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Transabdominal Resection: Abdominoperineal resection or low anterior 6 androgen hormone symptoms buy rogaine 5 60 ml amex,7 • Lymph node dissection resection or coloanal anastomosis using total mesorectal excision 4Biopsy or remove clinically suspicious nodes beyond the feld • Management principles of resection if possible androgen hormone replacement discount rogaine 5 60 ml fast delivery. In distal rectal cancers (ie duke prostate oncology purchase 60 ml rogaine 5 otc, <5 cm from anal verge) mens health 012013 chomikuj generic rogaine 5 60 ml visa, negative distal bowel wall margin of 1–2 cm may be acceptable; this must be confrmed to be tumor free by frozen section. All original sites of disease need to be amenable to place should have both sites resected with curative intent. Evaluation for Conversion to Resectable Disease • Arterially directed catheter therapy, and in particular yttrium 90 • Re-evaluation for resection should be considered in otherwise microsphere selective internal radiation, is an option in highly unresectable patients after 2 months of preoperative chemotherapy selected patients with chemotherapy-resistant/-refractory disease 24-27 and every 2 months thereafter. A randomized trial of laparoscopic versus open 17 Inoue M, Kotake Y, Nakagawa K, Fujiwara K, Fukuhara K, Yasumitsu T. Open versus laparoscopic surgery for mid-rectal or 18 Sakamoto T, Tsubota N, Iwanaga K, Yuki T, Matsuoka H, Yoshimura M. Impact of T and N stage and treatment 22Yano T, Hara N, Ichinose Y, Yokoyama H, Miura T, Ohta M. Results of pulmonary on survival and relapse in adjuvant rectal cancer: a pooled analysis. Five-year survival following hepatic resection after resection, radiofrequency ablation, and combined resection/ablation for colorectal liver neoadjuvant therapy for nonresectable colorectal. Combination of 9Resection of the liver for colorectal carcinoma metastases: a multi-institutional study of neoadjuvant chemotherapy with cryotherapy and surgical resection for the treatment of indications for resection. Chemotherapy regimen predicts steatohepatitis carcinoma metastases: a multi-institutional study of patterns of recurrence. Surgery and an increase in 90-day mortality after surgery for hepatic colorectal metastases. A ‘modifed de Gramont’ regimen of fuorouracil, alone and with oxaliplatin, for advanced colorectal cancer. Improving adjuvant therapy for rectal cancer by combining protracted-infusion fuorouracil with radiation therapy after curative surgery. Adjuvant therapy in rectal cancer: analysis of stage, sex, and local control-fnal report of Intergroup 0114. Capecitabine and oxaliplatin in the preoperative multimodality treatment of rectal cancer: surgical end points from National Surgical Adjuvant Breast and Bowel Project trial R-04. Chemoradiotherapy with capecitabine versus fuorouracil for locally advanced rectal cancer: A randomized, multicentre, non inferiority, phase 3 trial. The external iliac nodes should also be included for T4 tumors involving anterior structures. Positioning and other techniques to minimize the volume of small bowel in the felds should be encouraged. Male patients should be counseled on infertility risks and given information regarding sperm banking. Female patients should be counseled on infertility risks and given information regarding oocyte, egg, or ovarian tissue banking prior to treatment. Randomized trial of short-course radiotherapy versus long-course chemoradiation comparing rates of local recurrence in patients with T3 rectal cancer: Trans-Tasman Radiation Oncology Group trial 01. Evidence suggests that North American patients may experience greater toxicity with capecitabine (as well as with other fluoropyrimidines) than European patients, and may require a lower dose of capecitabine. Leucovorin and fuorouracil with or without oxaliplatin 17Falcone A, Ricci S, Brunetti I, et al. Evaluation of oxaliplatin dose intensity in 18 Cremolini C, Loupakis F, Antoniotti C, et al. Oxaliplatin plus irinotecan compared with irinotecan 5Emmanouilides C, Sfakiotaki G, Androulakis N, et al. Randomized, controlled trial of irinotecan plus infusional, second-line therapy of metastatic colorectal cancer. Regorafenib monotherapy for previously treated 13Martin-Martorell P, Rosello S, Rodriguez-Braun E, et al. Recommendations for high-risk individuals should be made on an 1-5 Management of Late Sequelae of Disease or Treatment: individual basis. Activity recommendations 4Encourage physical activity, energy conservation measures may require modifcation based on treatment sequelae (ie, ostomy, 6,7 neuropathy). Diet and vaginal dryness recommendations