Q9 CSA Written Flashcards
Referring to the tenderness grading system used at WSCC, describe the key differences between a grade 2 and grade 3 tissue tenderness:
a. +0/4T, no tenderness
b. +1/4T, no response
c. +2/4T, Flinch or grimace
d. +3/4T, withdrawal or jump sign
e. +4/4T, withdrawal from non-noxious stimuli
Describe 3 aberrant findings hip abduction movement pattern and specifically what muscle imbalance they suggest are present
incr External rotation = tight piriformis
decr Abduction = tight adductors, weak glut med
incr Hip flexion = tight iliopsoas muscle
Describe two exercises from the WSCC lumbar stabilization program that could be used to train the gluteus medius
Side lying track- working side down for side bridge up for
hip abduction
Single leg stand on rocker board
Single leg bridge
What is the order of the lung exam?
Observation, Palpation (fremitus), percussion, auscultation, excursion
List major findings that could be used to differentiate Lumbar internal disc derangement from a herniated disc with radiculopathy
a. Derangement – Sclerogenic pain referral, (-) nerve tension tests, no loss of
neuro, SLR produces LBP
b. Herniation – Dermatomal pain referral, Change in sensory, motor, DTR, (+) nerve tension tests
List 3 ways to test the third cranial nerve
H pattern, converngence/accomadation, papillary light reflex (direct & indirect)
Your patient has a torn medial meniscus of the knee. List two very suggestive symptoms and three common physical examination findings that would support this diagnosis
a. Symptoms – catching or locking, snap at time of injury
b. PE – pain at medial joint line, (+) Apley’s compression and distraction, (+)
Mcmurrary’s
Your patient has a murmur which occurs between S1 and S2 and sounds loudest over the right 2nd intercostals space
a. What valve is likely involved? Aortic
b. What is probably wrong with that valve? Stenosis
c. What would be an ancillary test that would confirm this diagnosis? Cardiac Echo
Describe three different hip orthopedic “stress” tests that you would chose that would Least likely test the SI at the same time.
Anvil, LaGuerre, Circumduction
You have a patient with lateral knee pain. Predict 3 of the most important findings in a knee exam that would suggest the presence of an ITB syndrome
(+) Obers, T at gerdy’s tubercle, (+) Nobel, (+) Renne, Crepetitus at lateral femoral condyle with flex/extension
You have a patient with a C6 radiculopathy due to a disc herniation, predict the following:
What would be the pure patch of sensory loss?
What would classically be the level of the herniation?
a. Posterior web of thumb
b. C5-C6
You have a patient with a C6 radiculopathy due to a disc herniation, predict the following:
c. What reflex would likely be diminished?
d. What would be the statistical likelihood that the shoulder abduction test would relieve the arm symptoms?
c. Brachioradialis/Biceps
d.
What are diastolic ranges for stage 1 HTN?
90-99
What is the systolic range for stage 1 HTN?
140-159
How many reading is the diagnosis based on?
4 2x/visit for 2 visits
List the most effective conservative interventions to use for treating high blood pressure.
Lose weight if overweight (at least 10kg or 22 lbs). Will start to see BP changes at 5kg, calorie or fat reduction
Limit alcohol intake to no more than 2 drinks per day.
Increase aerobic physical activity (30-45 min most days of the week).
Diet
Reduce sodium intake to no more than 2.4 g of sodium or 6 g of sodium
chloride.
Maintain adequate intake of dietary potassium (approximately 90mmol/d).
Maintain adequate intake of dietary calcium and magnesium for general health.
Stop smoking.
Reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health.
How much weight loss is required to see BP changes
5kg
Are lumbar subluxations more likely to cause leg pain associated with a positive SLR tension test or more likely to cause leg pain associated with a negative SLR tension test?
Leg pain associated with (-) SLR because the leg pain is likely deep referred from the joint itself, not a radicular pain caused by NR irritation/compression which would give a (+) SLR
Are subluxations more likely to create a paresthesia or more likely to create a grade 3 muscle weakness?
Paresthesia is more likely than muscle weakness because tissue irritation might chemically irritate the nerve with a subluxations syndrome but it is unlikely that actual NR compression would be present due to the biomech. Of the joint
Describe four local palpable finding that have been used for identifying spinal subluxations.
Edema, facet tenderness, decr ROM (segmental), Muscle Hypertonicity
List 3 conditions that could cause neck pain, weak wrist flexors, depressed biceps reflex, positive Babinski and grade 3 patellar reflex.
Cervical Myelopathy
Cervical space occupying lesion
Cervical stenosis/ central disc herniation
. Read the following case. You have a patient with low back pain and pain into the posterior thigh who has the following findings:
a. Gradual onset of pain after lifting heavy boxes at work.
b. Mild pain with AROM going into flexion, more sever pain when returning from
flexion
c. More pain with active prone extension than with passive prone extension
d. No pain with SLR, Kemps test, Farfan’s, or with both knees on flexed onto
chest
e. Muscle tests are all strong and painless. No change in DTR’s. No loss of
sensation
f. Moderate pain to static palpation over the C4 and C5 facets
g. At L3-L4, there is restricted and painful limitation into right lateral flexion
h. X-ray reveals mild to moderate disc thinning and sclerosing in the mid and lower lumbars
i. Extensors muscles have a grade 1 tenderness
Based on the information above write a 4 part diagnosis based on this case. Label all four parts…
- Mild acute facet syndrome w/
- Deep referred pain to the posterior thigh associated w/ 3. Lumbar joint dysfunction
- Complicated by lumbar DJD
You have a patient with a lumbar facet syndrome with referred leg pain. Describe the results that you would expect for each of the following tests…
Kemp’s test –
SLR –
Light touch on all of the dermatomes of the leg –
P-A static palpation of the lumbar spine –
Valsalva maneuver –
Kemp’s test – (+), pain in lumbar spine
SLR – Maybe local lumbar pain, likely not
Light touch on all of the dermatomes of the leg – normal
P-A static palpation of the lumbar spine – tender over facets
Valsalva maneuver – normal
Compare and contrast the neurological findings expected in a nerve root compression syndrome vs. a cord compression syndrome.
