MMD Exam 1 Lecture Flashcards
(104 cards)
1
Q
treatment threshold is determined by _____ probability and _____ ______
A
pretest, likelihood ratios
2
Q
a ____ _____ is useful if it can distinguish between diagnoses that mimic each other which moves the clinician closer to the treatment threshold
A
diagnostic test
3
Q
the following are stats for a ____ test
- pretest and posttest probability
- sensitivity and specificity
- positive and negative likelihood ratios
A
“good”
4
Q
1st step in the decision-making process or creating your “hypothesis”
based on a combo of:
– Prevalence rates
– History & MOI
– Results of any prior work-up – Clinician’s experience
A
pretest probability
5
Q
____ _____ is the “truth”; the diagnostic test that best identifies a specific condition (ex. arthroscopic findings for ACL tear)
A
reference standard
6
Q
(ideal/poor) study: blind, prospective with a consecutive group of subjects subjected of having the target dx
A
ideal
7
Q
sensitivity is the true ____ rate
A
positive - the tests ability to detect those who actually have a disorder as indicated by the reference standard
high sensitivity = few false negatives
8
Q
sensitivity or specificity? negative result rules out condition
A
sensitivity (SnNOUT)
9
Q
sensitivity or specificity? positive result rules in condition
A
specificity (SPIN)
10
Q
specificity is the true ____ rate
A
negative - the tests ability to detect those who actually do NOT have a disorder as indicated by the reference standard
high specificity = few false positives
11
Q
_____ _____ express the change in odds favoring the disorder given a positive or negative test
A
likelihood ratios
12
Q
likelihood ratios: large positive LR (>5)
(increases/decreases) odds favoring diagnosis given positive test
helpful for ruling (in/out) condition
A
increases, in
13
Q
likelihood ratios: small negative LR (<0.3)
(increases/decreases) odds favoring diagnosis given negative test
helpful for ruling (in/out) condition
A
decreases, out
14
Q
_____ _____ _____ are tools used by clinicians to determine the likelihood a patient is presenting with a certain disease based on certain variables; and to identify patients most likely to benefit from specific treatment intervention
A
clinical prediction rules
15
Q
T/F: most clinical prediction rules in PT practice are validated
A
false, NOT validated
must remain secondary to sound clinical judgement although they have the potential to improve outcomes, increase patient satisfaction, and decrease costs of care
16
Q
what is the minimal critically important difference (MCID)?
A
the smallest change score associated with a patient’s perception of a change in health status; an important concept when looking at effect size and clinical relevance of research findings
17
Q
interpreting “positive” trials:
if the lower boundary of the confidence interval (the end that suggests the smallest benefit from treatment) is greater than the MCID, you can conclude the trial is a ____ positive trial
A
definitive
18
Q
interpreting “positive” trials:
if the lower boundary of the confidence interval (the end that suggests the smallest benefit from treatment) is less than the MCID, you can conclude the trial is a ____ positive trial
A
trivial
19
Q
the practice of evidence-based medicine means integrating what 3 things?
A
best research evidence, clinical expertise, and patient values
20
Q
name pitfalls in making clinical decisions based on “tradition and authority”
A
tradition: “that’s how they taught me to treat x in PT school”
authority: power of persuasion by flashy techniques/doctors
21
Q
what is the chief virtue of the scientific method?
