DD Week 5 Study Guide.docx

Upper Quarter Screening: Head, Neck, Chest, Shoulder 10/27/2023 Head Pain Brain has no nerve endings Head pain is usually due to other causes Headache Cervical spine Cancer Systemic disorders Infections Sinus CVA Hormonal imbalance Temporal arteritis Headache Classification Primary headaches Migr...

Upper Quarter Screening: Head, Neck, Chest, Shoulder 10/27/2023 Head Pain Brain has no nerve endings Head pain is usually due to other causes Headache Cervical spine Cancer Systemic disorders Infections Sinus CVA Hormonal imbalance Temporal arteritis Headache Classification Primary headaches Migraine Tension Cluster headache Secondary headache – many types Cervicogenic Systemic cause of Headache: HTN, Stroke (hemorrhagic), temporal arteritis, cancer Migraine Throbbing/pulsating One sided Classic pattern for individual behind one eye Often accompanied by nausea/vomiting, visual issues, sensitivity to light and sound Triggers Alcohol, hormonal, hunger, lack of sleep, stress, meds, environment, food Can be preceded by other symptoms (aura) Visual changes, motor weakness, dizziness, paresthesia Age is yellow flag usually begin in childhood to early adulthood Associated signs and symptoms may give clues Tension Headache Dull pressure Band or vise-like sensation around head Bilateral or whole head Muscular tenderness or tightness in upper cervical spine No other associated symptoms Aggravated by loud noises/ bright lights Current or hx. of anxiety, depression, panic disorder Cluster Headache Sudden onset of severe pain Usually behind eye or one side of head Attack may last 1-3 hours. Frequency every few days to every few hours Occurs in clusters over several days and then subsides – may subside for months or years then reoccur. More common in males Cervicogenic Occipital region and spreads anteriorly Unilateral (sub-set of bilateral pain) Fluctuations in severity of pain Aggravated by neck movements Tenderness cervical musculature Limited cervical ROM Can resemble migraines/tension History of trauma Disc, whiplash, arthritis, concussion Temporal Arteritis Sudden severe headache Tenderness over temporal artery May see redness and warmth Can have visual changes Immediate referral – can cause blindness Headache: Red flags History of CA AM (awakening) headache Accompanied by HTN Insidious/new onset over 6 months New onset associated with neuro signs New onset with constitutional symptoms LOC with headache Sudden severe headache with flu-like symptoms, muscle pain, jaw pain No previous personal/family h/o migraine Cervical Spine Many mechanisms for pain Ask about trauma including domestic/intimate partner violence History of CA Systemic causes of neck pain Red Flags Age <20 or >50 Higher risk of bone cancer Previous hx of CA IV drug use Immuno-compromised Failure to improve No relief Recumbency/ position change Severe constant pain History of falls/trauma Severe morning stiffness Skin rash Non-response to PT interventions Rheumatoid Arthritis Can have upper cervical involvement early on in disease process Can refer pain to head, face, orbital and peri-orbital areas Can have atlanto-axial subluxation Sharp-purser test Radicular symptoms accompanied weakness, gait disturbances, bowel and bladder retention or incontinence or sexual dysfunction should be referred immediately Cervical Myelopathy Can be due to mechanical or medical cause Radicular symptoms, weakness, coordination impairment, gait, bowel/bladder problems, sexual dysfunction Special Test Cluster + Hoffman + Babinski + Inverted Supinator Test Unsteady gait Age >45 Imaging MRI for dx Thyroid Dysfunction Can present with torticollis/SCM tightness Anterior neck pain worse with swallowing or cervical rotation Question about previous h/o thyroid disease Associated signs and symptoms Temperature intolerance Hair, skin or nail changes Joint/muscle pain Throat pain/difficulty swallowing Anterior disc bulge or osteophyte into esophagus/pharynx Anxiety Ascending aortic dissection/aneurism Screen cranial nerves Vascular Screening Head and neck pain may be early presentation