Primary cancers of the musculoskeletal system are uncommon in adults, but secondary cancers are relatively common. Metastatic cancer of the musculoskeletal system is most frequently the result of primary cancer in the breast, prostate, lung/bronchus, thyroid, or kidney (Logothetis & Lin, 2005; NCI, 2017b). The development of metastatic cancer in bones is generally limited to the vascularized portions of the skeleton (i.e., the red marrow found in the proximal portions of the long bones and the axial skeleton; Goodman et al., 2018). Metastatic cancer in the musculoskeletal system results in bone resorption, periosteal irritation, and nerve entrapment resulting in pain. Approximately 50% of people with bone metastases suffer a pathological fracture and that bone fracture is often the presenting sign of bone metastasis. Bone pain from metastatic cancer is often described as deep, intractable, burning, stabbing, and poorly localized (Goodman et al., 2018). Pain is often worse with weight bearing and patients have a diminished tolerance for weight-bearing activities. At times this pain mimics mechanical pain from the musculoskeletal system, making the differential diagnosis difficult. However, the pain is often worst at night, lying down does not provide relief, and the pain is not responsive to conservative treatment (i.e., no aggravating or relieving factors can be found). Bone resorption can cause hypercalcemia, resulting in the onset of abnormal signs and symptoms in the CNS, musculoskeletal system, cardiovascular system, and GI system (Goodman et al., 2018). Many of the signs and symptoms that occur as a result of hypercalcemia produce positive responses on one or more general health questions and the screening questions for specific physiological systems. Approximately 20% to 40% of all primary cancers that metastasize will form secondary cancers in the CNS (Doolittle, 2004; NCI, 2017b). Lung cancer, breast cancer, and melanoma are the most frequent types of primary cancer to form secondary cancers in the CNS. New headaches and the onset of seizures are the most common presenting symptoms of cancer in the CNS, but personality/ cognitive changes, sensory loss, weakness, and atrophy are also frequently reported or detected using the general health and physiological screening questions (Goodman et al., 2018; NCI, 2017b). The pulmonary system is a common site for primary and secondary cancers to form. Primary lung cancer is associated with smoking while metastatic lung cancer is most often the result of a primary cancer in the breast, colon/rectum, and/or bone (Goodman et al., 2018). Summary of screening for cancer Screening for cancer by looking at the patient’s medical history and physical exam findings and identifying risk factors for cancer is important to the patient and the therapist. Therapists should be aware that the presence of cancer as an underlying cause of low back pain is more likely if the patient is age 50 or older, has a personal history of any type of cancer, has unexplained weight loss, and fails to respond to conservative therapy.
Except for the parietal pleura and large airways, the lungs do not contain nociceptors (pain receptors). As a result, development of cancer in the pulmonary system will remain pain-free until the tumor interacts with the parietal pleura or large airways. However, patients may report the presence of undue dyspnea, as well as the development of an unusual cough and/or sputum that is rust, green, or yellow in color prior to demonstrating obvious signs and symptoms of pulmonary cancer (Goodman et al., 2018; NCI, 2017b). The presence of metastatic liver cancer is an ominous sign of advanced cancer. Primary cancer of the colon, rectum, pancreas, and stomach cause the majority of secondary cancers in the liver (Goodman et al., 2018; NCI, 2017b). Liver cancer results in complaints of pain or tenderness in the upper right abdominal quadrant, with pain often referred to the right shoulder (Goodman et al., 2018). Peripheral edema and ascites are common findings in patients with liver cancer. These patients may also have jaundice, undue fatigue, and malaise. Signs of liver cancer include the presence of spider angiomas, palmar erythema, asterixis, and “Nails of Terry.” These nails present with an opaque white nail plate with a narrow band of pink at the distal end. Nails of Terry are associated with a number of disorders, including cirrhosis of the liver, hyperthyroidism, diabetes, and malnutrition. The onset of bilateral carpal tunnel syndrome is particularly suspicious in patients at risk for cancer, especially if the patient reports undue fatigue and malaise when the general health questions are asked (Goodman et al., 2018). The integument may present with signs of primary and secondary cancer. Unusual moles or skin lesions should be assessed using the A-B-C-D-E screening method advocated by the American Cancer Society. The A-B-C-D-E acronym from the American Cancer Society refers to evaluating skin lesions for Asymmetry, Border, Color, Diameter and Evolving/changing . Skin lesions that are asymmetrical, have irregular borders, are multicolored, have a diameter larger than a pencil eraser [approximately 1/4 inch (6 mm)] and/or are evolving in size, shape or color are considered to be highly suspicious and the patient should be referred to their physician. Moles that are tender, itchy, and bleed or discharge exudate are considered suspicious. Metastatic spread of cancer to the integument is most likely due to a primary caner in the breast, upper respiratory tract, lymphoma, or multiple myeloma. Metastatic spread to the integument may produce an unusual skin rash and/or produce changes in the nailbeds such as Nails of Terry (Goodman et al., 2018). If a patient has a personal history of cancer, the therapist should be familiar with which metastatic sites are most commonly associated with the patient’s specific type of primary cancer. Therapists should ask the general health questions, use the appropriate specific physiological screening questions, conduct an appropriate physical examination, and evaluate the patient’s response to conservative therapy to determine how to proceed with a client.
SCREENING FOR ADVERSE DRUG REACTIONS
Many adverse drug reactions cause a person to respond affirmatively to general health questions and specific physiological screening questions (i.e. many adverse drug reactions mimic organic disorders). Therapists need to be aware of a change in patient status due to a change in medical status versus the presence of an adverse drug reaction.
This section of the course guides the reader through the process of screening for adverse drug reactions by describing how to take a medication history as part of the medical history. It always describes for the reader the top 20 drugs prescribed in the U.S., to including the five drugs most likely to cause an adverse reaction, and the five physiological systems most frequently impacted by adverse drug reactions.
EliteLearning.com/Physical-Therapy
Book Code: PTOH1324
Page 94
Powered by FlippingBook