a. NR – decr DTR, decr sensation, flaccid paralysis
b. Cord – incr DTR, decr sensation, Spastic paralysis, clumsy gait, (+) Babinski, Hoffman’s
Suggest two important causes of eosinophillia
IgE allergic rxn, parasite infection
Suggest the CBC findings that would suggest a viral infection
Neutropenia, lympocytosis
Your patient has hepatitis. What abnormal finding would you expect to see in a blood chemistry panel?
a. incr: ALP, bilirubin, AST, ALT, GGT, LDH (BAAAGL)
b. decr: Albumin, polyclonal gammopathy
Your patient has a kidney infection that is compromising renal function. Predict the results for the following tests:
a. Serum creatinine – incr
b. Urinary creatinine – decr
c. CPK – normal
d. BUN – incr (azotemia)
e. Dipstick for blood – incr (inflammation) f. GGTP – incr (renal enzyme)
What are likely AS lab results?
a. ESR – (+)
b. HLA-B27 – (+)
c. Serum calcium –? (Bone resorption?)
d. RF factor – (-)
e. FANA – (-)
f. WBC in the urine – (-) (inflammation, not infection)
List the 8 parts of the WSCC lumbar stabilization core program (as outlined in the CSPE protocol)
Neutral pelvis, Quadruped track, Curl-up track, side bridge, proprioception, aerobic activity, change muscle imbalances, extensor endurance
Read the following case. You have a patient with neck pain and arm pain who has the following findings:
A 25 year old patient presents with neck pain and sharp pain radiating down the left lateral arm. He has paresthesia in the left thumb and first two fingers, +1 biceps reflex on the left, 4/5 wrist extensors strength (5/5 on the right), and diminished appreciation of sharp over the left thumb. Cervical compression reproduces the arm pain; Valsalva reproduces the tingling in the fingers. The mid cervicals are very tender and restricted, especially in right lateral flexion and rotation. Radiographs reveal a C3-C4 block vertebra.
b. Write a 4 part diagnosis for this patient and label all four parts.
Probable herniated C5-C6 disc with C6 radiculopathy and firm Neurologic signs with pain radiating to the left lateral arm associated with cervical joint dysfunction complicated by C3-C4 block vertebra.
According to the CSPE care pathway, list 3 of the indications to order an MRI in for a patient with a lumbar disc herniation with radiculopathy.
a. Progressive motor weakness
b. Evidence of Myelopathy
c. No response to conservative care
i. No pain relief with in 3 weeks
ii. No satisfaction of pre-injury status with in 3 months
d. Presurgical exam
Outline and explain the steps of a basic McKenzie evaluation for a patient with a suspected lumbar disc herniation.
Find the direction of movement that centralizes the pain by having the patient repeatedly flex, extend and laterally glide in their lumbar spine repeat up to 10 reps.
Based on the CSPE care pathway for Otitis Media, outline 5 of the most important physical examination procedures that should be preformed.
a. Vitals – temp, signs of infection
b. Otoscopy – pneumatic
c. Watch test
d. Palpation – external ear, mastoid process
e. Cervical palpation– lymph nodes, biomechanics
List the neurological exam findings that you use to establish compressed C7
a. Sensory loss – palmer 3rd digit
b. Cite 3 muscles – Triceps, wrist flexors, finger extensors
What are three causes for an elevated ALP value? Be as specific as you can.
Hepatitis, Pregnancy – placental formation, bone growth—infancy, pagets Disease
For each of the following tests and conditions, indicate whether a positive test/finding is commonly found (i.e., >80% likelihood) or uncommon (i.e., < 60%).
a. SLR test in a patent with a lumbar disc herniation – Common
b. Bakody’s sign for a cervical disc herniation – Uncommon
c. ANA test for SLE – Common
d. Anti-dsDNA test for SLE – Common
e. XSLR in a patient with a lumbar disc herniation – Uncommon
f. Urinary retention in a patient with cauda equina – Common
g. Chest pain brought on at rest in a typical angina – Uncommon (common if
atypical)
h. Cervical compression for a cervical disc herniation – Uncommon
List 4 different exam finding in the lower extremity that would make you suspect that a cervical disc herniation was also compressing the spinal cord
a. (+) Tandem Rhomberg
b. (+) Babinski
c. (+) Ankle clonus
d. Clumsy gait
As the patient begins to recover from the cervical disc herniation, you may wish to evaluate the endurance of their deep flexor muscles. Describe how to test the deep flexors while minimizing the influence of the SCM.
