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Liklihood ratio, above what is very likely to be and below what is very likely to not be?

Above 10 and below .10


4 key examination findings for identify-ing CA

•Weight loss
•Inadequate relief with rest
Personal hx
•> 50 y/o


When all 4 key examinations for CA findings are present

•Sensitivity = 1.0 very chance to not have
•Specificity = 0.60 some chance to have
Positive LR = 2.5 not ten so low likelyhood to have
Negative LR = 0 very likely to not have

So the sensitivity and the NEGATIVE LR match very well here, that both indicate that the person is not able to have cancer.



Clinical Prediction Rules

You go step by step to be able to figure out the pain or dysfunction that the person is having.

Tingling in their hand, local, CTS, or from their neck, Cervical Radiculopathy

And we will get into these, to be able to figure them out in future chapters of the PTE.


What structure is the most sensitive to pain?

1- Periosteum and joint capsule
2- Subchrondal bone, tendons, and ligaments
3 - Muscle and cortical bone
4 -Synovium and articular cartilage

It seems that the deepest to the most superficial is the way to go and decide if it is to have the most or to have the least amount of innervations.


What are the characteristics of visceralpain?

•Poorly localized (Does not have a directpathway)

•Not always reproducible (Bc the pain is not mechanical in nature)

•Corresponds with systemic sx’s (N & V, fever etc)


Any pressure to the dia-
phragm will cause pain to its innervation level of C3-5

(Shoulder Pain)


Central contact of the dia-phragm causes



Peripheral contact to the diaphragm

ipsilat-eral costal margin pain


PNS pain is usually

• Mechanical in nature, ie “Pinched nerve”• More common


CNS pain is

not reproducible
• Not mechanical
• Not very common
• Elicited by malfunction of the nervous system itself
• Due to alterations of efferent and afferent info

Can you really reproduce pressure on the spinal cord or on the brain?


Quality of neuropathic pain

Shooting, burning,
Producing electric shock

Ever have that pain in your lower leg that was coming from whenever you extended your leg? That pain... What was it like?


Therefore a goal of the PT is to__________pain to determine if the sources is due to musculoskeletal dysfunction.



What happens if the pt tells you that they have pain with movement but when you try to reproduce that pain you are not able to?

Maybe the pain is from repetitive motion so you will need to try to keep kn doing it.

But maybe there is pain with combined motions which we shall address in the neuronsection... Hang on.


What spinal motion(s) decreases the intervert foramen?



Lateral Spinal Stenosis

• Narrowing of the inter-vert foramen• Can cause compression of the spinal nerve
• Common if > 60 y/o

We see the idea of an elderly.

Keep these ideas in mind when trying to tabulate the different pains that can result. For example, young people do not get stenosis, usually.


Sign and Sxs of stenosis

• Lower back pain (LBP), that the tightening happens at the lower back area can give us the pain in the lower back area.

• Numbness and tingling in the feet, because the nerves that go to our feet are the ones that are being comoressed

• Decreased muscle stretch reflexes, if we consider this a LMN issue, so the reflexes are to be lessened.

• Altered sensation, as we did say earlier that the nerves are being pinched

• Motor weakness in the legs, because the nerves in the legs are being pinched

• Increased with extension type of activities, this is how the vertebral canal is to become even more occluded.

• Relieved by flexing the spine activities, because now the tightness of the vertebral canal is to be relieved.


What are the sign and symptoms of HNP?

• History of flexion type of
activities, because this is what goes and causes the nucleas to spill out

• Typically 25-45 y/o, the younger people have the nucleas to spill out

• Uncommon in older
population bc fluid por-
tion of nucleus becomes
more fibrous with age

• But can be extension
also, depends on how

• LBP, because it should not matter if the nerve is being pinched due to the compression from the vertebral canal as from the stenosis, or from the nucleas that is spilling anterior and again is now compressing the spinal cord.

• LE pain, so another reason why there should be pain.

• Increased with flexion ac-tivities, as we have explained

• Parathesias/altered sen-sation, just like all nerve compressions.

But with altered sensations we need to know if it is brain or at any of the other joint that come to the end area, for example, the hand, is it the brain, is it the neck, is it the shoulder, is it the elbow, is it the wrist, which the wrist is called CTS, and there are also dura tests that can be done.
• Motor weakness


What functional activities require flexion?

