Study Questions Flashcards
What are the risk factors for chronic RS? (5)
Deviated septum Tooth infection GERD Vitamin D deficiency Aspirin intake
Notes:
- The risk is increased with the severity of septum deviation.
- Infection of maxillary molars can provide portal of entry.
- Reflux esophagitis can be linked with chronic RS.
- Direct relationship between vitamin levels and degree of mucosal damage in sinuses and bone disease
- Aspiring acts as Sx trigger
What are the cardinal clues for rhinosinusitis (RS)?
Sudden onset on Sx often occurring after short course of rhinitis (several days) and consisting of: PODS
D or O
P or S
1) discharge OR obstruction (nasal)
AND
2) pressure OR smell (loss)
What are other additional Sx that may be present with RS?
Local ENT sx: sore throat, hoarsenEss, foul breath, nasal speech
Fullness in ears and maxillary toothache
Periorbital edema
Drainage may provoke Sx mimicking lung conditions: wheezing, coughing
General constitutional signs and Sx: fever, fatigue, malaise, irritability.
Chronic RS: Fatigue, poor sleep quality, depression, lower quality of life.
What physical exam procedures should be done on a patient with RS? Which PE is the most predictive of this condition?
Observe Vitals (temp, pulse, BP, respiratory rate) Percuss/transilluminate sinuses** Rhinoscopic exam Examine pharynx Tap maxillary teeth Palpate lymph nodes Examine cervical muscles and joints Screen TMJ Perform otoscopic exam (children) Lung auscultation (if indicated) Cranial nerves II to VI (if indicated)
**transillumination has been described as “highly predictive of disease” with 90% sensitivity for frontal sinuses
What are the 3 cardinal Sx of bacterial RS?
Purulent(infected, colored, oozing) nasal drainage
Nasal obstruction
Facial, dental pain
How do you differentiate 1) simple rhinitis from 2) acute (viral) RS vs 3) chronic RS?
Duration is key:
1) simple rhinitis = 2-3 days, mild Sx
2) viral RS = 4-7 days, mild to moderate Sx that peak 2-3 days after onset
3) bacterial RS = >10 days w/ possible “double sickening” around day 5, very severe Sx
What would a basic conservative care plan look like for acute RS?
- Watchful waiting
- First line Tx: Saline irrigation. Intranasal corticosteroid sprays. Analgesics.
- Manual therapy: spinal manipulation, sinus percussion/lymph drainage, argyrol Tx, steam inhalation, antibiotic
What would a basic conservative care plan look like for chronic (8-12+ weeks) RS?
With Nasal polyp
- 1st line: Saline irrigation. Referral for intranasal corticosteroid sprays. Analgesics.
- Option: manip, spinous percuss/lymph, referral for macrolides, argyrol, low salicylate diet
WithOUT nasal polyp
- 1st: saline irrigation, intranasal corticosteroid sprays, nasal specific therapy.
- Option: Manip, sinus percuss/lymph drain, referral for macrolides, argyrol, steam inhalation
If no improvement in 4-6 weeks: CT/endoscopy, Tx with macrolides and/or brief course of oral corticosteroids.
What in office interventions are most likely to promote drainage in chronic RS?
Nasal specific or argyrol applications may be useful to promote adequate drainage
What home care interventions are most likely to promote drainage in chronic RS?
Nasal lavage (in office and home care)
Which OTCs are most likely to be effective for RS:
Decongestants
Steroid sprays
Acetominophen cough syrups
Acetaminophen or OTC NSAIDS may help relieve P or fever in acute RS or chronic viral RS.
Notes
- Decongestants have short term effect on Sx of common cold, but do not affect sinuses
Which of the following interventions have the most evidence: steam inhalation, auto-inflation for the ear, nasal lavage, lymph massage?
Nasal lavage
What ancillary studies are most likely to be done to make the Dx of chronic RS?
CT w/o contrast or endoscopy
Mucosa thickening _____mm is consistent with sinus infection
> 5 mm
How does the presence of polyps (multiple or singular) affect your management plan for chronic RS?
With Nasal polyp
- 1st line: Saline irrigation. Referral for intranasal corticosteroid sprays. Analgesics.