A
reduction of bias
22
Q
____: justifications for treatment based on basic or applied work designed to answer the question of why something should work
A
theory
23
Q
_____: justifications for treatment based on applied work (on patients) designed to answer the question of if something works
A
evidence
24
Q
_____: the term that names the primary dysfunction which directs treatment
A
PT diagnosis
25
T/F: the PT diagnosis is all about probabilities and limiting uncertainty
true
pretest probability (baseline) and post-test probability (application of diagnostic test alters baseline probability a patient has a certain condition)
26
the instant realization that the patient conforms to a previously learned pattern of disease; usually reflexive not reflective (observing scoliosis)
pattern recognition
27
the formulation from the earliest clues of a “short list” of potential diagnoses
- subsequent tests are performed which will most likely reduce the length of the list
- requires an understanding of probability (zebras versus horses)
hypothetico-deductive method
28
match the following approaches: exhaustive or hypothesis-driven
A. bold hypotheses are proposed and then exposed to severe criticism; requires understanding of confirmatory/disconfirmatory tests
B. empty the mind of all preconveived notions; watch nature in action; draw conclusions after all facts are in
A. hypothesis-driven
B. exhaustive
29
the effectiveness of a hypothesis-driven approach hinges on:
appropriate selection and interpretation of diagnostic tests
remember - every element of the history and physical exam should be considered & clinicians must appraise the literature regarding diagnostic tests
30
name 4 prognostic factors
demographic, individual patient behaviors, disease-specific, co-morbidities
31
rank the 5 levels of evidence
1. RCTs
2. cohort studies
3. case-control studies
4. case-series
5. expert opinion
32
strong/grade A evidence vs. moderate/grade B evidence
one or more level 1 systematic reviews = strong
one or more level 2 systematic reviews or a preponderance of level 3 systematic reviews = moderate
33
be familiar with the following terms regarding outcome measures:
MDC
Test-retest Reliability
Content Validity
Responsiveness to change
MDC - minimal detectable change outside of measurement error
Test-retest Reliability - consistency of results when repeated
Content Validity - testing what it intends to test
Responsiveness to change - detect change over time
34
biomedical approach to patient care assumes:
all pain has a distinct physiologic cause and clinicials should be able to find and treat that physiologic problem
35
the biomedical model is not supported with
chronic pain
pathology but no sxs
36
cognitive-behavioral factors and patient expectations are strongly associated with patient ____ and pain _____
prognosis, outcomes
37
the biopsychosocial model is particularly useful for treating patients with ___ pain
chronic
38
the biopsychosocial model begins with ___, second is ____, and followed by ___ and ___ ____
nocioception, pain, suffering, pain behavior
39
nocioception vs. pain
encoding of damaging or potentially harmful noxious stimuli vs. unpleasant sensory and emotional experience associated with actual or potential tissue damage
40
T/F: sensitivity of nociceptors to painful stimuli is modifiable
true, increases or decreases in response to peripherally applied mechanical, thermal, or chemical stimuli
41
the following are characteristics of ____ ______:
- increases in random firing of nociceptors, responseness, and receptive field size
- increased responsiveness of nociceptive neurons to normal input
- activation with subthreshold input and silent nociceptors
- occurs within nociceptors receptive field
- basis for primary hyperalgesia
peripheral sensitization
42
the following are characteristics of _____ ______:
- increased receptive field size; spreading sensitivity that can include the entire (even contralateral) limb
- increased response to innocuous or noxious stimuli
- decrease threshold for activation
- basis for allodynia
central sensitization
43
goals for central sensitization
reduce input from sensitized peripheral nociceptors
if peripheral nociceptors not at play, focus on central mechanisms
44
inability to see anything but worst possible outcome; characterized by rumination, exaggeration, and helplessness
pain catastrophizing
45
distressing negative experience induced by perceived threat; belief that movement will lead to further tissue damage
pain related fear
46
what is a better predictor of diability than physical examination and pain intensity?
fear
47
persistent pain and disability are associated with increased ____
depresion
48
which of the following statements is false?
a. cognitions impact pain
b. pain is objective
c. chronic pain affects cognitions, beliefs, emotions, and behaviors
d. changing cognitions must occur to allow movement-based approaches to be effective
b. pain is subjective
49
if a patient answers "yes" on general health screen, PT may choose to ask more specific questions such as:
is there an explanation for it?
has the patient mentioned this to a MD?
if MD is aware, has it become worse?
50
from a screening perspective, the purpose of the diagnosis is to:
1. treat as specifically as possible
2. recognize the need for a medial/other referral
51
name 4 conditions or organs that refer pain to the shoulder
heart, lungs, gall bladder, upper GI (NSAIDS)
52
name 4 conditions or organs that refer pain to the back
pancreas, kidneys, liver, gallbladder
53
What are the constitutional signs?
weight loss/gain
fatigue
fever/chills
weakness
trouble sleeping
hx of cancer
recent infection
night pain
loss of bowel and bladder control
54
VINDICATES mnemonic to remember types of diseases to consider in differential dx
vascular
inflammatory/infection
neoplasm
degenerative
intoxication
congenital
autoimmune/allergic
trauma
endocrine
pSychosocial
55
the following are common symptoms of ___ ____:
throbbing, pulsating
cold, warmth
deep ache
symptoms worsen with activity
joints/bone affected causing "bone-type" symptoms
vascular patterns
56
define the cardinal signs of inflammation
rubor - redness
calor - heat
dolor - pain
tumor - swelling
57
the following are common symptoms of ____:
fatigue/malaise
fever/sweats/chills
nausea
temp over 100, elevated vital signs
infection
58
manifestations of a malignancy as a secondary growth arising from the primary site in a new location
neoplasm
59
bone metastasis: think P.T.B.L.K
prostate
thyroid
breast
lung
kidney
60
the following are common symptoms of ____:
sxs consistent/cyclical, wake at night, warm/red
joint pain with previous history of infections, medications, and IBS
degenerative
61
the following are common symptoms of ____:
signs similar to infection
mentation changes/memory difficulty
nervous system abnormalities
irritability
intoxication
62
the following are common symptoms of _____:
heat or cold intolerance
excessive sweating
changes in glove or shoe size
polyphagia - excessive eating
polyuria - excessive urination
polydipsia - excessive thirst
endocrine
63
what are risk factors for femoral head/neck fracture?