Jull’s test, keep the chin tucked in
For the following cranial nerves, cite 2 ways of testing each; II, III, VII, X.
a. Cranial nerve II – direct/consensual light reflex, peripheral vision, visual acuity
b. Cranial nerve III – H pattern, convergence, direct/consensual light reflex
c. Cranial nerve X – listen to speech, gag reflex, ahh (plate deviation)
d. Cranial nerve VII – facial expressions, taste to ant 2/3 of tongue, corneal reflex
Your patient is in the subacute phase of recovery from lumbar subluxations syndrome. You are now going to address some rehabilitation issues. Answer the following questions:
b. Describe a test to se if the gluteus maximus was inhibited (even if tested 5/5 on routine manual muscle testing).
i. Active hip extension, look for lumbar extensor and hamstring activity, instead of glut activation
Your patient is in the subacute phase of recovery from lumbar subluxations syndrome. You are now going to address some rehabilitation issues. Answer the following questions:
Describe the best test to measure low back extensor endurance.
i. Prone on the table with upper body off the tale, hold, lower body fixed to table
Your patient is in the subacute phase of recovery from lumbar subluxations syndrome. You are now going to address some rehabilitation issues. Answer the following questions:
Describe two weight bearing LUMBAR STABILIZATION TRACKS that could be used to build gluteus maximus endurance.
i. Squat track, lunge track
In the acute phase, what would be the single best orthopedic test for an ACL tear?
Lachman’s (anterior drawer)
If the patient reported locking or giving way of the knee, suggest 3 diagnoses that this would suggest.
Meniscus tear, osteocondritis dissicans, ACL tear
List the classical physical exam finding that that would suggest a Mitral valve prolapse.
Mid systolic click (between S1 & S2)
List the key history, physical and ancillary findings that would suggest a spontaneous pneumothorax
a. History – Acute onset chest pain and Dyspnea (no trauma)
b. Physical findings – Decrease breath sounds, hyperresonant percussion
c. Ancillary study finding – Chest filmair in chest cavity, mediastium shift to
the opposite side
List 3 red flags that would suggest that your patient has lumbar instability
Repetitive LBP w/o injury or trauma
Clunking or catching (especially w/ return from flexion) Abnormal movement w/ ROM
Based on Dr. LeFebvre’s lectures, list 5 high pay of locations to examine in patients with some combination of neck pain, arm symptoms/headache.
a. Upper cervical
b. CT junction
c. Shoulder
d. TMJ
e. Upper Thoracic, ribs 1-6
Your patient has increased MCV on a CBC. What are the two most common causes of this finding?
a. B12 and Folic acid deficiency
b. > 110 = megaloblastic
c. in 60’s thalassemia
Explain how the results of a serum iron and serum ferritin test could be used to differentiate iron deficiency anemia from anemia of chronic disease.
a. Fe deficiency – both decr
b. Chronic disease – Fe decr, Ferritin incr
Predict the key differential white cell changes (e.g., lymphocytes, neutrophils, etc) for each of the following conditions
a. Bacterial infection – incr Monocytes, incr neutrophils, incr total WBC
b. Viral infection – N/decr (neutrophils, WBC), Downey cells (lympocytosis)
c. Allergy – incr eosinophils, incr basophils
d. Parasitic infection – incr eosinophils
Two most common abnormal finding to look for in a dipstick urinalysis in a patient with a suspected bladder infection
Leukocyte esterase, nitrite
List the components of an upper cross syndrome along and indicate if the muscles are typically inhibited or short and tight.
a. Inhibited – mid/lower traps, deep neck flexors
b. Short and tight – upper traps, SCM, pecks
Passive prone extension increases LBP but centralizes leg pain=
Disc herniation
Both active and passive prone extension exacerbates LBP, but passive (especially with practioner overpressure) hurts the most.=
Lumbar facet syndrome
Sustained passive or active prone extension exacerbates leg symptoms in an
older patient=
Lumbar spinal canal stenosis
Passive prone extension exacerbates LBP and practitioner overpressure produces a palpable give or clunk.=
Lumbar instability
Active and resisted prone extension exacerbates LBP much more than passive prone extension=
Lumbar extensor strain
Holding neutral pelvis does not specifically focus on strengthening muscles. What is the therapeutic purpose of assigning patient neutral pelvis?
Activating the transverse abdominus so the patient can utilize core stability in other activities
What key stabilizing muscles are activated while performing abdominal bracing?
Transverse abdominus, obliques, multifidi
You have a patient whose pain may be coming from his SI joint or his hip joint
a. Describe the result of 3 different orthopedic “stress tests” that would make you think that the SI was the source of pain, rather than the hip.
i. (+) SI provocation, (+) SI compression, (+) SI distraction, (+) Nachlas
You have a patient whose pain may be coming from his SI joint or his hip joint
b. Describe the results of 3 different hip orthopedic “stress tests” that would make you think that the hip was more likely the cause of the patients pan than the SI joint.
i. (+) Circumduction, (+) anvil, (+) LaGuerre
As outlined in the CSPE care pathway, give the criteria for making a lumbar disc herniation with radiculopathy diagnosis. Be as complete in the description of each criterion as you can.
a. Presence of leg pain (Dermatomal)
b. Dermatomal paresthesia
c. (+) Nerve tension tests
d. Neuro defects
e. (+) Imaging
For each of the following tests, describe the results that would be most consistent with a cervical facet syndrome (do not just write +/-)
a. Max cervical compression – local cervical pain
b. Shoulder abduction – no change
c. Brachial stretch test – no change
d. Biceps reflex – +2/4
e. Cervical motion palpation – painful and restricted in extension
f. Valsalva maneuver – no change
Which shoulder muscles are most likely inhibited and which are most likely short and tight.
i. Inhibited – Lower/mid trap, serratus anterior ii. Short and tight – upper traps, levator, rhomboids
Besides the typical symptoms that may accompany lumbar radiculopathies, what other signs and symptoms are red flags for the presence of a cauda equina syndrome?
