Mental Probes Flashcards
What are 4 cardinal signs/Sx of rhinosinusitis?
_____ or _______
_____ or _______
Nasal discharge OR nasal obstruction/congestion AND
Facial pain/pressure/fullness OR reduction/loss of smell
PODS (pressure, obstruction, discharge, smell-loss)
D or O
AND
P or S
List 3 Sx (not the cardinal Sx or general constitutional Sx) that can be associated with rhinosinusitis
Sore throat
Hoarseness
Fetor oris (foul breath)
What are 3 basic PE procedures that should be performed whenever an infection is suspected anywhere in the head?
Take temp
Examine throat
Palpate lymph nodes
What is the Sx duration for separating viral RS and bacterial RS?
Bac RS >10 days
Viral RS 4-7 days and may go on for 14 days but Sx peak 2-3 days after onset and there is continual improvement
When is the threshold for bacterial RS if there is “double sickening”
Double sickening happens around day 5
Besides signs of ear inflammation, what are the other 2 criteria for making a definite Acute Otitis Media (AOM) diagnosis?
- Presence of middle ear effusion
- Rapid onset of signs and sx
Based on lecture, besides age, what other 2 circumstances would make hoarseness a red flag for possible tumor?
- Patient was not sick nor recently sick
- Hoarsness is a chronic nature
- There is no known cause
What are 3 Different otoscopic findings that would reveal swelling in the middle ear?
Absence/loss of mobility
Bulging tympanic membrane
Fluid d/t perforation
Cite what special PE procedure from the care pathway suggests is best for identifying effusion.
Pneumatic otoscopy (blow a puff of air)
Your 62-yo patient has Sx of rhinosinusitis and a single polyp. What concern does this raise?
Tumor/sol
Your patient has ear P but normal ear exam. Besides the neck and the jaw, what are the other 2 important structures to check?
Teeth for tooth decay
Throat to visualize tonsils and pharynx (r/o tonsillitis and/or pharyngitis)
What are 2 risk factors for getting rhinosinusitis ?
Deviated septum
GERD
What are 2 visual Sx that are suggestive of glaucoma?
Blurry vision
Auras around lights “haloes”
Your patient has a sore throat; what common additional Sx would make a strept throat LESS likely?
If there is a cough.
Remember ACAFE (age, coughless, adenopathy, fever, exudates)
Age <15yo = +1 point
Age >45yo = -1 point
From lecture, what are the 2 major indicators to call an ambulance for a conscious patient who is having chest pain in your office?
Respiratory distress (dyspnea) Abnormal vital signs e.g. low BP, weak or irregular pulse
For each of the following tests, indicate what condition it is used for. Also, is the test diagnostic or just testing for risk factors?
Troponin
Diagnostic Blood test to see if there is acute MI
For each of the following tests, indicate what condition it is used for. Also, is the test diagnostic or just testing for risk factors?
CAC
Test for risk factors for Coronary Artery Disease (CAD). It’s a special CT test.
For each of the following tests, indicate what condition it is used for. Also, is the test diagnostic or just testing for risk factors?
hsCRP
A test for risk factors of angina
What PE finding and what ancillary test are most useful in suspecting and Dx pleuritis?
PE _____
Ancillary test _______
PE: crackling sound
Ancillary test: radiograph
What type of arrhythmia typically requires urgent medical care?
Arrhythmias in the lower chamber typically require urgent medical care and include ventricular tachycardia and ventricular fibrillation.
What are the risks for patients with atrial fib?
5X greater risk for stroke or peripheral embolism
Based on LRs, what 2 characteristics of chest pain are LEAST likely associated with cardiac angina?
Positional chest pain
Palpable chest pain (pain that comes on with palpation)
Based on the CSPE care pathway, list 2 effective home care Tx options for patients with otitis media to help them with their current Sx?
- Heat, warmed oil ear drops
- Auto inflation
What does the evidence suggest about the effectiveness of steam inhalation as a Tx for rhinosinusitis?
Steam inhalation reduces HA in RS when combined w/nasal irrigation
AOM does not usually require antibiotics. What are 6 indicators that the patient should be referred for antibiotics at the first visit?
Patients with fever over 102.2˚F Infant <6 mo Patient with serious illness Failure of Sx to resolve within 48-72 hours Signs of mastoiditis Rupture of tympanic membrane
What are the 3 recommended Qs to ask patients with chest pain to screen for a panic or anxiety attack?
1) When are you nervous, how often do you think I am going to pass out?
2) During the last 7 days, including today, how much have you been bothered by pains in the chest?
3) To what degree is your chest pain tiring or exhausting?