• Sitting
• Bending forward
• Sleeping
• In fetal position


Is somatic insidiuos, is visceral insidiuous?

Somatic an be either trauma tic or it can be insidiuos.

Visceral, usualy is insidiuous, but it can also be traumatic.


Provoke for somatic and visceral.

Somatic usualy has a pattern, but visceral usually does not have a pattern.


Quality for somatic and visceral.

Somatic is Sharp or dul for
somatic. Nerve it is shooting or tingling,

Visceral Trobbing, searing. Knife stabbing, can be sharp.


Region for somatic and visceral

Somatic More specific but acute is more diffuse.

Visceral More diffused.



Can be bad or little for both somatic or visceral.



Somatic Observation, palpation, it is reproducable.

Visceral Cannot reproduce thepain that they have.


Response to PT

Somatic yes,

Visceral, no.


•Dizziness/syncope (fainting)•Fever
•Diaphoresis (unexplained)
•Night sweats
•Nausea & Vomiting
•Weight loss
•B & B2,

Comstituitional signs


When would we want to ask CS?

When we are concerned that perhaps it is not somatic. Because somatic is very muscles and bones. Not visceral.



• Insidious vs traumatic
• Not always obvious
• Ie prolong sitting incorrectly causes minor trauma•
Ie running with poor body mechanics
• Explain mechanism of accident
• When did the pain start?



• Find what words the patient to describe their pain to differen-tiate between
• Acute vs chronic pain
• Neurologic pain
• Somatic vs non somatic pain
• What words would a patient use?
• Systemic (Knifelike, Cutting, Throbbing, Bone pain)
• Somatic (Achy, Stiff, Sharp)



• Is the pain constant vs intermittent?
• What increases the pain?
Can also teach the movemnt pattern, to be able to dknow
• Attempt to find a pattern what motions to avoid.
• Ie. Is it a trunk flexion the pattern that is bother-
ing them?
• Ie. Is knee flexion activities the pattern is bother-ing them?



• Have the patient point to the pain, and indicate if it is su-perficial or deep
• Somatic pain is usually specific, but it can be vague.
• Systemic pain is usually vague
• Ask if they have pain anywhere else2,pg119
• Why should a PT be concerned if a patient has radiating



• What time of day does it hurt more?
• OA usually is painful for the first hour of day, due to stay-ing still while sleeping
• Will also show the severity of their pain


You go into the PMH and all of their sunpbjective history, and if the history and the subjective told you anything that made you guess at visceral you should ask about constituitional signs, and now we should have a very good idea if it is somatic or not, if you think that it is somatic, so then go and perform either an upper quadrant or a lower quadrant screen, there are only two, and if all the signs pointed to a specific sysytem, then you will go and perform a specific sysytem's screen.



What are red flags?

• Red Flag- tells the examiner that a symptom requires immedi-ate attention, to perform a screening, request a test or refer to
the MD 2,

• The mere presence of one flag does not indicate an immediate reaction2,


Remember musculoskeletal presentation

• A clear history of trauma (may be repetitive)• Predictable pain pattern
• Gets better with time
• Resolves in appropriate time

These may not be red flags, they are usuall msk


What are some red flags?

• Can be divided into the following categories

• PMH, their past
• Risk Factors, what they have socialy
• Clinical presentation, what they are showing now
• Constitutional Symptoms, side effects of visceral
• Pain patterning, the specific areas of pain and types of pain that visceral amd or somatic usually presents itself with


Red Flags: PMH

•Personal or family hx of CA
•Recent infection (last 6 wks)
•Recurrent colds or flu
•Recent hx of trauma (w/o appropriate medical follow Risk Factors
•MVA, fall, or a minor trauma if elderly (due to OP)

These past medical history can point to somatic, like by OP or to systemic diseaes like by CA.


