Vignettes Flashcards
A 55 year old male presents with hip pain. He reports that the pain is worse in the morning and at night and gets better about 30 minutes after getting up and moving around. The pain is worse after walking and standing. His father has a history of avascular necrosis. ROM is limited and painful. Thoracic and Lumbar ROM is normal.
What characteristics are seen with this condition?
Osteophytes
Pathological fracture
Non-uniform loss of joint space
A 55 year old male presents with hip pain. He reports that the pain is worse in the morning and at night and gets better about 30 minutes after getting up and moving around. The pain is worse after walking and standing. His father has a history of avascular necrosis. ROM is limited and painful. Thoracic and Lumbar ROM is normal.
What would be palliative factors for this condition?
Hot moist packs
Passive ROM exercises
Non-weight bearing exercises
A 55 year old male presents with hip pain. He reports that the pain is worse in the morning and at night and gets better about 30 minutes after getting up and moving around. The pain is worse after walking and standing. His father has a history of avascular necrosis. ROM is limited and painful. Thoracic and Lumbar ROM is normal.
What is the likely etiology of this condition
History of sports injury
Unrealized microtrauma
Genetic
A 55 year old male presents with hip pain. He reports that the pain is worse in the morning and at night and gets better about 30 minutes after getting up and moving around. The pain is worse after walking and standing. His father has a history of avascular necrosis. ROM is limited and painful. Thoracic and Lumbar ROM is normal.
What is the condition
DJD
A 28 year old male presents with low back pain that came on over the past 2 weeks. Severity is 9/10. The patient has urinary frequency, urinary urgency, and dysuria. No palliative activity. Positive SLR at 20 degrees that causes ipsilateral SI pain and contralateral leg pain. Bragard’s test is positive. Laboratory tests are pending.
What are the expected lab findings?
Increased WBCs
Neutrophilia
Increased ESR
A 28 year old male presents with low back pain that came on over the past 2 weeks. Severity is 9/10. The patient has urinary frequency, urinary urgency, and dysuria. No palliative activity. Positive SLR at 20 degrees that causes ipsilateral SI pain and contralateral leg pain. Bragard’s test is positive. Laboratory tests are pending.
What clinical findings are most common?
Hypertonic paraspinal muscles
Inguinal lymphadenopathy
Fever
A 28 year old male presents with low back pain that came on over the past 2 weeks. Severity is 9/10. The patient has urinary frequency, urinary urgency, and dysuria. No palliative activity. Positive SLR at 20 degrees that causes ipsilateral SI pain and contralateral leg pain. Bragard’s test is positive. Laboratory tests are pending.
Where in society could this condition develop?
Urinary Tract Infection
Post-surgical complication
IV drug users
A 28 year old male presents with low back pain that came on over the past 2 weeks. Severity is 9/10. The patient has urinary frequency, urinary urgency, and dysuria. No palliative activity. Positive SLR at 20 degrees that causes ipsilateral SI pain and contralateral leg pain. Bragard’s test is positive. Laboratory tests are pending.
What is the condition?
Osteomyelitis
A 56 year old male has a slight fever and normochromic, normocytic, anemia. This has been a slow, progressive onset. He describes the pain as 9/10 in severity. He has weight loss, complaints of feeling tired all the time, and has dysuria.
What do you see on the film?
Pathological collapse
Decreased posterior body height
Osteopenia
A 56 year old male has a slight fever and normochromic, normocytic, anemia. This has been a slow, progressive onset. He describes the pain as 9/10 in severity. He has weight loss, complaints of feeling tired all the time, and has dysuria.
What lab tests should be run?
Immunoelectrophoresis
A/G ratio
Sedimentation rate
A 56 year old male has a slight fever and normochromic, normocytic, anemia. This has been a slow, progressive onset. He describes the pain as 9/10 in severity. He has weight loss, complaints of feeling tired all the time, and has dysuria.
What other symptoms would be expected?
Joint pain and swelling
Unrelenting back pain
Fatigue
A 56 year old male has a slight fever and normochromic, normocytic, anemia. This has been a slow, progressive onset. He describes the pain as 9/10 in severity. He has weight loss, complaints of feeling tired all the time, and has dysuria.
What is the condition?
Multiple myeloma
A 24 year old female presents in your office with a headache. During the consultation she reveals that her vision is blurred approximately 30 minutels before each episode. The quality is throbbing. A cold cloth is palliative.
Distraction test produces slight suboccipital pain
Jackson’s compression test is negative
Decreased ROM in all planes
Normal BP and vitals.
What would the additional clinical findings for the condition be?
Photophobia
Prodrome/Aura
Nausea
A 24 year old female presents in your office with a headache. During the consultation she reveals that her vision is blurred approximately 30 minutels before each episode. The quality is throbbing. A cold cloth is palliative.
Distraction test produces slight suboccipital pain
Jackson’s compression test is negative
Decreased ROM in all planes
Normal BP and vitals.
What would be the best treatment/next step?
Adjust
Dietary log
Refer to massage therapist
A 24 year old female presents in your office with a headache. During the consultation she reveals that her vision is blurred approximately 30 minutels before each episode. The quality is throbbing. A cold cloth is palliative.