Besides chest pain/pressure lasting 10-30 minutes, what are the either 2 main criteria from the Hx suggesting typical angina until proven otherwise?
P induced By exercise/emotional stress
Relieved by nitro or rest
Besides a stress ECG, what is another stress test ordered to assess whether a patient has coronary artery disease?
Myocardial scintigraphy or stress echocardiogram
According to the CSPE care pathway, what do we recommend as the 3 first-line Tx for patients with chronic RS (without polyps)?
Nasal specific
Sinus irrigation
Intranasal corticosteroid spray
Based on a cervical facet block study, what are the 3 most pertinent positive exam findings helpful to rule in a favorable response to a block?
Positive ER test 3/10 OPS
Palpation tenderness over facets
Cervical restriction P-A joint glide
Which of these individual finding would carry the most weight predicting an unfavorable response to facet block:
Positive ER test 3/10 OPS
Palpation tenderness over facets
Cervical restriction P-A joint glide
No palpatory tenderness over the facet
Your patient has paresthesia into the thumb and lateral hand.
Name 3 locations in the nervous system where a lesion could be to cause this Sx.
Nervous tissue lesions
- nerve root
- brachial plexus
- radial nerve (peripheral nerve)
Your patient has paresthesia into the thumb and lateral hand.
Name 3 muscles that harbor trigger points which could cause this Sx.
MFTPs
- scalenes
- supraspinatus
- infraspinatus
What are 4 standard of care criteria for ordering an MRI within the 1st week of care for suspected cervical disc herniation?
Red flags for disease
Suspicion of myelopathy
Progressive motor deficit
Pre-surgical exam
Your patient has been on long term corticosteroid therapy for IBD. What 2 conditions are they are risk for which might affect your decisions regarding upper cervical manipulation and rib manipulation?
Osteoporosis Ligamentous instability (transverse ligament)
At what age does a palpable cervical mass start to increase the risk of cancer?
> 40 yo
Your patient comes in holding their neck with both hands. 1) what is this sign called? And 2) what does it suggest? (3)
Rust’s sign
Fracture, instability, severe sprain
What disease should you consider in an older smoker who has a gradual onset of shoulder and arm pain and brachial plexus symptoms?
Pancoast Tumor
What are the 2 classic deficits that are consistent with syringomyelia?
Pain
Temperature
It would be in a cape-like distribution.
Your patient has a cervical disc herniation. What are the 2 most likely directions that might centralize a patient’s arm Sx with repetitive loading?
Retraction
Extension
What is that the top of your DDX list as diagnoses causing cervical spinal cord compression?
Disc herniation
Stenosis
Based on the indications for radiographs in trauma cases, what are 3 findings from the PE (not the Hx) that would make you stop and order x-rays?
Unable to actively rotate neck 45˚ to the left and right
Midline cervical spine tenderness
Focal neurologic deficit
A 36-yo farmer slipped off her tractor, fell on her shoulder, and “twisted” her neck. She has Neck and right upper arm pain to the elbow. Cervical AROM is painful and limited in flexion and right rotation. Shoulder ROM is full and painless. Cervical distraction increases neck pain; resisted neck flexion and resisted right rotation are even more aggravating. Cervical compression and Valsalva are negative. The arm squeeze test is positive for pain (pain over AC joint 0/10, over upper arm 1/10). Sensory, motor and reflexes are WNL. Upper cervical joints are restricted in extension and tender. Jull’s test is positive.
Write a 4-part diagnosis.
Cervical sprain/strain with deep referred P to the right elbow with cervical joint dysfunction.
Describe 2 common trauma mechanisms that would place the nerve root at risk but not likely the brachial plexus
Compression
Hyperextension
List 2 mechanisms of injury that are likely to injury the brachial plexus instead of the nerve roots
Lateral flexion with shoulder depression
Arm traction
Besides spurs, stenosis, and disc herniation… name 4 other causes/Dx of a cervical radiculopathy.
Infection
SOL
Fracture
Structural instability
Besides Canadian/Nexus rules, what are 3 indicators from the PE signaling the need for cervical radiographs in a trauma case
Can’t rotate >45˚in either direction
Midline tenderness
Focal neuro deficit
Indicate 2 PE findings that might suggest presence of a fracture that are not part of the Canadian-Nexus criteria
Observable Rust’s sign
Spinal percussion
Your patient has TOS. Cite 3 exam findings that would support significant arterial obstruction (rather than venous).
BP asymmetry >20 mmHg
Asymmetrical cold feeling
Bruits
Based on observation only, what are 3 of the most striking features of the PAIN regarding the patient’s limb in a classic complex regional pain syndrome?
