndrome can additionally be caused by a very tight bandage causing constriction in the fasha (compartment) the compression causes a histamine release and additional compression, can lead to irreversible muscle and nerve damage in 2-4 hours ( in 24-48 hrs there may be complete limb function loss and a permanent deformity.Elastic bandages need to be removed every 2-3 hours for 15 minutes then re-wrapping snugly.
Carpal Tunnel Syndrome
peripheral neuropathy that involves entrapment and compression of the median nerve affecting the carpal tunnel in the wrist .The hand consists of a bony canal, known as the carpal tunnel, located at the base of the palm. The carpal tunnel is surrounded by the carpal bones on the ulnar, radial, and dorsal sides. The transverse carpal ligament covers the carpal tunnel which aids as a passage for blood vessels, tendons, and the median nerve of the hand. Any condition causing edema or irritation to the tendons of the hand will decrease the size of the canal, which will result in pressure to the median nerve by the transverse carpal ligament, eliciting symptoms of carpal tunnel syndrome
Discuss diagnostic tests used for carpal tunnel syndrome.
Several maneuvers can be performed when determining a diagnosis for CTS. A pin sensation test of the hand will identify the nerve distribution affected, which in the case of CTS the median nerve distribution would be affected. Three common tests performed to evaluate CTS include the Tinel's test, Phalen's test, and thumb abduction
Discuss how EMG could be used for diagnosis of carpal tunnel.
Definitive analysis of nerve function can be performed with studies of how well an electric impulse conducts along the nerve. A device called an EMG can detect abnormalities in nerve impulse conduction; these nerve conduction abnormalities are the cause of carpal tunnel syndrome symptoms. The EMG does not always need to be performed, but may be done if a patient's symptoms are not typical of carpal tunnel syndrome.
What is Tinel's Sign?
Tinel's Sign-Tinel's test is performed by tapping the median nerve along its course in the wrist. A positive test is found when this causes worsening of the tingling in the fingers when the nerve is tapped.
What is Phalen's Sign?
Phalen's test is done by pushing the back of your hands together for one minute. This compresses the carpal tunnel and is also positive when it causes the same symptoms you have been experiencing with your carpal tunnel syndrome.
How can you provide immediate relief from carpal tunnel?
Immobilizing the affected wrist, especially at night, with help alleviate symptoms. Ice to the affected area and tylenol for pain prn. Resting the affected extremity will be necessary.
Pregnant women may obtain relief from wrist splinting, massage, cold compresses, analgesics, and a combination of strengthening and stretching exercises
Why does carpal tunnel syndrome happen in pregnancy?
Because of the increase in fluid retention that will cause swelling within the tendon sheath around the median nerve of the hand. The syndrome usually occurs in both hands during the second or third trimester and will resolve when the swelling is gone (by 3 months postpartum). Carpal Tunnel Syndrome does tend to recur with later pregnancies. Generally, intervention is limited to splinting of the wrist at night and Tylenol for pain. It is only the severe cases (severe, debilitating pain of both hands and atrophy of the thenar area) that need to be referred (Blackburn, 2013, p. 522)
What is typical follow up plan for carpal tunnel during pregnancy?
A follow-up visit will be scheduled in 7-14 days for re-evaluation of CTS symptoms . This time period will allow for non-surgical interventions to take effect. The patient will be advised to schedule an appointment sooner or contact the provider if symptoms worsen.
Describe an appropriate work-up for a patient with complaints of Fibromyalgia
OLDCARTS
Definition: More than 3 months of musculoskeletal pain above and below the waist bilaterally associated with pain on palpation of tender points.
Hallmark Sx: persistent, widespread pain & chronic fatigue; may report allodynnia or hyperalgesia (basically an exaggerated pain response to stimuli that is not painful), and pain worse w/repetition. Pain is typically constant throughout day.
Other somatic complaints and/or comorbidities: non restorative sleep, cognitive difficulties, auditory, vestibular and ocular complaints, chronic rhinitis or "allergies", migraines, palpitations, irritable bowel syndrome, subjective sense of joint swelling and mood disorders, TMJ, female urethreal syndrome, chronic fatigue syndrome, depression, anxiety.
8-9x more prevalent in women than men, usual onset is gradual at 40-50y/o; affects 3-6 million americans; accounts for 2% of all primary care visits; 10% of internal medicine referrals and 20% of rheumatology referrals.
What is the physical exam of patient with complaint of fibromyalgia?
Pt will have normal muscle strength, no evidence of synovitis or soft tissue inflammation
Rule out other diseases-reumatological, infectious, neurological, endocrine
Labwork all results are normal CBC, ESR, RF, ANA, TSH, but are important in excluding underlying autoimmune disorders i.e.. lupus, and RA
How do you diagnose fibromyalgia?
By exclusion of other diagnoses, normal lab work, pain criteria met.
What is the major component in the pathogenesis of fibromyalgia?
Altered central pain processing which means pain is recognized at a lower threshold and over a larger area; elevated pain neurotransmitter substance is seen in brain as well as altered pain inhibitory mediators, dysfunction of HPA axis, decreased growth hormone (GH), insulin-like growth factor (IGF) and prolactin, causing interruption of stage 3 and 4 of sleep, which is responsible for the morning fatigue (text).
List two criteria for diagnosing fibromyalgia.
American College of Rheumatology developed criteria for classification of FMS in 1990. 2 criteria are: 1) pain in axial skeleton-low back, thoracic spine, anterior chest or neck, and all 4 body quadrants and 2) excessive tenderness elicited at 11 of 18 muscle-tendon sites, with 4kg of pressure-examiner uses pressure point of thumb, enough to blanch examiner's nailbed. However, patients can still have FMS w/o meeting this criteria. This tool is not meant to be used as rigid diagnostic criteria.
Discuss non pharmacologic therapies that have been proven effective in relieving symptoms of fibromyalgia.
Exercise, cognitive behavioral therapy that is goal oriented, works on relaxation, self-esteem. May try acupuncture, hydrotherapy, biofeedback.
Discuss pharmacologic therapies for fibromyalgia.
1st choice is TCAs tricyclic antidepressants-amitryptyline/elavil, noritryptyline and muscle relaxant cyclobenzaprine/flexeril. 2nd SNRIs cymbalta, effexor- Opioids should be used cautiously - they don't really work, are extremely addictive and may actually increase sensation to pain over time (opioid induced hyperalgesia)
Why do NSAIDS not work for fibromyalgia?
The pain is mediated by serotonin and norepinephrine in the CNS; NSAIDs act peripherally, not centrally
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