a. Urinary retention, diminished sphincter tone, sexual dysfunction, change in sensation in saddle distribution
During the leg kick of a quadruped exercise, what key low back and pelvic muscles are activated?
a. QL, erectors, Glut max, transverse abdominus
List 4 findings that would suggest acute cholecysitits (gallbladder inflammation)
a. Right upper quadrant tenderness (severe) b. Nausea and vomiting (after fatty meal)
c. (+) Murphy’s sign (rebound tenderness)
d. Fever
Your patient has iron deficiency anemia. Predict the results for each of the following tests
a. MCV –
b. RDW –
c. Serum iron –
d. % TS –
e. TIBC –
f. Serum ferritin –
a. MCV – Decreased
b. RDW – increased
c. Serum iron – decreased
d. % TS – decreased
e. TIBC – increased
f. Serum ferritin – decreased
Name three of the most common causes of microcytic anemia’s:
a. Fe deficiency, thalasemia, chronic disease
Which two blood chemistry values would be altered most in renal disease? Which is most sensitive and specific?
a. Creatinin (most sensitive and specific), Bun, GGT is only in urine for renal
List three findings that would suggest central canal stenosis of the lumbar spine (exclude signs and symptoms of cauda equine syndrome)
a. Patient better with sustained flexion
b. Aggravated by walking
c. Non-dermatomal leg pain
Besides a disc herniation, list 5 important causes of lumbar radiculopathies
a. Osteophytes, central canal stenosis, NR adhesions, SOL, infection
What exactly is neutral pelvis?
The action of bracing the pelvis and lumbar spine in a position where they are most stable and least painful. Contraction of core transverse abdominus, QL, Obliques, Multifidi
Your patient has congestive heart failure. List 3 common symptoms and 3 common
physical examination findings that would support this diagnosis
a. Symptoms – Dyspnea at rest, rapid heart rate, generalized edema
b. PE findings – Jugular vein distension, rales, abnormal heart sounds
List the tests for disc herniation/radiculopathy. List also the actual sensitivity and specificity numbers.
a. SLR 80% Sens, 45% Spec
b. XSLR 25% Sens, 95% Spec
c. Valsalva 22% Sens, 94% Spec
List 4 different exam findings in the lower extremity that would make you suspect that a cervical disc herniation was also compressing the spinal cord.
a. Babinski, increased DTR’s, ankle clonus, Tandem Rhomberg, spastic paralysis
If the diagnosis turned out NOT to be a cervical disc herniation, list 6 other possible differentials that could cause neck pain and a C7 radiculopathy.
a. SOL, Osteophytes (lateral stenosis), nerve root adhesion, stinger/burner, instability, infection
List 3 of the classical symptoms of an MI
a. Crushing chest pain radiating to left arm, jaw
b. Shortness of breath
c. Nausea/vomiting, sweating, near syncope, palpitations
List the classical symptoms of GERD
Substernal chest pain, worse with lying down, sour regurgitation, worse after a meal.
What is the best follow up test for SLE if the ANA demonstrates a high titer
a. Antibodies to native DNA (anti native DNA)
Two most common abnormal findings to look for in a dipstick urinalysis in a patient with suspected renal disease.
a. Protein, Blood
Compare a patient with lumbar central canal stenosis with a patient with a lumbar disc herniation. List 3 of the most useful findings from history or physical exam that would help you differentiate one condition from the other.
a. Canal stenosis – better with flexion, no trauma or single event, non- dermatomal, older
b. Herniation – Dermatomal, worse with flexion, younger
List the two most common causes of non-traumatic cervical radiculopathies
a. Disc herniation (traumatic)
b. Osteophytes
c. SOL
Outline the procedures in a standard abdominal physical exam in the order in which they should be performed
a. Observation, auscultation, percussion, light palpation, deep palpation, strength
Briefly describe the most useful findings from the various prone extension tests (e.g., active, passive, resisted, repetitive etc.) that would suggest each of the following conditions.
a. Disc syndrome with leg pain – pain centralizes (passive, repetitive)
b. Posterior facet syndrome – LBP worse (all)
c. Central canal stenosis – leg symptoms worse (all)
d. Extensor strain – LBP worse (active, resisted)
e. Instability – LBP worse (passive)
Your patient has a cervical disc herniation, pick the best answer.
a. Would the cervical distraction test be positive?
b. Would shoulder abduction test be positive?
i. Would the cervical distraction test be positive? Unlikely < 50% sens
i. Would shoulder abduction test be positive?
Unlikely <50% sens, 90% spec
Your patient presents with a cauda equina syndrome. Suggest three conditions well known to potential cause this syndrome.
a. SOL, central/large disc herniation, stenosis
List 3 ways to test the fifth cranial nerve.
a. V1,V2,V3, sensation, bite stick, corneal reflex
Describe three important tests to perform on a patient with dizziness as a primary complaint.
a. Nystagmus, hand/foot sensation, grip strength
Your patient has pneumonia. List two common symptoms and three common physical examination findings that would support this diagnosis.
a. Dyspnea, malaise, productive cough
b. Fever, crackles, tachypnea, lobar consolidation on chest film
When taking BP, what is the auscultatory gap and how do we avoid it?
a. The period of time b/t when the Korotkoff sounds are heard at a high BP, then again at low BP. Often causes mess reads of high BP. So pump 30 mmHg above the palpatory systolic.
You suspect that your patient has inhibited hip abductors. What finding seen on the hip abductor movement pattern would further support this suspicion? Give as specific an example as is possible.
a. Excessive early hip hiking
You have a patient with a L5 radiculopathy due to a disc herniation, predict the following:
What would be the pure patch of sensory loss?