Severe burning
Hyperalgesia (extra sensitive to P)
Allodynia (P sensation d/t non-noxious stimuli)
Based on observation only, what are 3 of the most striking features of the TISSUE CHANGES regarding the patient’s limb in a classic complex regional pain syndrome?
Fingernails brittle/rigid
Hair growth at the problem area
Dystopia especially 4th and 5th digits
What is the main concern regarding a patient with TOS and significant venous blockage?
Pulmonary embolism
A 47-yo obese salesperson fell and while falling reached up above his head and grabbed the top of a book shelf that was behind him to break his fall. He succeeded in wrenching his neck and shoulder. He now has neck pain and a burning sensation along the right medial hand. Cervical active and passive ROM is limited in left lateral flexion aggravating the neck pain. Cervical muscle tests are normal. Cervical compression, distraction and valsalva are negative for pain. ULTT for ulnar nerve and deep pressure applied just below the clavicle aggravates the hand pain. There is loss of sensation along the little finger. Resisted isometric finger flexion, wrist flexion and elbow extension all test 4/5 weakness.
Write a 4-part diagnosis.
Cervical strain and traumatic TOS with lower plexopathy to the R medial hand
A 60 yo farmer complains of reduced AROM in extension which causes sharp neck pain. She has paresthesia in her right thumb and first finger. Sustained extension makes her right hand “go to sleep.” Shoulder abduction offers some relief of the hand symptoms. Valsalva is negative. LE neuro is normal. UE DTRs are +2, right finger flexors are weak, and sensation is normal. Forced wrist flexion on the left reveals 5 beat clonus. X-rays demonstrate a cervical rib and generalized degenerative changes.
Write a 4-part diagnosis.
Cervical stenosis causing myelopathy with C6 and C8 radiculopathy to the right thumb and 1st finger complicated by cervical rib
A 52-yo banker complains fo deep, constant, Chronic ache in the back of his neck along with sharp intermittent pain over his right lateral shoulder almost to the elbow. Cervical AROM and passive ROM are complete and painless. Valsalva aggravates the neck pain. Cervical maximum compression aggravates the shoulder pain. All other cervical orthopedic tests are negative except for spinal percussion which causes a stinging sensation on the C5 spinous procures. C6-C7 Articular pillar is tender and there is segmental restriction in lateral flexion. Sensory motor and reflex testing are all normal Except for weakness of right shoulder abduction. Radiographs are pending. ESR is 45, CBC is normal, there is increased serum calcium.
Write a 4-part diagnosis.
Cervical osteolytic bone problem with C5 radiculopathy to the right elbow associated with cervical joint dysfunction
For each of the following statements about T4 syndrome, indicated whether they are consistent with the condition or not consistent with the way the condition presents.
Unilateral non dermatomal paresthesia in a hand
NOT consistent with T4 syndrome
For each of the following statements about T4 syndrome, indicated whether they are consistent with the condition or not consistent with the way the condition presents.
Loss of sensation in a dermatomal
Consistent with T4 syndrome
For each of the following statements about T4 syndrome, indicated whether they are consistent with the condition or not consistent with the way the condition presents.
Associated with HA
Not consistent with T4 syndrome
Sometimes generalized HA in “helmet” distribution (sometimes occipital)
The only 2 things: joint dysfunction around T4 level and glove paresthesia in upper extremity that may be accompanied by hyperalgesia to pin prick
For herpes zoster, how quickly should antiviral medication be administered after Sx onset to be effective?
Within 72 hours (acyclovir)
What are the 2 most prominent vertebral body changes seen on radiograph of a patient with Scheuermann’s disease?
Wedging of vertebral endplate
Notching of vertebral end plates
At what age should you consider taking an x-ray of a patient who complains fo sudden non-traumatic thoracic pain to r/o spontaneous compression fracture?
> 70 yo OR >50 yo if osteoporosis is indicated
Your patient has thoracic pain made worse by taking a deep breath. What are 3 different rib diagnosis that could do this?
Joint dysfunction
Fracture
Sprain
What part of the back does pancreatic pain classically refer to?
Midline of the back around the TLJ
Based on lecture, Scheppelmann’s sign with pain on the convex side can indicate what condition?
Pleuritis
Pain on CONCAVE side = intercostal neuritis
What are 2 of the 1st diagnoses to consider in a patient with evidence of thoracic cord compression?