Red Flag: Risk Factors

Certain factors will put a person at greater risk in acquiring certain diseases, such as:
• Substance abuse
• Tobacco use
• Age
• Gender
• Body mass index (BMI)
• Exposure to radiation
• Alcohol abuse
• Sedentary lifestyle
• Race/ethnicity
• Domestic violence
• Occupation


Red Flags: Clinical Presentation

• Insidious onset with unknown etiology
• Sx unrelieved by PT or get worst
• 10% weight loss or gain from 10-21 days, w/o ptknowing why
• Sx unrelieved by rest or change in position


Red Flags: Constitutional symptoms

•Dizziness/syncope (fainting)•Fever
•Diaphoresis (unexplained)
•Night sweats
•Nausea & Vomiting
•Weight loss
•B & B


Red Flags: Pain Patterning

• Night pain (unrelieved by re positioning)
• Pain is constant and intense
• Described as throbbing, knifelike, boring or deep
• Pain associated with other sx of visceral GI
• Change in pain with food intake or medication use(immediate or several hours later).
• Pain that is poorly localized

Things that mechanical cannot account for.


Additional Red Flags

• Originally relieved by rest however with time
this no longer helps, is it betting worse
• Sx’s out of proportion to injury, it is not making sense according to what we expect through our physical findings
• Sx’s lasting longer than normal, why is a somatic injury lasting this long?
• Unable to alter the sx’s during exam, we cannot do anything for it?!
• Change in ms tone if the pt has a neuro dx, its so bad that the tone of the muscle has indeed been chalenged
• Sx’s does not fit expected musculoskeletal or neu-romuscular dx, then what could it be.



What must be considered before a PT be-comes alarmed with the presence of a red flag(s)?

• Whole body must be taken into considera-
• Can the red flag be explained for a ms cause •Multiple red flags and no signs of somatic
pain that is a clear indication of danger


What should a PT do in the presence of a red flag(s)?

•Perform a screen
•Don’t call MD first, must screen in orderto give MD more info.
•Unless it is an emergency don’t do a
screen, call 911


•Screen should be appropriate for correspond-ing symptoms

•Ie. Pt c/o CP, Pain down Left arm, PT should to do a Cardiac screen

If all of the visceral signs and symptoms point to a specific systemic disorder, then we need to go and do that system's screen


•A screening process is done during the interview, AND must be verified with

the physical examination

• Cannot make a conclusion until the objective is done


Why do we a ask pt for their social history?

• Each component of a pt’s social hx exposes a pt to various health risks1,
• Repetitive strain at work, can we teach them how to do it differently, or can we guess at why they are injured the way they are, or while wea re treating them for this one issue, can we prevent a future issue.
• Dangerous jobs, can they get a new job
• Customs that conflict with PT intervention, will we be able to perform the interventions in a manner that will be comfortable by the patient.


Why do we ask pt for their past medical hx?

• May be relevant to current S&S, because if they are having pain and night sweats, and they have had cancer in the past, then this might be a recurring cancer
• May reappear
• May affect their treatment, if it is a visceral issue, will mechanical interventions help?
• Surgeries may be associated with infection or aDVT, if they have infection, then PT will not help them with that.
• Side effects associated with meds (elaborated
later), we need to know if they are week, or are able to do the exercises or regimets,


What questions are included in medical historytaking?

•Medication use

These can tell us that maybe a visceral systematic issue has resurfaced and it may have us perform a systematic screen to be sure that it is or it is not a visceral and so if they can or if they cannot go and be eligable for PT.


What f/u questions should a PT ask if a pt reveals that they have a medical problem?

• When was the last time you visited a MD for this
• Describe the condition?
• Are you currently receiving care for the illness, is itfully resolved?
• If a condition is current, ask about their sx’s associ-ated with the condition
• Have the sx’s recently changed?
• How is the condition currently being managed?
And by whom?


Why do we ask pt about their familymedical history?

• Important to identify potential health risk
• Especially important with first degreerelatives (Parents and siblings)

Like CA


What type of questions do you ask if a pt has afamily member with a medical history?

• Who in the family?, nuclear family or not
• What age? Young or old, the hounger, then it may be a predisposition that is hereditary in the family
• What is the current health status? Are they okay, are they sick


After asking constitutional questions the PT
should the patient into 1 of 3 categories:
Think that the patient has more of musculo-
skeltal problem
Think the patient has a non musculo-skeletalproblem but unsure what system
Think the patient has a non musculo-skeletalproblem but may think is one one particular system and ask more questions pertaining to that system

Either that you are sure that the person is msk or systematic and are very sure which system, at the very least systematic but not sure which,

But before you call the MD see if a more experienced PT can tell you what it is from the PMH, the Objective, and the screening.