B/t 1st & 2nd toe & top of foot
You have a patient with a L5 radiculopathy due to a disc herniation, predict the following:
Describe the location of the pain radiation.
What reflex would likely be diminished?
Lat leg and top of foot
Hamstring Based on statistical likelihood,
You have a patient with a L5 radiculopathy due to a disc herniation, predict the following:
Describe the most likely results of a straight leg raise test. .
At what angle would the SLR most likely be positive?
(+) 80% sens
35-45 degrees
How do you treat lumbar functional instability.
Lumbar stability, adj. Above and below
best screening test for SLE?
ANA, then anti DNA antibodies
Perhaps this patient has metatstatic cancer causing low back and leg pain. List 4 of the most important red flags FROM THE HISTORY that you need to ask the patient about.
a. Fatigue, weight loss, loss of appetite, history of cancer or smoking
Answer the following question about the XSLR (well leg raise)
a. Do you expect to have a positive XSLR in most lumbar disc cases?
b. Sensitivity?
c. Specificity?
d. Describe its effect on prognosis.
a. Do you expect to have a positive XSLR in most lumbar disc cases?
b. Sensitivity? 25%
c. Specificity? 95%
d. Describe its effect on prognosis. Poor prognosis to conservative care
Your patient has lumbar instability. After the patient is out to the acute phase, describe the SPECIFIC activities/exercises that you would employ based on each stated treatment goal.
a. Strengthen extensors –
b. Teach basic awareness of stabilizers –
c. Teach coordination and control while increasing speed of contraction –
a. Strengthen extensors – Prone track
b. Teach basic awareness of stabilizers – neutral pelvis
c. Teach coordination and control while increasing speed of contraction – rocker board
Describe briefly each of the following treatment and what therapeutic effect each is designed to have.
Neutral pelvis –
Abdominal bracing –
The bridge track –
McKenzie extension exercises –
Neutral pelvis – create awareness of lumbar stabilizers
Abdominal bracing – contraction of transverse abdominus and obliques to stabilize lumbar
The bridge track – strengthen gluts and quads
McKenzie extension exercises – Centralize disc/ radiculopathy pain
You test your patient for the HIP ABDUCTION MOVEMENT PATTERN. For each of the
following responses, predict what might be wrong (name the muscle and whether it is likely inhibited or tight)
a. Hip hiking in the first 30 of abduction –
b. Forward flexion during the first 30 of abduction –
c. External rotation and extension during the first 30 of abduction –
a. Hip hiking in the first 30 of abduction – weak glut med, tight QL
b. Forward flexion during the first 30 of abduction – Tight Iliopsoas or TFL
c. External rotation and extension during the first 30 of abduction – piriformis
You test your patient for the HIP ABDUCTION MOVEMENT PATTERN. For each of the
following responses, predict what might be wrong (name the muscle and whether it is likely inhibited or tight)
d. What tight muscle might be actually inhibiting the gluteus medius –
e. What would be a lumbar stabilization track that could be used to train and strengthen weak gluteus maximums?
f. Shaking or difficulty –
d. What tight muscle might be actually inhibiting the gluteus medius – adductor
Magnus / adductors
e. What would be a lumbar stabilization track that could be used to train and strengthen weak gluteus maximums –Bridge track
f. Shaking or difficulty – suggests weak glut med
In a thoracolumbar junction syndrome
a. List 3 pain referral patterns.
b. What muscle is often hypertonic in this syndrome?
i. Along clunel nerve to posterior iliac crest, anterior groin, greater trochanter
i. Psoas
Your patient is having an episode of asthma. Describe the likely findings.
Auscultation –
Percussion –
Test fremitus –
Auscultation – polysymphonic wheezes, prolonged expiration
Percussion – normal?
Test fremitus – normal
Describe an effective exercise that a patient could be given at home to strengthen the low back extensors.
a. Prone track
What muscles are targeted by the “donkey kick” portion of the quadruped track?
a. QL, lumbar extensors, glut max
Based on the CSPE care pathway, suggest four in-office procedures that could be used for treating patient with Otitis media
a. Endonasal technique, soft tissue manipulation, Cervical adjusting, local heat, warm oil
Read the following case. You have a patient with neck pain and arm pain who has the
following findings:
a. No trauma
b. Mild pain with AROM into left rotation
c. Limited active and passive cervical extension with mild neck pain
d. Pain in the posterior neck with max cervical compression (no radiation into the
arm)
e. Cervical distraction, shoulder depression, shoulder abduction, Valsalva are all
negative
f. Muscle tests are all strong and painless. No change in DTR’s. No loss of
sensation.
g. Moderate pain to static palpation over the C4 and C5 facets.
h. At C4-C5, restricted and tender joint play when motion palpating into left
rotation.
i. X-ray reveals mild to moderate disc thinning and sclerosing in the mid and
lower cervicals.
j. Write a 4 part diagnosis based on this case. Label all four parts.
Acute mild cervical facet syndrome with deep referral pain to the arm associated with cervical joint dysfunction complicated by cervical DJD
List the three most important physical exam findings that would confirm the diagnosis of an infrapatella tendonitis (jumper’s knee)
a. Tender over tendon, increase pain with knee flexion, weak VMO
You have a patient with a C5 radiculopathy due to a disc herniation, predict the following:
a. What would be the pure patch of sensory loss?
b. What muscle would most likely be weak?
a. What would be the pure patch of sensory loss? Deltoid tubercle
b. What muscle would most likely be weak? Deltoid
You have a patient with a C5 radiculopathy due to a disc herniation, predict the following:
c. What reflex would likely be diminished?
d. What would be the statistical likelihood that the cervical distraction test would relieve the arm symptoms in this case?
c. What reflex would likely be diminished? Biceps
d. What would be the statistical likelihood that the cervical distraction test would relieve the arm symptoms in this case?