of vascular pathology Cerebral ischemia Vertebral artery test - screening Chest Pain Musculoskeletal causes Cardiac Breast conditions Rib fractures Pulmonary Cancer (Ca) Musculoskeletal Causes of Chest Pain Cervical spine (C3-C4 refers) Costochondritis Tietze’s syndrome Xiphodynia Slipping rib syndrome Myalgia Trigger points Fractured rib Costochondritis Inflammation of one or more costal cartilages Sharp pain in front of the sternum Can radiate Tenderness over costochondral joint Tietze’s Syndrome Intercostal neuritis Irritation of dorsal nerve roots Herpes zoster Fever chills Headache/malaise 1-2 days of pain, itching or hyperesthesia before skin lesions develop Skin eruptions that appear along dermatomes Mechanical irritation from spine disease Thoracic outlet Post operative pain Cardiac Disease Chest Pain most common symptom Radiating pain down arm (ulnar nerve distribution), head, neck, jaw, upper back Vital signs pre-post activity Cardiac Origin: Other Signs & Symptoms Nausea Vomiting Diaphoresis Dyspnea Fatigue Pallor Syncope/dizziness Palpitations Edema Cough Cardiac conditions likely to present as musculoskeletal Angina MI Pericarditis Dissecting aortic aneurysm Angina Pain or pressure behind the sternum May radiate to neck, jaw, back, shoulder arm Toothache Burning indigestion Dyspnea Nausea Belching Typically brought on by exercise/stress relieved by rest/nitroglycerine Can be confused with heartburn, GERD, hiatal hernia, gallbladder Atypical angina women, diabetes, SCI Myocardial Ischemia in Women Do not always experience classic S & S Dyspnea Weakness, lethargy, unusual fatigue Indigestion, heartburn, stomach pain Sleep disturbances Mid thoracic, inter-scapular or R biceps pain May get relief from antacids Cognitive changes in elderly females Pericarditis Chest pain, may radiate to neck, upper back, upper trap, supra-clavicular, costal margins Difficulty swallowing Dyspnea Pain improves with breath holding Pain worsens with trunk movement Fever, chills Cough Adverse Reaction to Statins Statins Zocor, Mevacor, Lipitor, Crestor, Pravachol Myalgia Fatigue Unexplained fever Nausea/ vomiting Rhabdomyolysis Kidney/liver impairment Laboratory Values used in Cardiac Disease CBC Serum electrolytes Lipid Panel Enzymes Labs: Lipid Cholesterol <200 mg/dL Triglycerides <150 mg/dL LDL <100 mg/dL HDL 35-65 mg/dL HDL:LDL ratio Goal keep above 0.3 Ideal above 0.4 Pulmonary Pain Patterns Sub-sternal chest, anterior chest, side, upper back Can radiate to neck, upper trap, costal margins, scapulae, shoulder Pain typically increases with respiratory movements Associated with other S&S such as dyspnea, cough, fever, chills Pneumonia Sudden pleuritic chest pain with respiratory movements Productive cough Dyspnea Tachypnea Fever chills Headache Generalized aches myalgia/arthralgia Fatigue Confusion in elderly Diagnostic Test Listen for crackles in the lungs, X-ray Lung Cancer Recurrent pneumonia Hemoptysis Cough that does not improve Hoarseness/dysphagia Dyspnea Wheezing Chest, upper back, shoulder pain aggravated by breathing Unexplained weight change Pancoast’s tumor Apical tumor of lung parenchyma Can extend to C8 and T1 nerves in brachial plexus Pancoast’s syndrome Sensory changes C8, T1, T2 Horner’s syndrome with extension to Paravertebral sympathetic nerves Sharp shoulder pain which may radiate up neck and head GI causes of chest pain Esophagus Ant neck/chest pain, dysphagia, early satiety GERD Lower sub-sternal, confused with angina Ulcer pain Sub-sternal pain may radiate to back Gastric vs. duodenal Gall bladder Tenth rib syndrome Gall Bladdery S & S Abdominal Pain – RUQ Sharp/dull, crampy May extend to shoulder blade/neck Worse after eating meals High fat Vomiting Pain with deep breath RUQ tenderness Jaundice Clay colored stools Breast Pain Mastodynia Upper dorsal inter-costal nerve Mastitis Inflammation of mammary duct Benign tumors and cysts Breast Cancer Implants Post cosmetic or reconstructive surgery Breast Cancer Risks Female >male Caucasian Age > 60 Peak 45 – 70 Genetic BRCA1/BRCA2 Family history 1st degree relative PMH