may be modifed based on severity of bowel 4Screen for urinary incontinence, frequency, and urgency dysfunction. Survivorship Care Planning: Survivors are encouraged to maintain a therapeutic relationship the oncologist and primary care provider should have defned roles in with a primary care physician throughout their lifetime. How patients manage gastrointestinal symptoms after 8Hewitt M, Greenfield S, Stovall E. Patients who have a complete pathologic response Distant Metastasis (M) are ypT0N0cM0 that may be similar to Stage Group 0 or I. M1b Metastases in more than one organ/site or the peritoneum aThis includes cancer cells confined within the glandular basement membrane (intraepithelial) or mucosal lamina propria (intramucosal) with no extension through the muscularis mucosae into the submucosa. However, if no tumor is present in the adhesion, microscopically, the classification should be pT1-4a depending on the anatomical depth of wall invasion. These guidelines overlap the second leading cause of cancer death in the United States. The panel same year, it is estimated that 49,190 people will die from rectal and unanimously endorses patient participation in a clinical trial over 1 standard or accepted therapy, especially for cases of advanced disease colon cancer combined. Despite these statistics, the incidence per 100,000 population of colon and rectal cancers decreased from 60. In fact, the incidence of colorectal cancer decreased at a rate of approximately 3% per year or greater between 1 Literature Search Criteria and Guidelines Update 2003 and 2012. Results were confined to the following article rates for colon and rectal cancers will increase by 90. The cause of this Guideline; Randomized Controlled Trial; Meta-Analysis; Systematic trend is currently unknown. The data from key PubMed articles and guidelines begin with the clinical presentation of the patient to the articles from additional sources deemed as relevant to these Guidelines primary care physician or gastroenterologist and address diagnosis, and discussed by the panel have been included in this version of the pathologic staging, neoadjuvant treatment, surgical management, Discussion section (eg, e-publications ahead of print, meeting Version 3. The cost effectiveness of this approach, first-degree relative with colorectal cancer diagnosed before age 50 referred to as universal or reflex testing, has been confirmed for years or two first-degree relatives with colorectal cancer diagnosed at colorectal cancer, and this approach has been endorsed by the 15 any age can safely be screened with colonoscopy every 6 years. An international risk for colon cancer in men and the consumption of nonfermented 59 consortium has recently reported a molecular classification, defining milk. Furthermore, the use of aspirin or (Mesenchymal), prominent transforming growth factor activation, nonsteroidal anti-inflammatory drugs may also decrease the risk for 30 63-68 stromal invasion, and angiogenesis. In addition, some data suggest that smoking, metabolic syndrome, Other Risk Factors for Colorectal Cancer obesity, and red/processed meat consumption is associated with a poor 37,69-72 prognosis. Conversely, post-diagnosis fish consumption may be It is well recognized that individuals with inflammatory bowel disease 73 associated with a better prognosis. A family history of colorectal (ie, ulcerative colitis, Crohn’s disease) are at an increased risk for 74 31-33 cancer increases risk while improving prognosis. Other possible risk factors for the development of dairy consumption on prognosis after diagnosis of colorectal cancer are colorectal cancer include smoking, the consumption of red and 75,76 conflicting. Results of a small randomized study suggest that 1 correlated with N stage (N0, N1a, N1b, N2a, and N2b). M1b is used for metastases to multiple distant colorectal cancer and diabetes appear to have a worse prognosis than 86 th those without diabetes, patients with colorectal cancer treated with sites or solid organs, exclusive of peritoneal carcinomatosis. The data regarding the for peritoneal carcinomatosis with or without blood-borne metastasis to effects of metformin on colorectal cancer incidence and mortality, 90 visceral organs. In this edition, T1 depth of penetration and extension to adjacent structures (T); 4) number tumors involve the submucosa; T2 tumors penetrate through the of regional lymph nodes evaluated; 5) number of positive regional lymph submucosa into the muscularis propria; T3 tumors penetrate through nodes (N); 6) the presence of distant metastases to other organs or the muscularis propria; T4a tumors directly penetrate to the surface of sites