List 3 findings that would support the diagnosis of an upper motor neuron lesion.
a. Hyperfeflexia, spastic paralysis, (+) Babinski
When writing a musculoskeletal diagnosis at WSCC, a four part-diagnosis should be used. Write a sample diagnosis illustrating these 4 parts. Name/label each part.
a. Pathoanatomical w/ neurological associated w/ biomechanical complicated by local complicator.
What are some clinical clues for lower motor neuron compression?
Paresthesia, DTR, motor weakness (flaccid paralysis)
Explain how subluxations in the lumbar spine might create radiating pain into the posterior thigh.
a. Sclerogenic pain referral from the deep structures within the joint. Pain efferents cross paths with other are neurons widening the pain area. Central sensitization.
Explain what physical exam procedures (along with their results) that you could use which would differentiate arm symptoms that were primarily due to an anterior scalene trigger point from arm symptoms that were primarily due to a short tight anterior scalene creating a thoracic outlet syndrome.
TOS – Eden’s, Wright’s, Roo’sreproduce arm symptoms
MFTP – Palpation reveals tight band with tender nodule that reproduces the pain with pressure
What are the 5 high pay off locations to find a pain generator for a patient with low back or leg pain?
L/S, SI, Pubic symphisis, hip, TLJ
List 5 of the most likely differentials for a 50 year patient with LBP, leg pain past the knee and neurological deficits consistent with SI root compression.
Lateral stenosis, NR adhesion, disc herniation, SOL, lumbar instability
After hearing the history, you suspect that your patient could have sinusitis. Based on the WSCC CPSE care pathway, outline a brief treatment plan.
Nasal specific or argyral with daily nasal lavage
Natural decongestant (ST massage/percussion)
Immune support supplement
Allergy evaluation
Briefly, describe when to perform the belt test and how to interrupt the results.
To DDX LBP from SI pain, standing patient flexes with sacrum pinned by examiner. If painful the think LB, if not think SI confirm with flexion without support to see if pain returns.
What is plica? Name or describe two tests for plica.
A band in the synovial lining of a joint that can catch and be painful. An embryological remnant.
Plica stutter, Houghston’s plica test.
What related muscles are often over facilitated compared to weak deep neck flexors?
SCM, Suboccipital
What is McKenzie’s centralization phenomenon?
In the disc herniation, the peripheral pain will decrease and the spinal pain may increase as the nucleus pulpulsis is pulled back with in the disc or resporbed.
Besides prone extension, list 3 other repetitive testing positions that make up the core of the McKenzie evaluation?
Flexion, lateral glide, lateral flexion
List findings for a positive knee exam that would suggest the presence of a meniscus tear (please choose the BEST tests in terms of reliability and validity)
McMurray’s = incr Pain, joint locking
Appley’s compression = incr Pain
Appley’s distraction = decr Pain
When evaluating a patient with musculoskeletal injury, what are the key issues that must be decided?
a. Mechanism of injury – repetitive torsion to the lumbar spine
b. Pathoanatomical (facet syndrome)
c. Neurological (radiculopathy)
d. Biomechanical (joint dysfunction)
e. Severity (moderate)
f. Local complicators (DJD)
g. Underlying factors (posture)
List important characteristics to distinguish an MI from angina.
a. Angina – better with rest, starts with activity, relieved by nitro, substernal pain last < 10 min
b. MI – Lasting longer than 1 hour, nausea/vomiting
List the four earliest symptoms in cervical Myelopathy
Clumsy hands (also numb)
Clumsy gait
Proximal muscle weakness
Urinary retention = cauda equina
List post treatment procedures for MFTP..
- Warm and moist heat on muscles involved for a few minutes
- 3x through full ROM of muscles involved
- Light stretching
- Don’t strain the muscle, i.e., no activity rest of the day
List the causes of cervical radiculopathy
a. Disc herniation (soft disc)
b. Degenerative changes (hard disc)
i. Osteophytes
ii. Stenosis
c. Trauma
i. Hyperexteinsion
ii. Blow to top of head in extension
iii. Traction injury with head in lateral flexion
d. SOL
e. Instability
f. Infection – rare
g. NR adhesions
List the findings in a Dx for facet syndrome (cervical)
a. Tender facets
b. Local edema
c. Pain with kemps
d. Decreased extension ROM
e. Joint restriction
f. Neck pain with compression
List the findings with Instability
a. Recurrent back pain
b. Unprovoked back pain
c. Painful catch when returning from flexion
d. Clunking with flexion/extension
What tests are used to Screen for cord damage (lower extremity)
a. Babinski, ankle clonus
b. Proximal muscle tests (Psoas/quads)
c. Sharp dull
d. DTR’s
e. Tandem Rhomberg
Why order an MRI with disc herniation?
