Exam 1- Diagnostic statement Flashcards
Diagnosis that should be listed in a chart note, in correct order
Primary Dx (Name the pain. Worst thing. Basic Dx, as specific as possible)
Associated diagnosis
Complicating Diagnosis
6 components of a Dx statement
Time modifier
Mode of onset modifier
Primary Dx term
Associated modifier term
Complicating modifier terms
Aggravating modifier
Time modifier terms:
Acute
Subacute
Chronic
Which time modifier?
1st 72 hours of an inflammatory process, or a non-inflammatory severe pain event— 3 days
Acute
Which time modifier?
After 72 hours and up to 18 months depending on the amount of tissue damage for an inflammatory condition. For non-inflammatory, looking at a moderate pain even to full recovery.
3 days-1 1/2 year
Subacute
Which time modifier term?
Condition that resolves to a max medical improvement (less than full recovery) not getting any better.
Chronic
Which stage of inflammation?
1st 72 hours initiated by cellular and vascular destruction
1st stage (inflammation)
Signs of inflammation
Pain (dolor)
Heal (calor)
Redness (rumor)
Swelling (edema)
Causes of inflammation
Trauma
Infection
Chemical
Which stage of inflammation?
Swelling terminated
Pain decreased
No redness/heat
Tissue going through the inflammatory process is drying out and beginning to harden.
2nd stage (consolidation)
What is a result of the hardening process in the consolidation stage?
Stiffness
Which stage of inflammation?
Damage tissues begin to repair
3rd stage (repair)
What happens in the repair stage of inflammation?
Cellular activity begins to repair w/ scar tissue
Tissue can lay down in any direction (cross matrix pattern)
Results in adhesion
What is the result of proper repair- passive, active and resistive rehab exercise
Works on healthy scar tissue promotion
Results in scar tissue laying down in a linear fashion… allows the pt to have more flexibility.
Stage of inflammation:
Pts condition has resolved
4th stage (resolution)
What are the 2 states in which the pts condition can resolve
Full recovery - NO residual problems
Max medical (chiropractic) improvement (MMI, or MCI)
What happens with MMI/MCI?
Pt does not reach full recover- they are left with residuals.
Mode of onset modifier terms
Traumatic
Insidious
What does the traumatic mode of onset modifier term state?
Tissue is taken beyond it’s normal limits
Vascular and cellular tissue damaged
Ligament tears
Muscle and/or tendon tears
Which mode of onset modifier term is the slow onset of symptoms which are progressive over time?
Insidious
Histological grade I strain/sprain
0-50% tearing of tissue
Histological grade II strain/sprain
> 50-<100% tearing of tissue
Histological grade III strain/sprain
> 100% tearing of tissue
Functional def of Grade I strain/strain
Mild-moderate symptoms with no dysfunction. Recovers in 2-4 weeks with no intervention
Functional def of grade II strain/sprain
Moderate to severe symptoms with physical and lifestyle impairments,
Recovery 6weeks to 18 months w/ health care interventions
Functional definition of grade III strain/sprain
Severe symptoms w/ complete loss of function
Achilles’ tendon rupture, cruciate ligament rupture, and surgical interventions are an example of what type of sprain/strain?
Grade III
What is the term used to describe the pt’s tissue causing their main complain?
Primary diagnosis term
What are the diagnostic terms that are conditions (symptoms) which accompany the primary Dx, but are not the actual symptoms of the pts CC?
Associated modifier terms
What are diagnostic terms that complicate the pt’s condition?
Complicating modifier terms
What do complicating modifier terms indicate?
That the pt will be harder to treat and take longer to treat.
Degenerative pathologies
Systemic disease
Congenital abnormalities
Structural abnormalities
These are examples of:
Complicating modifier terms
Which modifier term indicates pt lifestyles that causes the pt’s symptoms to worsen when the perform those duties?
Aggravating modifier
Work duties
Home chores
Emotional stresses
These are examples of which modifier term?
Aggravating modifier term
Painful tissue in the dura mater indicates:
Recurrent meningeal nerve
Innervated sinuvertebral nerve
Nerve of von Luska
Which tissue is affected?
Local symptom lateral to the spine and when severe enough can radiate along the course of the peripheral nerve
Nerve root
Which tissue is affected?
Irritation compresses blood vessels causing numbness and pain
Compression causes pain and nerve dysfunction can radiate
Peripheral nerve
What innervates the IVD?
Where are symptoms for this when aggravated?
Recurrent meningeal nerve and the gray ramus communicans
Local to the spine
Facet and diarthrodial joint symptoms are from what?
Ligaments
Cartilage (joint surface)
Synovium
What can elevate the pressure of the IVD?
Compression forces
And increased intra thoracic and abdominal pressure (ex- coughing, sneezing, bearing down)
These can result in increased symptoms
What causes joint surface symptoms to increase?
Compression forces
Joint capsule ligament symptoms are increased with what?