including non-regional lymph nodes (M); 7) the status of proximal, the visceral peritoneum; and T4b tumors directly invade or are adherent 92-96 90 distal, circumferential (radial), and mesenteric margins; 8) to other organs or structures. The number of lymph nodes that 108 that are either not encased or only partially encased in peritoneum. The literature lacks consensus regarding the minimal of the tumor and the edge of resected soft tissue around the rectum (ie, number of lymph nodes needed to accurately identify early-stage rectal 116 the retroperitoneal or subperitoneal aspect of the tumor) or from the cancer. Most of these studies have combined rectal and colon edge of a lymph node and should be measured in millimeters. A more recent 109 inking of the outer surfaces and “bread-loaf” slicing of the specimen. Although results of some of these studies seem viable cancer cells observed) to 3 (poor response – minimal or no tumor 97,98,114,134 promising, there is no uniformity in the definition of “true” clinically kill; extensive residual cancer). For example, rectal cancer, the sensitivity for the sentinel node procedure was only one retrospective analysis of 269 consecutive patients who had 128 40%.

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Anticonvulsants (antineuropathics) for neuropathic pain hydrochloride) [package insert]. Tylenol with Codeine (acetaminophen and codeine phosphate) Tablets 1991;41:1024-1028. Tegretol (carbamazepine) Chewable Tablets, Tablets, Suspension; and newly developed antiepileptic drugs. Lidocaine patch: dou matic treatment of painful neuropathy in patients with diabetes mellitus: ble-blind controlled study of a new treatment method for post-herpetic a randomized controlled trial. Topical lidocaine patch of painful neuropathy: a multicenter, double-blind, placebo-controlled relieves postherpetic neuralgia more effectively than a vehicle topical trial in patients with diabetes mellitus. Antidepressant therapy for nents independently contribute to the mechanism of action of tramadol, unexplained symptoms and symptom syndromes. The value of ”multimodal” or “balanced” analgesia in American Society of Addiction Medicine. Bonica’s Management al bupivacaine and morphine in prevention of stump and phantom pain of Pain. Medication nonadherence: finding solutions to a costly med Scientific Meeting, April 26, 2001. Basic concepts in biomechanics and Anesthesiologists, Task Force on Pain Management, Acute Pain Section. Lesions of primary afferent and sympathetic effer Lippincott Williams & Wilkins; 2001:780-787. Efficacy of multidisciplinary pain centres: an antidote Practice guidelines for chronic pain management. Prevention of postoperative pain Manual for and Interpretive Guidelines for Medical Rehabilitation. Acute Low Back Problems in Adults: management treatment on locus of control and pain beliefs in chronic Assessment and Treatment Quick Reference Guide No. Gabapentin for the sympto Rheumatology 1990 criteria for the classification of fibromyalgia. Opioid maintenance in chronic non-malignant pain [syl features of fibromyalgia syndrome. Recommendations for individ gesia, allodynia and myoclonus related to morphine metabolism during ual drugs. Progress in Pain Research and evidence-based guidelines for migraine headache (an evidence-based Management. Headache Consortium, American Rheumatology Ad Hoc Committee on Clinical Guidelines. The fibromyalgia syndrome: myofascial pain and the chron Practice guidelines for cancer pain management. Evidence-based guidelines for Agency for Health Care Policy and Research; February 1993. AnesthesiologistsTask Force on Sedation and Analgesia by Non Available at: Anesthesiologists. Practice parameter: Anesthesiologists Task Force on Pain Management, Chronic Pain Section. November 15, 2000;62(10):2359-2360, ment of osteoarthritis, part I: osteoarthritis of the hip. The Eastern Cooperative Oncology Group University of Wisconsin-Madison Board of Regents; 2000. Stratis Health-Medicare Health Care Quality Improvement guidelines for the treatment of acute pain and cancer pain. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Permission is hereby granted to reproduce the Appendices in this publication in complete pages, with the copyright notice, for instructional use and not for resale. With respect to any drug or pharmaceutical products identifed, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4377-2543-8 Vice President: Linda Duncan Executive Content Strategist: Kathy Falk Senior Content Development Specialist: Christie M. Hart Publishing Services Manager: Catherine Jackson Senior Project Manager: David Stein Design Direction: Jessica Williams Working together to grow libraries in developing countries Printed in the United States Thanks for taking all those late night calls, searching for references, writing and rewriting textadjusting from the yellow legal pad to the electronic ageand offering your expertise and wise counsel through four editions of this text. This page intentionally left blank pthomegroup pthomegroup F O R E W O R D T O T H E F O U R T H E D I T I O N Catherine Goodman and Teresa Snyder are to be commended But as Catherine Goodman and Teresa Snyder have so for making several important contributions to the role of wisely stated in the preface, the primary focus of this book is physical therapists as diagnosticians with this revision of their just the frst step in an evaluation that must ultimately lead classic text. The frst step in the diagnostic process is to deter to a diagnosis that directs physical therapy intervention. To mine if the patient’s condition necessitates a referral to a their credit they have also provided an introduction to the medical doctor. Therefore this book is an invaluable guide next steps in the complete diagnostic process. In keeping with because the authors have provided a model that is focused the Guide to Physical Therapist Practice, Goodman and Snyder and complete. Although the focus of the text is on identifying have addressed the importance of the concept of the move the most common conditions that mimic musculoskeletal ment system to physical therapy and thus to another level of problems, Goodman and Snyder also note that this is just the differential diagnosis. They have directed our attention to a frst step in the diagnostic process and have made suggestions developing system of diagnoses of movement system impair for future directions. This system requires differentiating among movement guide to practice and professional development by addressing system impairment conditions at both the tissue and the the issue of terminology associated with diagnosis. For many years, the issue of appropriate should be referred to a physical therapist. This effort is terminology and/or the context in which it is used with another refection of their prescient recognition of the direc regard to diagnosis in physical therapy has been one of confu tion of practice. The scope of the confusion is refected in a variety of physical therapist, whether for ruling out or identifying a editorials,1-8 textbooks, and advertisements that are inconsis medical condition or cogently labeling a movement impair tent in their use of differential diagnosis. Appropriately, this book’s title, Differential Historically the profession has mainly been considered Diagnosis for Physical Therapists: Screening for Referral, clari one in which the practitioner provided treatment based on fes that a primary responsibility of the physical therapist is the physician’s diagnosis. Evaluation, examination, diagnosis, to recognize the possible presence of a medical condition that and program planning whether sought by a client, a physi supersedes or mimics a condition requiring physical therapy cian, or another health professional is the necessary direction treatment. Clarifcation that differential diagnosis does not for the profession if we are to assume our role in health pro mean identifying the specifc disease is important in our rela motion, maintenance, and/or remediation. Exercise, which is tionship with physicians and in maintaining our legal scope the prevailing form of physical therapy treatment, continues of practice, as physical therapists assume a larger role in direct to receive increased attention as the most effective form of 1 access and primary care. As stated in this text, the frst step in the diagnostic process Yet physical therapists are not readily consulted for their is for the physical therapist to be able to identify medical expertise in developing programs that cannot only address conditions that are to be referred to the appropriate practi life-style–induced diseases but that can also prevent inducing tioner. Clearly this is a skill that any physical therapist must musculoskeletal problems. Not only does this book provide the An important goal of the profession is to promote recogni necessary information, but also the manner in which the tion that we are the health profession with the expertise to material is presented should enable every reader to achieve a appropriately screen, diagnose, and then develop treatment high level of skill. This book is intended to augment both the programs that are safe and effective for individuals with all reader’s skill in screening for medical conditions and also his levels of movement system dysfunction.