Progressive motor defect
Signs of cauda equina
No response to conservative care
What are the High payoff areas in LBP exam?
a. SI
b. TLJ
c. Hip
d. L/S
e. Pubic symphisis
High payoff areas for cervical pain=
a. Suboccipital/upper cervical
b. TMJ
c. Shoulder (GHJ)
d. CT
e. T1-T6, R1-R6
Deviated septum problems=
a. Sleep apnea
b. Sinusitis
Associated symptoms for infection/cancer/infection
a. Fever
b. Fatigue
c. Malaise
d. Loss of appetite
e. Unexplained weight loss (4-5kg over 3 months)
f. Sharp/severe intolerable pain
g. Unvarying symptoms
h. Chronic shoulder pain in smoker over 50
Cauda equina symptoms=
Urinary retention 90% sensitive
Saddle paresthesia 75% sensitive
Bowel incontinence (decr anal sphincter tone)
Sexual dysfunction
What is a possible cause of hoarseness in Pt 50+ years old?
a. Maybe tumor affecting recurrent laryngeal nerve to the vocal cords
What are the findings with Horner’s syndrome?
a. Ptosis, anhydarosis, myosis
Ancillary studies if suspecting organic disease=
a. X-ray
b. CBC
c. ESR, CRP
Possible Mechanism of injury=
a. Trauma
b. Repetitive motion
c. Postural overload
d. Sudden unguarded movement
e. Normal movement of an unstable spine
f. Stress- incr muscle tension
g. Local disease
h. Viserosomatic reflexes
What are common muscles where MFTP mimic radiculopathy?
a. Anterior Scalene (C6)
b. Infraspinatus (C6)
c. Supraspinatus
d. Subscapularus (C8)
e. Serratus anterior (C8)
Motor weakness + DTR = ___% ppv of radiculopathy
86%
Effects of Cervical stenosis
a. Myelopathy
b. Amplification of injury
c. More dramatic whiplash
Indications for cervical x-ray with Trauma=
i. High impact >60 mph ii. Palpable tenderness (fracture)
iii. >50 years old (osteopenia risk)
iv. Multiple injures areas (indicating high impact)
v. Impaired mentation (can’t accurately indicate pain)
vi. Congenital anomalies
vii. Neuro deficits viii. Splinting
Indications for cervical x-ray without Trauma=
- Red flags for disease
- Radicular or Myelopathy signs
- Chronic/non-responsive cases
Likelihood ratios for cervical radiculopathies
(C6) – DTR > sensory > motor
(C7) – DTR»_space; motor > sensory
(C8) – Sensory»_space;» DTR»motor
Cervical DDX list=
a. Sprain
b. Strain
c. Joint dysfunction
d. Disc derangement
e. Facet syndrome
f. Disc herniation
g. DDD/DJD
Most common causes of Cauda Equina=
a. Central disc herniation
b. Severe spinal stenosis
c. SOL
(+) XSLR=
a. Likely uncontained disc fragment
b. Poorer prognosis to conservative care but better outcome with surgery
c. Medial herniation
List the statistical reliability for the following Lumbar neuro tests:
SLR
XSLR
Ankle reflex
SLR (80% sensitive)
XSLR (90% specific)
Ankle reflex (50% sensitive, 60% specific)
Best tests for SI joint (FATT)=
a. Forton’s finger
b. ASLR (80% sensitive, 94% specific)
c. Thigh thrust (with adduction) (80% sensitive & specific)
d. Thomas-Gaenslen’s test
List the following referral patterns…
Heart –
Lungs –
Esophagus –
Heart – midline in between scapula
Lungs – left thoracic paraspinal region
Esophagus – refers midline thoracic region
List the following referral patterns…
Gallbladder –
Pancreas –
Gallbladder – refers classily to right lower scapular region
Pancreas – Over TL junction in broad pattern
Thoracic high payoff areas=
a. Vertebra
b. Ribs
c. Paraspinals
d. Scapula and associated muscles
List the most common non-MFTP causes of Chest pain
a. GERD 42%
b. Ischemic heart 31%
c. Chest wall 28%
What are the four components of a Heart evaluation?
a. BP
b. Pulse
c. Auscultate
d. Palpate for thrills
Cardiac red flags=
a. Pain stops activity
b. Nausea/vomiting
c. Right arm pain (80% specific)
d. Crushing pain
6 Cardiac associated symptoms=
a. Diaphoresis
b. Dyspnea
c. Palpitations
d. Nausea
e. General weakness
f. Near syncope
Ancillary cardiac studies=
a. 12 lead EKG
b. Troponins, myoglobin, ESR
c. CPK, AST, LDH, cardiac enzymes
Lung evaluation=
a. Respitory rate, excursion
b. Palpate, fremitus
c. Percuss
d. Auscultate
e. Ancillary test – chest film, CBC, ESR, chem. Panel
Describe the functional tests of the cranial nerves.
I – smell
II – visual acuity, peripheral vision, papillary light reflex
III – H pattern, Nystagmus? Convergence
IV – H pattern into nose, superior oblique
V – motor masseters, facial sensation, corneal reflex
VI – H pattern into abduction, lateral rectus
VII – facial expression, corneal reflex, taste ant. 2/3, lacremation, salavation
VIII – watch test, Weber, Rinne, Rhomberg
IX – taste post 1/3, gag reflex
X – motor to palate (ahh), phonation
XI – motor to traps and SCM
XII – motor to tongue
Identify the findings of I, II and malignant HT
Stage I – 140-59/90-99
Stage II – >160/>100
Malignant = end organ damage Diff of > 10 mmHg from R to L = occlusion or error
Pulse pressure should = 40 mmHg, the pressure actually reaching the tissues
What are the end organs of HT?
End organs= heart, kidney, lungs, eyes, brain
What are the three parameters of taking a Radial pulse?