Paresthesias, Numbness, or weakness•

May be due to

• Neurologic d/o, CTS, cervical radiculopathy, elbow inpingement, shoulder inpingement.

• Renal and endocrine diseases, wow.

Adverse drug reaction, the drugs make the nerves more sensitive.


What are the red flags associated with paresthesias,numbness or weakness?

• Progressive worsening, always bad
• Glove and stocking distribution, not sure why glove and stock are an issue for neurological matters
• Bilateral extremity deficits, that it is not local, it has reached the spinal corda nd both extremities, with one illness, has become affected.
• Combination UE and LE, how did it get to affect all the extremities? It can be four individual local injuries, but if it is sourced in one issue, then it is very distressing.
• Weakness leads to decr in fnl tasks, always with functional loss we are concerned.

• Disorders that can cause this are chronic renal failure, multiple sclerosis, a degenerative neural disease, and hypothyroidism
• More of a concern if combined with other neuro sx’s such as sensation changes, balance problems, visual sx, or taste, smell or hearing deficits


What can cause of fevers?

• Systemic illnesses such as infections, can-

• Connective tissue disorder such as RA, it is an inflammatory disease, so connect that with fever
• Due to the release of pyrogens into the
bloodstream by toxic bacteria or from degen-erating body tissues, which causes the “set point” of the hypothalamic thermostat to rise.


When is a fever considered a red flag?

• Longer than 2 weeks, and the MD has not seen
the pt for this sx
• should be self-limited
• 39C (102F) requires hospitalization 1,pg89
• In the elderly population, they may not perceivethat they have a fever
• Common causes of death by pna


Nausea and Vomiting!
• Not always associated with GI dysfunction

• May be due to
• Ketoacidosis, Inferior MI, Hepatitis, Medication,Pregnancy vestibular disturbances, Migraine


Unexplained weight change

• Change of 5 to 10% is a red flag
• No explanation = no change in diet or physicalactivity
• Several causes
• Cancer
• Depression
• GI dysfunction
• Thyroid dysfunction
• CHF & Kidney dysfunction(weight gain)


What are possible causes of dizziness/lightheadedness?

•Neuro d/o

•MS, a degenerative neurnal disease
•Benign positional vertigo, vertigo is prime for headaches and dizziness
•Acoustic neuromas, a cancer in the ear, that can cause a problem with the vestibular aparatus
•Basilar insufficiency, basilar!
•Cardiac and Vascular d/o if enough blood is not getting to the brain then we will feel light headed and dizzy, for example by orthostatic hypotension, the temporary solution is to lye the person down so that the blood would return to their brain and make them come to again.

•Severe anemia, low O2 to the brain
• Usually worsen with standing and improve
with recumbence, because the blood has to fight gravity to get to the brain, but lying down there is less gravity to overcome and the personw ill have more blood to their brain and this less dizziness.
•Critical aortic stenosis, the blood cannot be pushed out properly enough.
• Vestibular disease
• Head spinning or the room spinning around the pt


What S&S are associated with the dysfunction to cardiovascular system?

• Dyspnea – difficulty breathing
• Palpitations
• Syncope – fainting
• Pain with sweats
• Cough – especially at night
• Peripheral edema
• Cold hands/feet
• Open wounds
• Skin discoloration
• Chest pain or discomfort

• May radiate to neck, jaw, upper trapezius, up-per back, shoulder or arms


What S&S are associated with dysfunction of the Pulmonary system?

• Similar pain pattern as cardiac, however sx’s are increased with inspiration, laughing, cough-ing, sneezing or deep breathing
• Dyspnea
• Cough
• Clubbing of the nails
• Wheezing – high pitched noise caused by a partial obstruction of the airway
• Stridor – high pitched sound also associated with obstruction of the larynx or trachea


Where do you see the pattern of pain for GI dysfunction?

Pain to neck, shoulder, sternum, scapula, low back, sacrum, groin and hip

Imagine food going in and going in tough and coming out tough.

It goes in through the neck, and it gets stuck, so then you raise your shoulders and then press on your sternum and scapula, so then the food goes down and then it gets bottle necked at the triangle the sacrum, which causes low back pain, and you push on your hips and you push on your groin for the remains to come out.

So neck, shoulder, sternum, scapula, lbp, sacrum, hip and groin pain.