female (hormonal, menstrual irregularities)
heavy involvement in jumping, running, marching
change in training program/routine
nutritional deficiencies
LLD
diminished muscle strength
64
what are risk factors for cauda equina syndrome?
low back surgery/disk herniation
spinal stenosis
spinal fracture
ankylosing spondylitis
65
____ ____ _____ commonly manifests as:
urinary dysfunction (retention/incontinence)
bowel dysfunction
sexual dysfunction
sensory deficits (saddle anesthesia/ LE)
motor deficits (LE)
gait ataxia/balance problems
cauda equina syndrome
66
what are common manifestations of cervical myelopathy?
impaired hand dexterity (clumsiness)
gait/balance deficits
numbness/paresthesia (extremities)
neck stiffness
urinary dysfunction (retention, urgency/freq)
67
what are common findings upon physical exam indicating cervical myelopathy?
hand intrinsic atrophy
muscle weakness (triceps, hands)
muscle weakness (LE, proximal)
UMN signs (hyper DTRs, clonus, +babinski, +hoffman)
68
what are risk factors for abdominal aortic aneurysm?
age 70+
male
smoking hx
hypercholesterolemia
coronary heart dx
family history of AAA
69
patient describes back or abdominal pain as hot, searing, ripping, tearing pain. you suspect?
vascular dissection (AAA)
clinical exam includes: abdominal palpation and auscultation
70
what are risk factors for DVT?
previous hx of DVT
age 60+, hx of CA, CHF, lupus, chemo, major surgery, major trauma, immobility, limb paralysis, women (pregnant, oral contraceptives, hormone therapy)
50% asymptomatic in early stages
most occur in proximal veins, ~30% in calf
71
DVT Wells score
+1 active cancer
+1 paralysis/immobilization
+1 bed-ridden >3 days, major surgery past 12 weeks
+1 TTP along deep venous system
+1 swelling entire LE
+1 calf swelling >3 vs asymptomatic side
+1 pitting edema confined to symptomatic side
+1 collateral superficial veins
-2 alternative diagnosis about as likely as DVT
72
pulmonary embolisms can go undiagnosis ~50% of the time; however, a majority of PE's are complications of a ___
DVT (LE)
73
describe an atypical myocardial infarction?
MI presents wtihout chest pain; "silent MI"
74
clinical manifestations of MI in women
SOB
fatigue
sleep disturbance
nausea
palpitations
dizziness
diaphoresis: excessive sweating
anxiety
75
modifiable risk factors for MI
smoking
high cholesterol
HTN
DM
obesity
sedentary
excessive alcohol (ETOH)
76
what are the top 5 cancers for men and women, respectively
men - prostate, lung, colorectal, bladder, skin
women - breast, lung, colorectal, uterine, non-hodgekin lymphoma
77
when do you refer a patient to another appropriate profession?
no apparent movement dysfunction, causative factors, or syndrome identified
history, reported MOI, and/or findings are not consistent with MSK/neuro dysfunction
78
describe red flags for weight changes
recent unexplained weight change (5-10% BW over 6 months)
• gain: CHF, hypothyroid, CA, liver or renal dz
• loss: CA, GI, hyperthyroid, DM, depression
79
describe osteomyelitis
bone infection
cause: surgery, penetrating wound, chronic wounds, poor dental hygiene
sxs: fever, fatigue, edema, erythema, tenderness, decreased function
80
what are 3 common benign bone tumors?