Rate – bpm
Amplitude – weak, strong
Regularity – pulses alternans
What would Heart sounds at each auscultated region indicate clinically; APETM
a. A – stenosis, regurgitation
b. P – stenosis, regurgitation
c. E – septal defect
d. T – stenosis, regurgitation
e. M – prolapse, regurgitation
What would the following Lung sounds correlate to?
a. Rales (crackles) –
b. Rhonchi (wheezes) –
c. Polyphonic wheezes –
d. Stridor –
e. Pleural friction rub –
f. Fremitus –
a. Rales (crackles) – inspiration, CHF, pneumonia
b. Rhonchi (wheezes) – expiration, obstruction, bronchitis
c. Polyphonic wheezes – asthma
d. Stridor – croup, aspiration
e. Pleural friction rub – pleurisy (low vibration)
f. Fremitus – inflamed pleura (squeak)
d. Stridor –
e. Pleural friction rub –
f. Fremitus –
d. Stridor – croup, aspiration
e. Pleural friction rub – pleurisy (low vibration)
f. Fremitus – inflamed pleura (squeak)
a. Rales (crackles) –
b. Rhonchi (wheezes) –
c. Polyphonic wheezes –
a. Rales (crackles) – inspiration, CHF, pneumonia
b. Rhonchi (wheezes) – expiration, obstruction, bronchitis
c. Polyphonic wheezes – asthma
Best follow up test for suspected acute spondylolysis seen on x-ray=
SPECT, MRI
The strongest clues from history suggesting a cervical radicular syndrome are Neck pain with:
i. Arm pain in dermatome
ii. Paresthesia radiating to fingers (dermatomal)
iii. Numbness or weakness
iv. Interscapular pain
v. Neck trauma
vi. Neck and leg symptoms suggesting cord involvement
Common referral for Maigne’s syndrome=
Over iliac crest and SI
Inguinal region
Greater trochanter
This to consider when performing ASLR=
Active SLR
Note which leg can be raised higher
Which is easier
Quantify the pain
Press down as patient resists and compare pain and strength
Retest with abdominal bracing or trochanter belt
(+) ASLR Test interpretations=
i. Suggest SI problem/instability
ii. Posterior pelvic pain syndrome – pregnancy
iii. If creates pain on side of SI (SI problem/pathology)
iv. If can’t raise leg that high on one side = SI instability
v. If reproduces pain or more difficult to raise with resistance this causes stress on joint = SI instability
Acute Alcoholic Liver disease Test=
GGTP
Any kind of anemia
BAAAGL
Acute Liver disease (hepatitis) Test=
Hepatitis panel
Any kind of anemia or none
BAAAGL (AST & ALT the most)
Chronic liver disease (cirrhosis) Test=
Biopsy
Any kind of anemia
decr (BUN, proteins, cholesterol)
Multiple Myeloma Test=
Protein Electrophoresis
N/N Anemia
incr Globulin A/G ratio may reverse
MI Test=
CK
Paget’s disease
incr ALP
Prostate cancer Test=
PSA
N/N Anemia
UA changes: Protein, blood
Rheumatiod arthritis Tests=
RA Factor
incr WBC, N/N anemia
ESR
Systemic lupus erthymatosis Test=
ANA screening
FANA more specific
Anti double strand
DNA
Systemic lupus erthymatosis CBC changes=
N/N Anemia, hemolytic, Coombs Kills decrease WBC
SLE chem panel changes=
50% have kidney failure
Temporal arthritis Test=
ESR
Thalessemia Test=
MCV in 60’s
Mild anemia
Thyroid disease Tests=
TSH
N/N anemia
Increased Cholesterol
Decreased T3 T4
Three most common causes of microcytic anemia=
a. IDA, Thalessemia, Chronic Disease
Typical iron panel findings with uncomplicated iron deficiency anemia=
a. decreased Fe, decreased %Saturation, increased TIBC
Typical iron panel findings for microcytic anemia associated with chronic disease=
a. decr SI, N/decr TIBC, increased Serum FE
Typical causes of microcytic anemia and follow up tests of choice=
a. B12 deficiency – serum B12
b. Folic acid deficiency – serum folic acid
Typical blood chemistry panel findings in a hemolytic anemia
a. incr (SI, LDH, indirect bilirubin), decr haptaglobin
The role of reticulocyte count in differentiating normocytic anemia into problems with blood cell production vs blood cell loss or destruction=
a. 3% for good marrow response, cell loss or destruction
Most common causes of normochromic, normocytic anemia=
a. Acute blood loss, Hemolytic anemia, Chronic disease, marrow failure
Typical RDW for normocytic normochromic anemia, microcytic anemia, and uncompilated iron deficiency anemia.
N/N – normal
Macrocytic – incr
IDA – incr
Viral infection CBC=
N/decreased (WBC & Neut)
increased WBC
Bacterial infection CBC=
increased WBC & neut
Non-infection acute inflammation CBC=
increased WBC & neut
Do Disc Derangement, Facet, Anterior disc derangement
have neuro deficits?
no
Bacterial infection CBC=
incr Monocytes, incr neutrophils, incr total WBC
Viral infection CBC=
N/decr (neutrophils, WBC), Downey cells (lympocytosis)
Allergy CBC=
incr eosinophils, incr basophils
Parasitic infection CBC=
incr eosinophils
a. Rales (crackles) –
inspiration, CHF, pneumonia
b. Rhonchi (wheezes) –
expiration, obstruction, bronchitis
c. Polyphonic wheezes –
asthma
d. Stridor –
croup, aspiration
e. Pleural friction rub –
pleurisy (low vibration)
f. Fremitus –
inflamed pleura (squeak)