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For example prostate zonal anatomy buy discount rogaine 5 60 ml line, arterial insuffciency as a • What kind of pain patterns do we expect to prostate cancer hormone shot buy 60 ml rogaine 5 free shipping see with each of the cause of low back prostate cancer meaning discount rogaine 5 60 ml with mastercard, hip androgen hormone kit trusted rogaine 5 60 ml, buttock, or leg pain is presented as viscerogenic causes Likewise, known risk factors for bone cancer or metastases as a cause of hip, groin, or lower extremity pain are presented in Chapter 13. The therapist must be aware that (see Chapter 14) or pelvic pain (see Chapter 15). A careful history and physi as well as for direct education and prevention efforts. Many cal examination usually differentiate these entities from true risk factors for disease are modifable. Recognizing red fags in the history and clinical presen musculoskeletal or systemic cause (Table 16-2), is usually felt tation and knowing when to refer versus when to treat are posteriorly deep within the buttock or anteriorly in the groin, topics of focus in this chapter. She remains an inpatient with complications Observe for side effects related to congestive heart failure. She has a previous medical of medications or drug history of gallbladder removal 20 years ago, total hysterectomy interactions: 30 years ago, and surgically induced menopause with subse • Diuresis from Lasix (loop quent onset of hypertension. Blood pressure was 100/76 mm Hg monitor serum (measured in the right arm while lying in bed). Systolic measure electrolytes, and observe ment dropped to 90 mm Hg when the client moved from for signs/symptoms of supine to standing. How would you screen a client with this history and • Common adverse current comorbidities Read the medical record to stay up with what everyone else this can be compounded by weakness knows or has observed about the patient. Read the physician’s osteoporosis, if present as a • Tachycardia notes to see whether medical intervention has been ordered. In some spasmodic cough hospitals, a pulse less than 60 bpm in an adult would indicate (check sputum) that the next dose of digoxin should be withheld and the physi • Peripheral edema; check cian contacted. The protocol may be different from institution to jugular distention (see institution. When positive, this test may Giant cell tumor Synovitis help the therapist to identify serious extracapsular hip or Ewing’s sarcoma Femoral, inguinal, or sports pelvic disease. Often, an antalgic gait pattern is observed as • Septic hip bursitis* Developmental hip the individual leans away from the affected hip and shortens • Tuberculosis dysplasia; hip dislocation the swing phase to avoid weight bearing. Metabolic disease Legg-Calve-Perthes When the underlying problem is related to soft tissue. Cyriax’s • Ectopic pregnancy • Femoral artery “Sign of the Buttock” (Box 16-2) can help differentiate 11-13 catheterization between hip and lumbar spine disease. Identifying the †This is not an exhaustive, all-inclusive list, but rather, it includes the hip as the source of a client’s symptoms may be diffcult most commonly encountered adult neuromuscular or musculoskeletal because pain originating in the hip may not localize to the causes of hip pain. B, Hip pain from the lower lumbar vertebrae and sacrum is usually felt in the gluteal region, with radiation down the back or outer aspect of the thigh. After 5 or 10 steps, izes to the base of the spine may be accompanied by radicular the groin pain subsides. Pain may increase again after a mod pain extending across the buttock and down the leg. Often, the pain Overlying soft tissue structure disorders such as femoral is localized to the site of the prosthetic stem tip. The client hernia, bursitis, or fasciitis; muscle impairments such as points to a specifc spot along the anterolateral thigh. Pain on weakness, loss of fexibility, hypertonus or hypotonus, strain, initiation of activity that resolves with continued activity sprain, or tears; and peripheral nerve injury or entrapment, should raise suspicion of a loose prosthesis. Persistent pain including meralgia paresthetica, can also cause localized hip that is not relieved with rest and continues through the night (and/or groin) pain. A noncapsular pattern of radiate into the anterior aspect of the thigh, whereas hip pain restricted hip motion. Empty end feel is A 46-year-old male long-distance runner developed sudden described as limiting pain before the end range of motion is onset of right hip pain. He was given a diagnosis of trochanteric 12 reached but with no