Additional GI issues? These are wwhat will hint strongly to you that it is a GI issue.

Dysphagia - Swallowing difficulties•
• Food intolerance
• Bowel Dysfunction
• Color or size of stool –
• Constipation
• Diarrhea
• Difficulty initiating


Melena (black tarry stools) indicates

indicates GI bleeding


Hematochezia – what is it and what does it indicate?

bright red stools, usually associated withleft of the colon or the anorectal area


Light gray or pale stool, is associated with



Pencil-thin or flat are suggestive stool is suggestive of

anal or distal colon car-cinoma,

Imagine a block due to a growth in the canal, so will the fecal matter come out in its usual cylindrical manner or will it come out compressed? I say compressed.


Impaired motility

Inadequate dietary fiberInactivity


Neurologic dysfunction

Spinal cord injury

Ms and sci
Sci and ms




situational stress



infectious agents
Laxative abuse
colon cancer
Crohn's disease


What pain pattern are associated with the GU system?

Shoulder, lower back, or iliopsoas pain

Lower back pain because of the area that the GU is associated with, the iliopsoas is also the abdominal area that is associated with the GU system, and shoulder, well who will shoulder this burden if the GU is not working properly?


Urination factors?

• Flow
• Frequency•
• Output
• Retention
• Dysuria


Endocrine System S&S’s•

Muscle weakness
• Muscle atrophy
• Myalgia
• Fatigue
• Carpal tunnel syndrome
• Osteoarthritis
• Periarthritis – infl. of tendons, ligaments and joint capsules


Endocrine System S&S’s

• Systemic

• Polydipsia
• Mental changes
• Changes in hair
• Changes in skin pigmentation• Heart palpitations


With DM you have vascular and neuronal damage, so it would cause two things...

Impaired healing due to the lower amount of blood flow to the area and tingling of the handsa nd of the feet, the extreme extremities.


General Neurologic S&S’s

• Confusion
• Depression
• Weakness
• Change in muscle tone•
• Blurred vision
• Change in memory


Cervical myelopathy what is it?

Compression of the cervical portions of the spi-nal cord


CM signsa nd symptoms, what if you see it on a person will you consider that perhaps this perhaps has CM?

• Wide based spastic gait
• Clumsy hands
• Visible change in handwriting•
Extremity dysfunction, the hands and feet.
• Positive Babinski
• Positive hoffman's sign
• Lhermitte’s sign
All of these are UMN signs of dysfunction, since we see that CM is a CNS issue, it is an UMN.
So whenever you consider a neurological issue, you should wonder if it is UMN or it is LMN issue.

Babinski, Hoffman's, lhermittes. These, if positive, would indicate, a UMN issue.
• Urinary retention


Histroy of hypertension can lead to what kind of neurological condition?

Subarachnoid hemoragghe


A sudden onset of a headache will indicate what?



Trunk and extremity weakness, not just trunk and not just extremity, but both, could be an indication of....

SAH, that it is not like CM that is more extremity aince it is more distal than the SH, and the SAH is more central than the CM, so the CM is expremity and the SAH is like a CM but more, that it is the extremities and another aspect of the Central trunk, since the SAH is more central than the umn issue of the CM.


Vertigo and vomitting csn be a sign of?



Cervical myelopathy CPR

– Babinski Test
– Inverted Supinator Sign
- Gait Abnormality
– Hoffmann’s Sign
– Age >45 years


CPR for Unilateral Cerebral Lesions

Combination of 3 tests
• Pronator drift
• Finger tap
• DTR’s
•All three positive SP of 97% and SN of 76%
These tests are tests that are unilateral, the pronator drift, the finger tap, the DTR's, they are all compared to the other side, but the babinski and the hoffman and the inverted suppinator is not comparing both sides together.


Cauda Equina Syndrome S&S’s is compressing what?