Stretching forces
Spinal exams reveal what?
Mostly extensor muscle involvement
Spinal stresses are from what?
Stretching forces
Resistive forces
What type of symptoms does bone pathology produce
Local deep symptoms
What type of symptoms do fractures cause
Local symptoms, deformity and dysfunction
What are diagnostic terms for the tissue causing the CC?
Root words
Prefixes May describe what?
Conditions.. or may be multiple root words
Suffixes usually describe what?
The pathological condition of the root word.
Suffix for pain
-Algia
Suffix for inflammation
-itis
Suffix for condition. Generally means pathology
Opathy
Suffix for condition of root word….. generally describes degenerative changes … when something is injured but not inflamed
Osis
Suffix for separation, break, tear
Lysis
Root words w/in the NS
Myelo
Meninges
Myelopathy
Meningitis
Root word for spinal cord fibrils
Myelo
Meninges- root word meaning
Covering of the cord
Myelopathy root word meaning
SC fibrils pathology
Inflammation of the covering of the SC, caused by infectious and chemical processes
Meningitis
Root word describing the nerve root found in the spinal canal and IVF
Radical/Radicular
Nerve root pain, not radiating, no neurological findings
Radicualgia
Normal MRS tests! Still pain
Nerve root inflammation, AKA irritation (hyperexcitable) , can have paresthesia.
May radiate along peripheral nerve, may have exaggerated neurological signs
Radiculitis
Increased MRS- potential for UML
Nerve root pathology which is depressed nerve function (decreased MRS), may have radiating symptoms
Radiculopathy
Peripheral nerve pain, no neurological signs
Neuralgia
Inflammation of peripheral nerve. May have increased neurological signs, paresthesia and pain
Neuritis
Neuritis has (INCREASED/DECREASED) MRS
Increased
Peripheral nerve pathology which has decreased function and may have depressed neurological signs
Neuropathy
Neuropathy shows (INCREASED/DECREASED) MRS
decreased
Condition of the spine referring to disc degeneration or evidence of it.
Spondylosis
Evidence of spondylosis
End plate thickening (sclerosis, spurring, etc).
Also a complicating factor to the Dx
Separation of the pars interarticularis. There is no forward slippage of the vertebral body, is traumatic or developmental. Also a complicating factor to the Dx
Spondylolysis
Anterolistesis that may be due to a lysis (anterior slippage of the body).
Spondylolisthesis
Causes of spondylolisthesis
Traumatic
Degenerative
Developmental
Slippage/translation of the top vertebrae
Listhesis
Joint surface pain
Arthralgia
Joint surface inflammation
Arthritis
Condition of the joint. Describes joint pathology, generally degeneration.
Arthrosis
X-ray signs for arthrosis
Irregular surfaces
Sclerosis
Hypertrophy of joint surface
Joint pathology, usually referring to organic pathology
Arthropathy
Inflammation of the synovium.
Synovitis
Indications of synovitis
No X-ray indications.
There may be physical exam indications. Fluid will be over Produced.
Capsular pain
Capsalgia
Capsule inflammation-swelling, possible heat, redness and painful
Capsulitis
What irritates the capsule?
Stretch
Disorder of peripheral ligamentous or muscular attachments of spine
Spinal enthesopathy (inflammation @ site of ligaments or tendinous insertion)
Myalgia
Muscle pain
Muscle inflammation
Myositis
Muscle facial inflammation
Myofascitis
Spasm of muscle implies what?
Acute and painful nature
Inflamed tendon
Tendonitis
Chronic tendon pain and adhesion
Tendonosis
Tendon synovial inflammation
Tenosynovitis
Increased joint movement
Hyperkinesia
Decreased joint movement, can be used as the diagnostic term for joint fixation, restriction
Hypokenesia
Painful musculoskeletal tissue w/ gross joint movement (active)
Kinesalgia
Injury or tear to muscle and tendons (overuse).
Strain
Injury or tear to ligaments.
Sprain
Which takes more force to damage- muscle or ligament?
Ligaments
Blunt trauma, generally to soft tissue. Shown as warm, bruised, swelling
Contusions
Skin scraping (road rash)
Abrasions
Cuts with sharp objects
Lacerations
Bone damage from trauma
Fractures
Right convexity curve of the spine
Dextro- scoliosis
Left convexity curve of the spine
Levo-scoliosis
When vertebra turns toward concavity
Idiopathic
End plate hypertrophy and facet joint degeneration, both present
Spondyloarthrosis
Spondylosis + arthrosis
Pain symptoms, neurological findings normal
Radiculoneuralgia
Nerve root + Peripheral nerve problem
Pain, paresthesia, increased MRS.
Radioculoneuritis
Nerve root + peripheral nerve inflammation
Nerve with pain, paresthesia and decrease MRS
Radiculoneuropathy
Pathology of nerve root + peripheral