Stenosis
Tumor
(THEN disc herniation)
36-yo air conditioner repairman with LBP and right buttock pain. She stands with left pelvic shift. AROM of motion Is limited mostly in extension. Sitting aggravates her pain as does the valsalva maneuver and prone extension. The double active SLR is too painful to perform. the SLR is negative except for significant hamstring tightness. Sensory, motor and reflex testing are WNL.
1 - Write a 4-part diagnosis.
2 - Should this patient get an MRI as part of the initial work up?
Lumbar disc derangement with deep referred pain to right buttock complicated by hypertonic hamstring muscle
No because there are no true deficits. Tx with conservative care for 30 days.
What percentage of patients with acute non-specific LBP still have significant effects on ADLs 1 year later?
20%
What percentage of patients with acute non-specific LBP will have residual or recurrent pain over the course of the year?
33%
Which of the following positive test results would help confirm a suspected rheumatoid arthritis for a patient with sacroiliac inflammation?
HLA-B27 anti-CCP ANA Anti-DNA Protein electrophoresis
Anti-CCP
Note:
- HLA-B27 suggests AI seronegative arthropathy
- ANA is sensitive to Lupus (SLE)
- Anti-DNA is another test for SLE
- Protein electorphoresis is a follow up blood test for multiple myeloma
Is ANA more sensitive or specific for SLE?
Sensitive
Other than ANA, what is the other classic antibody test for SLE?
Anti-ds DNA test
What disease is the first to think of with increased globulins and an A/G shift in a patient with LBP?
Multiple myeloma
Your patient with LBP has suspected MM, because there is increased globulins and an A/G shift. What would be the follow up blood test to order?
Protein electrophoresis
What of the following medical treatments has the most evidence supporting its effectiveness for treating sciatic pain in a lumbar disc herniation patient?
Opioids
Gabapentin
Acetaminophen
Epidural glucocorticoid injection
Epidural glucocorticoid injection
Note: these offer short term pain relief and increase function
What does the “alarm” sign specifically suggest when performing the SLR?
Local mass e.g. soft tissue or bony tumors
What serious condition can cause LBP to be aggravated by lying down?
Retroperitoneal lymphadenopathy
How strong a red flag is night pain?
Night pain isn’t strong because it can mean a lot of things. Though there is still a concern if the pain is severe, doesn’t change with body position, or the pain is progressively worse.
What LB condition is associated with taking anti-coagulants?
Retroperitoneal hemorrhage
If there is a specific bony pain with palpation, especially on the sternum or tibia, what might this be?
Bone disease such as multiple myeloma
Based on lecture, besides signs or symptoms of neurological involvement, wha are 3 of the most important findings that would make a lumbar facet syndrome diagnosis less likely?
(-) kemps
Pin centralization
(+) SLR
What is the strongest PE clue that would support a Dx of lumbar disc herniation?
XSLR
Your patient has a soft positive SLR test. What is the next test to do?
XSLR then max SLR
Besides diabetic neuropathy, what are 2 other peripheral nerve diseases that might cause sciatica?
SOL (non-cancerous cysts, endometriosis, fibroids)
HIV/AIDS
Lyme disease
35 yo man has right LBP, groin pain, and both a sharp pain and a “crawly sensation” down his anterior thigh nearly to the knee. His pain is aggravated by forward flexion, Farfan torsion test performed on the right, knees to chest testing, and the four quadrants test. Passive hip extension creates a sharp anterior thigh pain when performing Yoeman’s test. SLR and XSLR are painless. Patient has grade 4 hip flexor strength on the symptomatic side and no patellar reflex. The L2 spinous is tender when pushed to the left and there is a palpable restriction.
1 - Write a 4-part diagnosis.
2 - does this patient need any ancillary studies? If yes, what tests exactly? If no, why not?
1 - Lumbar disc herniation with L3 radiculopathy to the knee with lumbar joint dysfunction
2 - yes first xray then MRI then EMG or nerve conduction
Cite 5 indications for ordering MRI in a lumbar disc herniation case
Suspected upper lumbar disc herniation Progressive motor weakness Severe motor weakness of 3/5 or worse CES Non-responsive or poor response to conservative care
What are 4 key pain patterns suggestive of a quadratus lumborum MFTP?
Upper posterior buttock
SI joint
Greater troch of the femur
Ischial tuberosity
What are 2 key areas for psoas trigger point referral?
Anterior thigh
Along lumbar paraspinals ipsi to psoas trigger point
What are 2 special PE procedures which may be positive in a patient with an acute isthmic spondylolisthesis?
Positive passive leg extension
Step defect
What are the 3 pain referral patterns for thoracolumbar syndrome?
Inguinal crease
Upper buttock
Greater trochanter of femur
Where is the best place to palpate for cluneal nerve sensitivity?