Compression of the lumbar nerves in the central canal


Cauda equina that has it compressing the lower part of the cords will present itself with the following signs and symptoms...

sensory and motor deficit, saddle anesthesia, and bowel and bladder dysfunction
• LBP!!!!!!!!!!!
• Loss of sensation in the LE’s
• Muscle weakness and atrophy
• Bowel and bladder changes (urinary retention (90% sens), dif-ficulty starting a flow of urine, constipation)
• Saddle parathesias
• Unilateral or bilateral sciatica
• Change in DTR (absent or hypo


Musculoskeletal (MS) system screen
• The main purpose of a MS screen is to

r/o serious pathologies such as
• Fractures
• Inflammatory arthritis (RA & AS)


• Three common causes

• Sudden impact (most common)
• Stress fracture – associated with repetitive activities
Pathologic fracture – associated with disease (ie. ca)


S&S’s of fractures

• Severe Pain and local tenderness
• Painful weak MMT
• Unable to wb
• Pain with vibration (tuning fork 256 Hz)
• Deformity
• Immediate Edema
• Ecchymosis
• Loss of general function and mobility

So if wes ee that there is localized oain, that the person is not able to olace weight on that area an also lets say we see that it is black and it is blue, the mmt is weak because of pain, what does all of these put together hint for us? It seems to be very much pointing towards a fracture.


Those who are at great for OP risk are:

• Smokers, alcohol use
• Low vitamin D intake
• 5F’s = Female, Fifty, Fair skin, Fair haired, Frail• Prolong corticosteroid and anti coagulant use
• Bed ridden, which is non-weight baring.


S&S’s of RA

• Symptoms last longer than 2 weeks
• Malaise and fatigue
• One or more hot and swollen joints, systemic will be multijoint
• A.M. stiffness longer than 45’ (OA is less than 30’), because of the lack of movement at night it will cause pain in the morning.
• Diffuse joint pain & tenderness, especially MTP and MCP, at the joints of the toes and the joints of the hands.
• Can lead to infl. of ligaments to C1-C2, which can produce lax-ity and lead to anterior dislocation of C1, and causing spinal
cord damage


Ankylosing Spondylitis (AS)
• Is a

chronic, progressive infl d/o of undetermined cause
• Infl of fibrous tissue affecting the insertions of ligaments, tendons, and capsule into the bone
• Commonly affect the SI joint, the spine, and large peripheral joints.


S&S of AS

• History of heel pain, uveitis (20-40%, usually unilateral), psoriasis, these are extremities
• Responds well to NSAIDS, an anti-inflammatory.
• May take 5-12 years from first sx’s before dx (Feldtkeller et al, 2003)
• Insidious onset of middle and LBP and stiffness for 3 months, because it does affect the spine, so there will be LBP
• Usually male under the age of 40
• Pain may also be deep gluteal region
• Worse in the am, lasting more 1 hour. Better with movement worst withrest, because in the morning there is rest.
• Ache or sharp pain, can be confused with sciatica
• Loss of normal lumbar lordosis, often bilateral pain
• Decrease rib cage expansion ( less than one inch)
• Decrease rib cage expansion, specificity of 99% (Gran 1985)
• Intermittent low grade fever
• Anorexia, weight loss
• Painful limitation of cervical joint motion


Decreased rib expansion by ine inch is an indication of?



Pain in the morning is an indication of?

RA and AS, because they are bith inflammatory issues.


What are S&S of Breast CA?

• Nontender, firm, or hard lump
• Unusual d/c from nipple
• Skin or nipple retraction dimpling, erosion, itchingof nipple
• Generalized hardness, enlargement, shrinking of
• Unusual prominence of veins over the breast
• Enlarged rubber lymph nodes
• Axillary mass
• Swelling of arm
• Bone or back pain
• Weight loss (2,pg791)
Chest pain or shoulder pain


What are S&S of Prostate CA?

• 1/3 men > 50.
More common in African American
• Bladder palpable above the symphysis pubis
• Urinary problems
• Hesitancy; difficulty in initiating or interrupted flow
of urine
• Small amounts of urine with voiding
• Dribbling at the end of urination
• Frequency (more than 2 every hour)
• Nocturia
• Lower abd discomfort, with the need to void
• Low back and or/hip pain, upper thigh pain or stiffness•
Difficulty having an erection
• Blood in urine or semen
• Suprapubic or pelvic pain


S&S of Pulmonary Metastases

• Most common metastases bc venous drainage
goes thru the heart and the lung, and they be-
come the first to filter the cancer
• Wheezing
• Sx relieved when sitting up
• Productive cough w/ bloody or rust colored sputum


After the subjective should you ask constituitional questions?

It depends, was there anything really that indicated that it moght be systemic.


After subjective and constituitional, if warranted, what do you do next?

