Upper Quarter Screening Head, Neck, Chest, UE Handout 2023 PDF

Upper Quarter Screening Head, Neck, Chest, Shoulder R Hansen PHTR 619 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 Classif...

Upper Quarter Screening Head, Neck, Chest, Shoulder R Hansen PHTR 619 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 – Covered in adulthood • Ask about trauma – including domestic/intimate partner violence • History of CA Systemic causes of neck pain Red Flags • • • • • • Age <20 or >50 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 Tests? 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 movements • 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 – covered week 3 Serum electrolytes – covered week 3 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 MARKERS USED IN DIAGNOSIS OF AMI Marker Normal Start Peak End CK 25-200U/L 4-8 h 16-30 h 16-30 h CK-MB 12 IU/L 6-10 h 24 h 72 h LDH 140-280 12-24 h 72 h 10 d LDH1 18-33% LDH2 28-40% Normally LDH1 will be less than LDH2 in AMI LD2 remains constant and LDH1 rises when LDH 1 becomes greater than LDH2 suggests MI SGOT 10-42 U/L 8-12 h 18 -30 h 3-4 d Myoglobin <1 1-2 h 4-8 h 12 h Troponin <0.4 4-6 h 10-24 h 1-2 w Troponin I 3.1 ng/ml Cardiac selective subunits of troponin Troponin T 0.1 ng/ml 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? 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 Para vertebral 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) Never dismiss chest pain without careful evaluation 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 Upper Quarter: Shoulder and UE 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