- Option: manip, spinous percuss/lymph, referral for macrolides, argyrol, low salicylate diet
WithOUT nasal polyp
- 1st: saline irrigation, intranasal corticosteroid sprays, nasal specific therapy.
- Option: Manip, sinus percuss/lymph drain, referral for macrolides, argyrol, steam inhalation
If no improvement in 4-6 weeks: CT/endoscopy, Tx with macrolides and/or brief course of oral corticosteroids.
What are the risk factors for AOM? (9)
Bottle feeding and pacifier use Smoking Daycare Socioeconomic factors Winter months Craniofacial distortions (FAS, trisomy 21) Diary Allergies Lack of vitamins
What are the criteria for “certain” AOM?
Rapid onset
Presence of middle ear effusion
Signs/Sx of middle ear inflammation
In what critical ways is AOM different from OME?
Only AOM has acute oneself of signs/Sx
AOM <48 hours
OME is chronic onset
How long is watch and wait period for AOM? For OME?
AOM: 48-72 hours/2-3 days
OME: 3 months
What PE finding suggest the presence of middle ear effusion? What is the most accurate in-office test?
- Limited or absent mobility of tympanic membrane (Dx by pneumatic otoscopy)
- Opacification w/ or w/o erythema
- Full, bulging, swollen tympanic membrane
- Hearing loss
Pneumatic otoscopy
What PE procedures should be done in the case of a patient with ear pain?
Otoscopic exam to view tympanic membrane
Check vitals
Evaluate for pain referral
- TMJ
- CN V, VII, IX, X
- MFTP in Lateral and medial pterygoid, masseter, SCM
- Tonsillitis
- pharyngitis
- carcinoma of hypopharynx, larynx
- cleft defects
What would a basic conservative care plan look like for AOM?
- Watchful waiting 48-72 hours
- In office: affect Eustachian tube, endonasal technique and auto inflation
- Optional: manip, STM, teach self lymph drainage
Do not do watchful waiting for someone <12 yo with a fever >102˚, severe illness or complications
What are the 4 most likely causes of referred pain to the ear when the ear itself is not the pain generator?
TMJ syndrome
Dental causes
Tonsillitis or pharyngitis
Cervical spine syndrome
What are the indications to refer someone for antibiotics if they have AOM?
Less than 12 yo, fever >102˚ F, severe illness or complications
What characteristics of a patient’s hoarseness would lead you refer for a medical workup?
No recent or current sickness
If it is chronic in nature (not acute presentation)
If they are older
*concerned that there is a tumor affecting the recurrent laryngeal nerve
Doing a PE on a patient with suspected infection anywhere in the head should always include which 3 assessments?
Take temp
Inspect throat
Palpate lymph nodes
What cluster of 4 signs/Sx suggest that a sore throat may be d/t strep?
ACAFE: 3 (+) and 1 (-)
A -age <15yo = +1 point >45yo= -1 point C -coughless - NO Cough A -adenopathy (tender anterior cervical lymphadenopathy) F -fever E -exudates (tonsillar exudate)
What are the Sx associated with glaucoma?
- > 50 yo
- Blurred vision, haloes around lights
- Eye pain
- HA
What are the three most common causes of chest pain?
LC reason?
MSK e.g. costochondritis Nonspecific chest pain GI disease Stable CAD Psychosocial/psychiatric disease
LC: unstable CAD
What is the prevalence of acute coronary syndrome in a walk in primary care office?
1.5% or 1.5 patients out of 100
What indicators should trigger a call for ambulance for a patient with chest pain?
Chest pain plus respiratory distress or abnormal vital signs including erratic pulse or low BP
What associated Sx should you ask a patient with chest pain?
Confusion Restlessness Combo of dyspnea, palpitations, sweating N/V Weakness/fatigue (Near) syncope
Which Sx have the highest LR for an MI?
History
i. Nausea (+LR 10)
ii. Both arm P (+LR 9.7)
iii. R arm P (+LR 7.3)
PE
i. 3rd heart sound (+LR 3.2)
ii. Hypotension (+LR 3.1)
iii. Pulmonary crackles (+LR 2.1)
MFTPs in what muscles are most likely to mimic the pain associated with cardiac angina?
Scalenes
Pectorals
Serratus anterior
What steps are involved in using Prilosec to test a patient to see if they have GERD?