Use that info to try to rule out systemic issues.


Omwe just use sunpbjective and constituitional symptoms to rule out for systemic issues?



If we do not just use subjective and constititutional symptoms to rule out systemic issues, then what do we use?



If we find it that it indicates for a systemic issue,mwhat woukd we do next?

Verify that it is that system


D if it is negative from our objective then what do we do next?

If it is in the upper quadrant, we use the UQ screen and if it is in the lower quadrant we will perform the LQ screen.


If after all the screens we still are not able to reproduce the pain that the patient was complaining of, then what do we do?

We pursue the other areas that had indications of being an issue, when before it was only ine wign of being systemic and five signs of being somatic, which we then pursued the somatic angle, and now that that turned up dry, we will pursue the visceral angle.


Angina pain not relieved in 20’ with reduced activityand/or administration of nitroglycerin would warrant what?

Immediate medical attention


Requires immediate medical attention.

• Angina pain not relieved in 20’ with reduced activity and/or administration of nitroglycerin, they are not getting better with their medication and for such a long time.
• Angina at rest, why is he with chest pain when he is not at all working out.
• Angina with N&V, and profuse sweating, I get it that he has pain, but sweating? And n&V, why thesea sw ell?
• B&B incontinence and/or saddle anesthesia secondaryto cauda equina lesion or cervical spine pain with urinary incontinence. The nerves are so compressed that it causes saddle paresthesia.
• Anaphylactic shock, dude, he can't breathe!
• Inadequate ventilation, dude he can't breathe.
• Pt with DM, that appears confused or lethargic with AMS. Dude, he can't think properly.

So anything that is very unwarranted is to require imeediate medical attention. Can't breathe, the heart is messed up, the nerves are messed up, and thinking is messed up.


Worsening intermittent claudication• S&S’s

skin discoloration, trophic changes (thin, dry hair, hairless skin), pain with movement
• However if gets worst, or if pain at rest, then immediate medical refer-ral


Acute Appendicitis

To see if the appendix is messed up, you go and pressed the mcburney's point, or have them jump up and then down, if there is pain, it indicates and issue with the appendix.


• Throbbing

chest, back or abd pain, that is increased with
exertion, accompanied by a sensation of a heartbeat whenlying down

Because this is the track of the Abdominal Aorta, then the pain ought to be exactly there, on ht echest on the abdomin on the back,


Classic Triad of Sx - in ~50% of cases

• Hypotension
• Abdominal / Back Pain
• Pulsatile abdominal mass

Exactly where you could feel it and with pain there, and the lower blood pressure because the person will have a wider blood vessel.


Pain for the GI is? And why?

Abdominal and back, well, it makes sense abdominal, because we will say that their stomach does hurt and the back, because it is just the posterior of the abdominal.


Besides for the abdominal or the back pain where else would GI cause pain and what woukd cause GI to bpcause these pains?

NSAIDS would cause GI conditions and then you would get abdominal and you would get back and you woukd get shoulder pain.


What are the guidelines for MD referral forwomen?

• LBP, hip, pelvic, groin or SI with unknown etiol-ogy and constitutional sx’s
• Sx’s with menses
• Any spontaneous uterine bleeding after meno-
• For pregnant women;!
• Vaginal bleeding
• Elevated bp
• Increased Braxton-hicks (uterine) contractions in pregnant woman during exercise


What are the guidelines for MD referral for MS system?

•Sx’s out of proportion to the injury, or sx persist-ing than expected normal time
•Severe or progressive back pain with constitu-
tional sx’s, especially if they have a fever
•New onset of joint pain following sx with infl
signs(warmth, redness, tenderness, swelling)


What are the guidelines for MD referral for Cancer?

• All soft tissue lumps that persists or grows,whether painful or painless
• Woman p/w chest, breast, axillary or shoulder pain of un-known etiology with presence of cancer
• Any man with pelvic, groin, SI, LBP accompanied with sciatica and h/o prostate CA, and presents with a non movement pattern
• Bone pain, especially on WB, that persists more that 1 week, and is worse at night


What are the guidelines for MD referral for GU system?

•Abnormal urinary constituents – for example, change in color, odor, amount, flow of urine
•Any amount of blood in urine
•Cervical spine pain accompanied by urinary incontinence (unless cervical disk protrusion already has been medicallydx)