Breast, uterine, ovarian, colon CA Estrogen Onset of menses <12 Menopause > 55 First live birth > 35 Environmental estrogens (esters) Immediate medical attention Sudden onset of acute chest pain with dyspnea Sudden change in clients typical anginal pattern Referral Women with chest, breast, axillary, shoulder pain of unknown origin that cannot be reproduced Symptoms of unknown cause and history of CA Suspected drug use Cocaine Anabolic steroids Shoulder Pain: Musculoskeletal Onset Trauma, repetitive stress/overuse, posture Pain reproduced Active or passive ROM Resistive movements Special tests Trigger point Shoulder pain Thoracic Outlet Vascular Neurological Tests Adson & Halstead Maneuvers, Allen test Many conditions that can cause neck pain, chest, upper back pain can also refer pain to shoulder Systemic Causes of Shoulder Pain Diaphragmatic irritation Supra-clavicular, posterior shoulder pain Many organs can put pressure on the diaphragm L shoulder pain can be caused by ruptured spleen = Kehr’s sign Ectopic pregnancy – typically lower pelvic pain/cramping but can cause shoulder pain. Shoulder pain Systemic multiple organs can refer pain to the shoulder Shoulder is unique Pain felt in shoulder will affect the joint as if pain is originating in the joint Need to screen if No known mechanism/insidious onset High risk population: >65, h/o CA Associated signs and symptoms Yellow or red flags Shoulder Pain: systemic causes Diaphragmatic irritation Supraclavicular, posterior shoulder pain Multiple organs can put pressure on the diaphragm L shoulder pain can be due to ruptured spleen – Kehr’s sign GI Liver –gall bladder Cardiac Angina MI Pericarditis Endocarditis Pulmonary Gynecologic Diaphragmatic Irritation Irritation of central diaphragm refers pain to ipsilateral upper trapezius, neck, supraclavicular Can be bilateral if irritation crosses midline Peripheral portion of diaphragm refers pain to costal margins or lumbar region Renal refers to ipsilateral side Spleen L shoulder Pancreas Lies in midline often refers to back Tail of pancreas can irritate L diaphragm Gall bladder irritate R side of diaphragm R shoulder pain Reproduction of symptoms with palpation of diaphragm and altered breathing pattern are clues Pulmonary Causes of Shoulder Pain Parietal pleura sharp, localized pain aggravated by breathing. Relieved by lying on that side/auto splinting Pain aggravated by lying down may indicate impaired CP system Increased venous return Pneumonia if inflammation involves or puts pressure on diaphragm S & S persistent/productive cough, chest pain, tachypnea, dyspnea, hyperventilation, adventitious breath sounds Chest auscultation must be done Cardiovascular Causes Angina or MI Complex regional pain syndrome (CRPS) Thoracic Outlet Bacterial Endocarditis Most common musculoskeletal symptom is arthralgia of proximal joints Shoulder most common Pericarditis Aortic Aneurysm DVT of UE not as common as in LE Renal Causes of Shoulder Pain Can refer pain to shoulder if causes pressure on diaphragm (posterior upper abdominal cavity) Usually causes pain posterior subcostal and costovertebral regions Aching and dull Ask about change in urine color, odor, frequency, urgency, blood in urine, fever. GI Causes of Shoulder Pain GI bleed Who is at risk S & S Ulcer pain associated with eating Gastric Duodenal Liver and biliary causes of Shoulder pain Mid back, scapula or R shoulder pain Bilateral carpal tunnel Question about: h/o cirrhosis, Ca, hepatitis, alcohol abuse, statin use S&S Skin changes Jaundice, palmer erythema, bruising, spider angioma, white nails, dark urine, light color feces, RUQ pain, feeling full or bloated, edema Rheumatic Causes Polymyalgia rheumatic Polymyositis RA Ankylosing spondylitis Infectious causes Septic arthritis of acromioclavicular joint Osteomyelitis Mononucleosis Enlarged spleen L shoulder pain Gynecological causes Ectopic pregnancy Sudden sharp/constant lower abdominal or pelvic pain on one side Can but not commonly refer pain to shoulder Accompanied by irregular bleeding/spotting, late menstrual period Life threatening