High-dose PPI (proton pump inhibitor e.g. Omeprazole 40 mg b.i.d.) 2x/day in patients woh
- do NOT describe typical reflux
- have NO Hx of surgery in upper GI, esophagus, thorax
- have NO signs/Sx that indicated serious/malignant disease
What are the top 3 clues that would suggest that a patient’s chest pain is not cardiac in origin? And which one is the best clue?
Pain that is: pleuritic, positional, palpationable
Pain that is reproducible with palpation is the best clue
What special ancillary tests are options for the initial round of testing patients for cardiac angina? Which one is gold standard?
12 lead Resting EKG
Stress test (EKG, stress echocardiogram, myocardial perfusion scintigraphy)
Chest radiography (optional)
Angiography ** 🌟 gold standard
What are the 3 types of stress tests when testing for a patient with cardiac angina?
EKG
Stress echocardiogram
Myocardial perfusion scintigraphy
How does the CAC test fit into a cardiac assessment?
Coronary artery calcium (CAC) test checks the degree of calcification (amt of calcium) of the coronary artery.
This is a special CT scan, NOT blood test.
More calcium = more risk.
What blood tests are ordered to assess risk factors for coronary artery disease?
Lipid profile
Glucose/Hgb A1C
hsCRP
Remember CAC is NOT on this list because it is NOT a blood test.
What are other risks for CAD derived from the patient’s Hx and PE?
Male > F Overweight or obese LDL cholesterol >130 mg/dL Physically inactive HDL cholesterol <40mg/dL Tobacco use Metabolic syndrome Prehypertension diabetes mellitus
What tests are done in the ED to Dx an MI?
12 lead EKG
Troponins
Cardiac enzymes
What is the classic triad of findings that suggest typical angina?
- Substernal chest discomfort with characteristic quality and duration
- Provoked by exercise or emotional stress
- Relieved by rest or nitroglycerin
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
Angina (3 Sx and 3 ancillary)
Typical angina Sx:
1- substernal chest discomfort
2- provoked by exercise/emotional stress
3- relieved by rest/nitro
Ancillary studies:
1- 12 lead resting EKG
2- Stress tests (EKG on treadmill, stress echo, myocardial perfusion scintigraphy)
3- Angiography 🌟
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
pericarditis (3, 1)
Sx:
1- non-pleuritic friction rub (crackling sound like rubbing hair on pinnae of ear)
2- precordial pain that radiates to trapezius ridge
3- aggravated by supine relieved by bending forward
Ancillary study:
4- characteristic ECG/EKG echocardiogram changes
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
Valvular disease e.g. aortic stenosis, mitral valve prolapse (1, 1)
Sx
1- mid systolic murmur or closing click
Ancillary
2- echocardiogram
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
Pleuritis (ancillary studies - 5)
Sx: pleuritic pain, respiratory friction rub, fever/malaise
Ancillary: 1- chest radiograph 2- CBC 3- blood chem 4- ESR 5- ANA (because why not test for lupus)
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
MI
Hx: nausea, both arm pain or just right arm pain
PE: 3rd heart sound, hypotension, pulmonary crackles
Ancillary studies
1- 12 lead EKG
2- troponins blood draws
3- cardiac enzymes CPK-MB which follows the same pattern as troponins but test not recommended anymore
How long do troponins take to show up in the blood? And when do they peak? And when are they gone?
2-3 hrs to show up
12 hrs peak
24 hrs disappear
What serious risk can arrhythmias subject a patient to?
Stroke or peripheral embolism
What are some common Sx associated with arrhythmias?
Irregularly irregular pulse Tachycardia 110-140 beats/min Palpitations Fatigue Dizziness Angina Decompensated heart failure
What % of arrhythmias are asymptomatic?
90%
What arrhythmias require urgent/emergent referral?
Lower chamber
What is the natural Hx of pain and disability for patients with typical neck complaints?
Favorable: 80-90% will resolve w/i 8 weeks
40% will relapse w/i 1 year
What are the Canadian/Nexus rules for when to order radiographs in trauma cases?
