1. Name three predisposing factors to cancer that the therapist must watch for during the interview process as red ﬂags.
Previous personal history of cancer; age in correlation with a personal or family history of cancer; age and gender in correlation with incidence of certain cancers; exposure to environmental and occupational toxins; geographic location; lifestyle (e.g., consumption of alcohol, smoking cigarettes, poor diet)
2. How do you monitor exercise levels in the oncology patient without laboratory values?
In any patient or client who is undergoing cancer treatment (especially chemotherapy), laboratory values offer a guide for determining appropriate frequency, intensity, and duration of exercise. In an outpatient setting, laboratory values may be unavailable or outdated. Without the benefit of laboratory values (and even when laboratory values are available), the therapist can and should monitor vital signs and rate of perceived exertion (RPE), and should look for associated signs and symptoms (e.g., pallor, dyspnea, unexplained or excessive diaphoresis, heart palpitations, visual changes, dizziness). Anything out of the ordinary should be considered a yellow (cautionary) flag that requires careful observation, further evaluation, and possibly medical referral.
3. In a physical therapy practice, clients are most likely to present with signs and symptoms of metastases to:
a. Skeletal system, hepatic system, pulmonary system, central nervous system
b. Cardiovascular system, peripheral vascular system, enteric system
c. Hematologic and lymphatic systems
d. None of the above
4. What is the signifcance of nerve root compression in relation to cancer?
In any individual, any neurologic sign may be the presentation of a silent lung tumor.
5. Complete the following mnemonic:
C A U T I O N S
- Changes in bowel or bladder habits
- A sore that does not heal within 6 weeks
- Unusual bleeding or discharge
- Thickening or lump in the breast or elsewhere
- Indigestion or difficulty in swallowing
- Obvious change in a wart or mol
- Nagging cough or hoarseness
- Supplemental signs and symptoms (rapid unintentional weight loss, changes in vitalsigns, frequent infections, night pain, pathologic fracture, proximal muscle weakness, change in deep tendon reflexes)
6. Whenever a therapist observes, palpates, or receives a client report of a lump or nodule, what three questions must be asked?
- How long have you had this area of skin discoloration/mole/spot/lump?
- Has it changed over the past 6 weeks to 6 months?
- Has your physician examined this area? (Alternate question: Has your physician seen this?)
7. How can the therapist determine whether a client’s symptoms are caused by the delayed effects of radiation as opposed to being signs of recurring cancer?
This is a medical decision and is not within the scope of physical therapist practice. If the clinician has any doubt, the physician should be contacted. The therapist can certainly take vital signs, ask about the presence of constitutional symptoms such as fever, weight loss, nausea, vomiting, and look for and document associated signs and symptoms. All of these findings can be submitted to the physician for consideration.
8. Give a general description and explanation of the changes seen in deep tendon reﬂexes associated with cancer.
Space-occupying lesions (whether discogenic, bony spurs in the foraminal spaces, or tumor cells invading and occupying the spaces next to nerve roots) may cause an increase in deep tendon reflexes when compression irritates the nerve but does not obstruct the reflex arc. When any anatomic obstruction is large enough to compress the nerve and interfere with the reflex arc, the deep tendon reflex is diminished or absent.
9. Why is weight loss a signifcant red ﬂag sign in a physical therapy practice?
Pain, movement dysfunction, and disability usually result in weight gain due to inactivity. When someone is experiencing back pain, for example, and reports a significant weight loss, this may be a red flag for systemic origin of the problem.
10. When tumors produce signs and symptoms at a site distant from the tumor or its metastasized sites, these “remote effects” of malignancy are called:
a. Bone metastases
c. Paraneoplastic syndrome
11. A client who has recently completed chemotherapy requires immediate medical referral if he has which of the following symptoms?
a. Decreased appetite
b. Increased urinary output
c. Mild fatigue but moderate dyspnea with exercise
d. Fever, chills, sweating
12. A suspicious skin lesion requiring medical evaluation has:
a. Round, symmetric borders
b. Notched edges
c. Matching halves when a line is drawn down the middle
d. A single color of brown or tan
13. What is the signifcance of Beau’s lines in a client treated with chemotherapy for leukemia?
a. Impaired nail formation from death of cells
b. Temporary longitudinal groove or ridge through the nail
c. Increased production of the nail by the matrix as a sign of healing
d. A sign of local trauma
14. A 16-year-old boy was hurt in a soccer game. He presents with exquisite right ankle pain on weight bearing but reports no pain at night. Upon further questioning, you fnd he is taking Ibuprofen at night before bed, which may be masking his pain. What other screening examination procedures are warranted?
a. Perform a heel strike test.
b. Review response to treatment.
c. Assess for signs of fracture (edema, exquisite tenderness to palpation, warmth over the painful site).
d. All of the above
15. When is it advised to take a work or military history?
a. Anyone with head and/or neck pain who uses a cell phone more than 8 hours/day
b. Anyone over age 50
c. Anyone presenting with joint pain of unknown cause accompanied by multiple other signs and symptoms
d. This is outside the scope of a physical therapist’s practice
16. A 70-year-old man came to outpatient physical therapy with a complaint of pain and weakness of his fngers and morning stiffness lasting about an hour. He presented with bilateral
swelling of the metacarpophalangeal (MCP) joints of the index and ring fngers. He saw his family doctor 4 weeks ago and was given diclofenac, which has not changed his symptoms. Now he wants to try physical therapy. Since he last saw his physician, he has developed additional joint pain in the left knee and right shoulder. How can you tell if this is cancer, polyarthritis, or a
a. Ask about a previous history of cancer and recent onset of skin rash.
b. You can’t. This requires a medical evaluation.
c. Look for signs of digital clubbing, cellulitis, or proximal muscle weakness.
d. Assess vital signs.
17. A 49-year-old man was treated by you for bilateral synovitis of the proximal interphalangeal (PIP) joints in the second, third, and fourth fngers. His symptoms went away with treatment,
and he was discharged. Six weeks later, he returned with the same symptoms. There was obvious soft tissue swelling with morning stiffness worse than before. He also reports problems
with his bowels but isn’t able to tell you exactly what’s wrong. There are no other changes in his health. He is not taking any medications or over-the-counter drugs and does not want to see a doctor. Are there enough red ﬂags to warrant medical evaluation before resumption of physical therapy intervention?
a. Yes; age, bilateral symptoms, progression of symptoms, report of GI distress
b. No; treatment was effective before—it’s likely that he has done something to exacerbate his symptoms and needs further education about joint protection
18. A client with a past medical history of kidney transplantation (10 years ago) has been referred to you for a diagnosis of rheumatoid arthritis. His medications include tacrolimus, methotrexate, Fosamax, and Wellbutrin. During the examination, you notice a painless lump under the skin in the right upper anterior chest. There is a loss of hair over the area. What other
symptoms should you look for as red ﬂag signs and symptoms in a client with this history?
a. Fever, muscle weakness, weight loss
b. Change in deep tendon reﬂexes, bone pain
c. Productive cough, pain on inspiration
d. Nose bleeds or other signs of excessive bleeding
19. A 55-year-old man with a left shoulder impingement also has palpable axillary lymph nodes on both sides. They are frm but movable, about the size of an almond. What steps should you
a. Examine other areas where lymph nodes can be palpated.
b. Ask about history of cancer, allergies, or infections.
c. Document your fndings and contact the physician with your concerns.
d. All of the above