resistance perceived by the examiner. With Objective Findings the client in the supine position, the examiner supports the For tenderness on palpation over the greater trochanter client’s heels in the examiner’s hands and passively rolls the Trigger points (TrPs) of the hip and low back region feet in and out. Decreased range of motion (usually accom + Noncapsular pattern of restriction of the hip (capsular pattern in the hip is fexion, abduction, and medial rotation); client panied by pain) is positive for an intraarticular source of was limited in extension and lateral rotation symptoms. If normal hip rotation is present in this position + Heel strike test but the motion reproduces hip pain, then an extraarticular the major criteria for a medical diagnosis of trochanteric cause should be considered. The log-rolling test should be com look for a pattern in the past medical history, clinical presenta bined with Patrick’s or Faber’s (fexion, abduction, and exter tion, and any associated signs and symptoms. Palpate the lymph nodes in the inguinal and 22 factors and clinical presentation will guide this decision. Possible systemic and/or visceral causes further medical evaluation, and the client was returned to the of groin pain are wide ranging, whether appearing as an physician with a recommendation for imaging studies. He reported a skateboarding accident as the • Spinal cord tumors (adductors, hamstrings, cause of the symptoms. He was coming down a fight of stairs, • Osteoid osteoma iliopsoas, abdominals, hit the last step by mistake, and caught his foot on the stair • Hodgkin’s disease/ tensor fascia lata, lymphoma gluteus medius)35 railing. His leg was forced into wide abduction and external • Leukemia Internal oblique avulsion rotation. No (heard or felt) pop or snap was perceived at the • Testicular Nerve compression or time of injury. At that time, he could “hardly walk” and Osteoporosis femoral cutaneous, has had trouble walking without limping ever since. He tried Fluid in peritoneal cavity sciatic nerves) getting back to skateboarding but was stopped by sharp pain • Ascites (cirrhosis) Stress reaction, stress in the groin. No other symptoms were reported (no saddle • Congestive heart failure fracture, avulsion anesthesia, no numbness and tingling, no bladder changes, no • Cancer fracture, or complete constitutional symptoms). Trendelenburg gait or Trendelenburg test was peripheral arterial aneurysm Osteitis pubis not positive. He Gynecologic conditions Apophysitis (young could not put enough weight on the left leg to try heel walking • Cancer (uterine/ovarian athletes) or toe walking. Abduction was limited to 30 degrees with • Endometriosis (causing femoral hernia painful empty end feel. During active hip fexion, the hip auto pubalgia) Hip joint impairment matically fexes, abducts, and externally rotates. Pain increases • Ectopic pregnancy (not • Subluxation, common) dislocation, dysplasia with active assisted or passive hip fexion when one is trying to • Sexually transmitted • Avascular necrosis keep the hip in neutral alignment. He did admit to being slightly constipated Box 16-3) subsidence) because of the pain. As you look at the left column of Systemic kidneys or ureters (spinal stenosis, disk Causes, what clinical presentation and signs and symptoms (infammation, infection, disease) might be expected with each of these conditions Are past medical history, risk factors, or • Infammatory bowel disease clinical presentation consistent for any of these problems For Seronegative example, pain in the hip or groin area in anyone who is not spondyloarthropathy skeletally mature raises the suspicion of an orthopedic injury. This condition may be labeled osteitis pubis Data from Learch T, Resnick D: Groin pain in a 13-year-old when there is articular involvement such as arthritis, articular instability, or other articular lesions involving the pubic symphysis. Little to no pain • Appendicitis—Perform McBurney’s test, Blumberg’s sign, and was reported, but a feeling of “fullness” in the left proximal thigh iliopsoas and obturator tests (see Chapter 8 for descriptions) was described. She was unable to cross her legs when sitting On the Musculoskeletal Side because of this fullness. No other constitutional symptoms or • Muscle strain—As already tested, no loss of motion or strength; associated symptoms were noted. Red fag: Clinical presentation is not consistent with it had been present for the past 3 months. No tenderness, • Sexual assault/domestic violence—Even though the client bruising, erythema, or skin temperature changes were reported.

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