Hx - 7
PE - 3
History:
- Age 65+
- Dangerous MOI
- Paresthesia in extremities
- Painful, distracting injury elsewhere
- Altered level of alertness
- Evidence of intoxication
- Patients w/known vertebral disease
PE:
- Unable to actively rotate neck 45˚ to the left and to the right
- Midline cervical spine tenderness
- Focal neurologic deficit
What blood tests in a blood chem panel may point to a bone cancer? (And what kind?)
Alk phos = bone building disease
Ca2+ = bone breakdown disease
Protein = MM
How does syringomyelia present?
Diffuse “cape-like” distribution of pain/temp loss over 1 or 2 shoulders
What cervical conditions do oral corticosteroids put the patient at risk for? (2)
Osteoporosis
Ligamentous (transverse ligament) instab especially in upper cervicals
How do you perform the arm squeeze test? How do you interpret it?
When there is NR compression, 1+ nerves of the arm are sensitive to moderate compression of the biceps and triceps area and should be more painful than other areas of the shoulder and upper arm.
A positive test hurts 3+ more (3/10 pain scale) or during the pressure on the middle third of the upper arm, compared with compressing the AC and anterolateral-subacromial areas.
Example: if shoulder hurt 1/10 but arm hurt 4/10 that suggests it may not be a shoulder problem, but a nerve problem that is from the neck.
What are causes of cervical radicular syndromes?
Break them into A-3, B-5, and C-3 lists
A list: osteophyte, disc hern, stenosis
B list: structural instab, tumor/sol, infection, NR adhesion, trauma to NR
C list: disc derangement, facet syndrome, joint dysfxn
Which one of these (A list: osteophyte, disc hern, stenosis) should you consider in trauma cases?
Disc herniation
Stenosis
**NOT osteophyte
What are a variety of neck mechanisms of injury that can directly damage a NR? (3)
How about mechanisms to damage the brachial plexus? (2)
NR: hyperextension, compression, lateral flexion w/shoulder depression
Brachial plexus: lateral flexion w/shoulder depression, arm traction
What are the various signs and symptoms of cervical spinal cord damage?
- P not common presenting sx
- Sx often vague and variable
- Clumsy numb hands
- Clumsy gait (stumbling, shuffling/stiff-legged, wide-base, Romberg)
- Lower ext- paresthesia, intermittent prox leg P, low back or mid-thoracic P
- 2/3rd pts w/ disc hern have bladder dysfxn (urinary freq, urgency, incontinence, retention)
- L’Hermitte sign (25%)
- Motor hand: intrinsic atrophy, finger escape sign, rapid open
- Abnormal reflex (+3 or 3), paradoxical reflex, clonus, pathological reflex
- Vibration diminished
What would a complete exam look like for cervical spinal cord damage?
Neck flexion (look for L’Hermitte’s sign)
CN exam
UE:
- Observe hand intrinsics
- Finger escape sign ( + the patient is asked to squeeze his/her fingers together (adduction) while extending them backwards with the wrist in neutral. A positive test occurs if the two ulnar digits “escape” into flexion and abduction within 30 seconds.)
- Rapid open and close (NOT Roos)
- Hoffman (dynamic) or clonus
- SMR including sharp, vibration/position sense** know how to do position sense
LE
- Gait/Romberg
- SMR: sharp, vibration/position
- Babinski/clonus
- Single leg stand
What are the MC causes of cervical cord compression? What are other causes?
Causes of Cervical myelopathy
A list-2
B list- 6
A LIST:
1- disc hern (<50-60 y.o)
3- stenosis (>50-60 y.o)
B LIST 1- Trauma (hyperflexion) 2- Structural instability 3- Tumor/SOL 4- Infection 5- Fx 6- Spinal cord adhesion
What interventions are contraindicated when managing cervical cord compression?
Cervical traction
Adjusting
What are the various signs and symptoms for a cervical facet syndrome?
Palpatory:
- Tenderness over the facet
- Tissue changes around the joint
- Joint restriction
Joint loading:
- Local pain with active or passive extension
- Local pain with cervical compression
- Local pain with quadrant position or cervical Kemp’s
MOI for cervical facet syndrome?
Trauma (micro or macro)
Sustained postural loads
Simple activities of daily living (if neck is functionally unstable)
Based on a facet block study, what combination of findings were most predictive? Which of those findings carried the most weight in decreasing the probability of a cervical facet syndrome?