7 cm lateral to L5 over the iliac crest
Name 2 separate conditions that can cause cluneal nerve sensitivity to be positive?
Thoracolumbar syndrome
Superior cluneal nerve entrapment
Based on lecture, what would be 2 useful home care recommendations for a patient with psoas syndrome?
Kneeling psoas stretch
Thoracolumbar self mobilizations
What condition is the ANA blood test used to screen for?
Autoimmune lupus
Your patient has upper paralumbar pain. What key additional clues from the Hx or PE would suggest that your patient’s kidney pain is from an infection rather than just a renal stone?
Fever
Malaise
In the case of suspected kidney stone, what key associated Sx/signs should you ask the patient about that would strongly supports stone Dx?
Discolored urine?
Colicky, episodic pain that refers to front of body?
38 yo accountant has pain on the right in the lower lumbar region. It has come on gradually over the last 4 weeks. Her back bothers her if she sits all day. AROM is WNL. Knees to chest at end range flexion mildly reproduces the pain if the position is maint for more than 10 seconds. Modified Thomas test and Gaenslen’s tests are tight but painless bilaterally. The rest of the lumbar orthopedic tests, sacroiliac tests, and neurological testing are unremarkable. Motion palpation reveals a tender extension restriction at L5-S1.
Write a 4-part diagnosis.
Lumbar postural sprain associated with Lx/SI segmental dysfunction complicated by hypertonic psoas muscle
List 4 positive clues from the Hx or PE that would support a spinal stenosis dx more than lumbar disc herniation dx.
1 - Pain with walking
2 - Flexion relieves
3 - Extension aggravates
4 - Shopping cart sign
List 4 positive PE findings that would fit a herniated disc diagnosis much better than a spinal stenosis diagnosis for a patient with LBP and leg Sx.
1 - Flexion aggravates
2 - Pain centralization with sustained or repetitive end range loading often into extension
3 - (+)ve SLR or XSLR (or femoral nerve stretch test for upper lumbar disc herniation)
4 - Mannequin sign
Name 2 hip snapping syndromes. Cite the muscles involved in each and the typical location of the pain
External snapping hip
- muscle: ITB/glut max
- location: lateral hip
Internal snapping hip
- muscle: iliopsoas
- location: anterior hip
Other than external snapping hip, Cite 3 more hip DDX for lateral hip pain
1 - Gluteus medius tendinopathy
2 - ITB tendinopathy
3 - Trochanteric bursitis
Based on a 2004 study, what 3 findings suggest a hip lesion instead of a lumbar cause of LBP?
Limp
Groin pain
Limited hip internal rotation
The CSPE protocol on lumbar functional instability describes 6 different tests that might signal poor motor control. Name them and an example of a positive finding for each.
1 - Pelvic clocking: inability to find and hold a neutral pelvis
2 - Hip extension test: lateral shift toward side of hip extension
3 - Single leg stand: wiggling or falling over during 2-second single leg stand or spine deviation from vertical
4 - Trunk forward lean: inability to bend forward more than 15˚w/o flexing lumbar spine
5 - Segmental abnormal movement: wiggling spinal motions in any plane
6 - Painful arc abolished: abdominal bracing improves or abolishes painful arc
List 2 positive clues from the PE that would be more suggestive DVT (veins) than PAD (arteries)
Swelling in the lower extremity P at rest Increased temperature Dilation of superficial veins Palpable tender, hard “cord” along the vein
Of DVT or PAD, which one is potentially life threatening and why?
DVT because its a blood clot in the vein that, if it mobilizes, could cause PE.
You think your patient may have SI instab based on a positive ASLR. What is the very next procedure to do to confirm this suspicion?
Brace the hip with trochanteric belt (pregnancy) and/or retest with bdominal bracing
Fill in the blanks: if ______ (number) of the “big 5” sacroiliac tests are positive, then the +LR is ______
if 3 or more of the “big 5” sacroiliac tests are positive, then the +LR is 4.1
Janda suggested a specific muscle imbalance pattern that may accompany a SI joint dysfunction. What 2 muscles did he implicate which are NOT part of the traditional lower cross syndrome?
Piriformis
Glut med
Janda suggested a specific muscle imbalance pattern that may accompany a SI joint dysfunction. He implicated glut med and piriformis which are NOT part of the traditional lower cross syndrome.
What different key examination procedures should you perform on each muscle to confirm its predicted involvement?
Glut med: key movement pattern hip abduction and muscle testing
Piriformis: Pace test, Beatty test, FAIR, log roll, look for “piriformis sign” / limited internal rotation