osteoblastoma (short/flat bones)
osteoid osteoma (long bones)
*pain is predominating symptom for all
osteochondroma (metaphysis of long bones, abnormal shape and interferes more with function)
81
describe multiple myeloma
most common malignant bone tumor
sxs: back pain, recurrent infection, anemia, renal impairment
red flag: persistent back pain associated with loss of height and osteoporosis
82
describe chordoma
uncommon malignant bone cancer found in the sacrum and/or from the spine to the skull
sxs: progressive weakness, pain, numbness (spinal cord)
83
define osteosarcoma
malignant bone tumor affecting the metaphysis of long bones
sxs: fracture may be first sign
84
define ewings sarcoma
malignant bone tumor known to frequently metastasize from long bones
85
define chondrosarcoma
malignant cancer in which cartilage cells produce cartilage rather than bone
86
describe lyme disease
systemic infection transmitted by ticks
sxs: rash and redness around bite, flu-like symptoms, joint pain, fatigue, myalgia, headache, mononeuritis multicomplex (including bells palsy)
87
sxs of pneumonia
fever, headache, thoracic back pain, chest pain
88
sxs of pyelonephritis (UTI affecting kidneys)
fever, chills, nausea, flank pain, LBP, dysuria, increased frequency, neck pain/stiffness
89
medications affecting the MSK system
• corticosteriods– osteonecrosis
• epilepsy meds– osteonecrosis
• neurotin (Gabapentin, anticonvulsant)– myopathy
• statins (lipitor)– myopathy
• humira (adalimumab, RA)– neuropathy, general or focal (radial nerve)
• chemotherapy– distal neuropathy
90
what is the goal of an electrophysiologic test (EPT)?
Classify/clarify/test function
– Nerve(s)
– Location
– Motor vs. sensory vs. both
– Axonal vs. demyelinating vs. both
– Timing (chronic, acute, etc)
– Re-innervation?
– What its not
– Recommendations
91
Excellent for identifying demyelination
Entrapment neuropathies
Only technique for sensory study
+/- identifying axonal injury
Limited use for radiculopathies or myopathies
Not helpful for timing
nerve conduction studies
92
Gold standard to identify axonal injury
Identifies radiculopathies and myopathies (muscle disease)
Helpful for classifying acuteness
Not helpful to identify demyelination
Only evaluates motor nerves or muscle
electromyography
93
the amplitude on a motor/sensory nerve conduction study represents the total number of physiologically _____ axons
intact
94
decreased amplitude proximal and distal are consistent with what nerve conduction abnormality?
axonal damage/dysfunction (axontomesis)
95
increased latency, decreased conduction velocity, and decreased amplitude proximal to injury is consistent with what nerve conduction abnormality?
demyelination (neuropraxia)
96
what are the differences between late EMG responses: F-wave and H-reflex
F-wave = motor only, polysynaptic
H-reflex = motor and sensory, monosynaptic
97
1st neural defect is demyelination of sensory fibers
increased median DSL (more important)
decreased median SNAP amplitude (less important)
increased median DML (less sensitive, appears later)
decreased median CMAP amplitude (less sensitive, appears later)
normal NCV forearm segment (usually but not always)
EMG abnormalities in hand intrinsic Mm. supplied by median N. (thenar Mm. & lumbricals I-II)
- least sensitive, appear in advanced cases
- PSWs, Fibs, increased insertional activity, decreased recruitment
carpal tunnel syndrome
98
classifications of carpal tunnel
Mild = prolonged DSL +/- decreased SNAP amplitude
Moderate = as above, plus prolonged DML
Severe = prolonged DSL, prolonged DML, decreased CMAP amplitude, EMG abnormalities (PSWs, Fibs, decreased recruitment, MUP changes)
99
T/F: positive health assessment outcomes are synonymous with improved impairment measures
false, measures of function and impairment together indicate the effectiveness of an intervention
100
phases of healing timelines from acute to chronic
acute: 0-6 (protection)
subacute: 3-20 (controlled motion)
chronic: +9, ~6 weeks (return to function)
101
more _____ conditions need fewer bouts and repetitions; more painful conditions need more frequent _____ exercises and activities
irritable, pain-easing
102
exercises and time of day:
____ and ____ exercises early in the day to improve range for ADL
______ exercises later in the day to prevent fatigue with ADL
_____-_____ exercises as needed throughout the day
_____ or ____ _____ exercises throughout the day
ROM and stretching exercises early in the day to improve range for ADL
Strengthening exercises later in the day to prevent fatigue with ADL
Symptoms-easing exercises as needed throughout the day
Stimulation or motor learning/re-learning exercises throughout the day
103
keep total number of exercises to minimum (5 or less) by ____ exercises when the effect of the exercise is no longer a priority
replacing
104
rule of 90% performance
do not sacrifice the effects of 90% of the program to get the additional 10%
-exercise not liked by patient
-performance of one exercise not perfect
-exercise invented by patient