1 - (+)ve ER test >3/10 OPS
2 - Pain w/palpation over the facet >3/10 OPS
3 - Cervical restriction P-A joint glide
Most weight: palpatory ternderness
What are medical interventions for cervical facet syndrome?
Radiofrequency neurotomy
DEFINED:
medial branch of dorsal Ramos is enervated by coagulating and denaturing the proteins in the nerve. The nerve is not destroyed. This blocks the conduction of painful messages along the nerve to the DRG. The nerve may grow back to its target facet joint after 6-9 months and pain may return.
What are the “big five” orthopedic tests to diagnose cervical radicular syndromes?
Which one is more sensitive for this condition? Which ones (4) are more specific?
Cervical compression -SPEC Cervical distraction -SPEC Shoulder ABD -SPEC Valsalva -SPEC ULTT - median nerve **SEN
What is the peak age range for cervical disc herniations?
50-54 yo
Rare <30yo
What are the MFTP referral territories for the scalenes, infraspinatus, supraspinatus, latissimus dorsi, serratus anterior and the pecs? What nerve root or peripheral neuropathies might each mimic?
Scalenes mimic C6 NR or radial n → lat arm (esp delt) and postlat thumb and index finger (snuff)
Supraspinatus mimic C6 or radial n→ Lat delt, ant palm & index, and post hand
Infraspinatus can mimic C6 or radial n→ go into lat hand
Lats mimic C8 or ulnar nerve→ down med arm to pinkie and ring fingers
Serratus ant mimic C8 or ulnar nerve→ down med arm to pinkie and ring fingers but extending more into palm
Pec minor mimic C8 or ulnar nerve→ down medial arm and into little finger
What are the signs and symptoms of a cervical disc derangement? Which one is more accurate? What findings would cast the most doubt on the Dx?
- Cervical discogenic referred P
- Deep referred arm P may be improved by rep end range movement into chin
retraction, extension, or some other direction→ STRONGEST - Neck &/or chin retractions may be beneficial; neck flexion &/or chin protrusion may aggravate
- Less likely to have tenderness localized over facets
- May have (+)ve valsalva
- May be relieved by cervical distraction
- May be aggravated by cervical compression
Signs/Sx of neuro involvement would cast doubt on deranged disc.
What are the first directions to attempt when looking for a directional preference by repetitive or sustained cervical joint loading?
Protraction
Retraction
Extension
Flexion
What are the medical interventions for disc derangement? (2)
Intradiscal electro thermal therapy (IDET)
Percutaneous intradiscal radiofrequency thermocoagulation
What are the signs/Sx of CRPS? (Pain, Autonomic dysfxn, Motor dysfxn)
Pain: severe, burning, extremity, non-dermatomal, palmar/plantar dominance, allodynia/hyperalgesia
Autonomic dysfxn: swelling, tropic changes, sweating, altered skin temp
Motor dysfxn: hyperreflexia, tremor, muscle weakness, movement disorder, dystopia leading to contractures
In a patient with neck pain, but no evidence neuropathic involvement, what are the most likely pathoanatomical diagnoses?
Sprain Strain Facet syndrome Disc derangement Fracture, if traumatic
In a patient with neck and arm symptoms, what are the 5 broad diagnostic possibilities to consider regarding how the neck and arm symptoms are related?
Cord Nerve Root Peripheral nerve Deep referred pain 2 Separate lesions
What indicators from the history or physical exam tend to be most accurate at predicting which cervical nerve has been injured?
Deficits and paresthesia distribution more predictive than P distribution (C6 or C7)
Which neurological deficits are most specific for each of the following nerve roots?
C6
REFLEX: decreased biceps or brachi-radialis reflex
Then sensory loss of thumb
Then weak wrist extension
Which neurological deficits are most specific for each of the following nerve roots?
C7
REFLEX: diminished triceps reflex
Then weak elbow extension
Then sensory loss of middle finger
Which neurological deficits are most specific for each of the following nerve roots?
C8
SENSORY: loss little finger
Then diminished triceps reflex
Then weak finger flexion
What are all of the key characteristics and features of nerve pain that you want to try to elicit from your patient with arm pain?
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