Distraction test produces slight suboccipital pain
Jackson’s compression test is negative
Decreased ROM in all planes
Normal BP and vitals.
What woulod be aggravating factors to this condition?
Hormone imbalance
Hypoglycemia
Consumption of red wine
A 24 year old female presents in your office with a headache. During the consultation she reveals that her vision is blurred approximately 30 minutels before each episode. The quality is throbbing. A cold cloth is palliative.
Distraction test produces slight suboccipital pain
Jackson’s compression test is negative
Decreased ROM in all planes
Normal BP and vitals.
What is the condition?
Classic migraine
A 30 year old male presents with severe headache behind his right eye. He reports that he had this a few months ago and it recently came back about 2 weeks ago. Each episode lasts less than 2 hours and can occur 3-4 times per day. MD recommends aspirin 4 times per day, but has no relief. He has a runny nose and states that symptoms are worse with alcohol.
Kernig’s is negative
Brudzinski is negative
L’Hermitte’s is negative
What is the most likely diagnosis?
Cluster headache
Autonomic nervous system disturbance
Vasomotor disturbance
A 30 year old male presents with severe headache behind his right eye. He reports that he had this a few months ago and it recently came back about 2 weeks ago. Each episode lasts less than 2 hours and can occur 3-4 times per day. MD recommends aspirin 4 times per day, but has no relief. He has a runny nose and states that symptoms are worse with alcohol.
Kernig’s is negative
Brudzinski is negative
L’Hermitte’s is negative
What would you expect to find on examination?
Unilateraly facial sweating
Unilateral eyelid ptosis
Unilateral constricted pupil
A 30 year old male presents with severe headache behind his right eye. He reports that he had this a few months ago and it recently came back about 2 weeks ago. Each episode lasts less than 2 hours and can occur 3-4 times per day. MD recommends aspirin 4 times per day, but has no relief. He has a runny nose and states that symptoms are worse with alcohol.
Kernig’s is negative
Brudzinski is negative
L’Hermitte’s is negative
What additional tests would you perform?
Cranial CT scan
Cranial nerve evaluation
Allergy testing
A 30 year old male presents with severe headache behind his right eye. He reports that he had this a few months ago and it recently came back about 2 weeks ago. Each episode lasts less than 2 hours and can occur 3-4 times per day. MD recommends aspirin 4 times per day, but has no relief. He has a runny nose and states that symptoms are worse with alcohol.
Kernig’s is negative
Brudzinski is negative
L’Hermitte’s is negative
What is the condition
Cluster headache
A 50 year old female presents with insidious onset of right calf pain, pitting edema, and red, hot, swollen leg. Walking increases the pain. The patient is a 10 year smoker, overweight, has high BP…
What is in the differential diagnosis?
Deep vein thrombosis
Phlebitis
Vascular claudication
A 50 year old female presents with insidious onset of right calf pain, pitting edema, and red, hot, swollen leg. Walking increases the pain. The patient is a 10 year smoker, overweight, has high BP…
What test would be best to assist with diagnosis?
D-dimer test
Doppler ultrasound
CBC
A 50 year old female presents with insidious onset of right calf pain, pitting edema, and red, hot, swollen leg. Walking increases the pain. The patient is a 10 year smoker, overweight, has high BP…
What is the best recommended treatment
Elevate leg
Anticoagulant therapy
Compressive stocking on the leg
A 50 year old female presents with insidious onset of right calf pain, pitting edema, and red, hot, swollen leg. Walking increases the pain. The patient is a 10 year smoker, overweight, has high BP…
What is the condition
DVT
A 12 year old boy presents with a history of ankle pain for the past 24 hours. He reports having injured the ankle playing basketball. It is worse with movement and better with rest. All ranges of motion produce pain. Anterior drawer sign is positive.
Pick 3 radiographic findings
Metaphyseal lesion
Diaphyseal lesion
Expansile lesion
A 12 year old boy presents with a history of ankle pain for the past 24 hours. He reports having injured the ankle playing basketball. It is worse with movement and better with rest. All ranges of motion produce pain. Anterior drawer sign is positive.
Which 3 are the most likely differential diagnosis
sprain/strain injury
simple bone cyst
benign bone tumor
A 12 year old boy presents with a history of ankle pain for the past 24 hours. He reports having injured the ankle playing basketball. It is worse with movement and better with rest. All ranges of motion produce pain. Anterior drawer sign is positive.
Which of the following are the best diagnoses?
Aneurysmal bone cyst
Anterior talofibular ligament sprain
Inversion sprain
A 12 year old boy presents with a history of ankle pain for the past 24 hours. He reports having injured the ankle playing basketball. It is worse with movement and better with rest. All ranges of motion produce pain. Anterior drawer sign is positive.
What is the condition
ABC
A 34 year old male complains about pain in the right buttock that extends to the right foot. He can not sit on that buttock due to pain and the pain is increased when going from a sitting position to a standing position. The pain is worse with activity and internal rotation of the hip. Pain is at the right PSIS when lying on his side. Lesague’s and hip abduction tests are positive.
What are 3 diagnoses
Piriformis syndrome
Sciatica
Nerve Entrapment
A 34 year old male complains about pain in the right buttock that extends to the right foot. He can not sit on that buttock due to pain and the pain is increased when going from a sitting position to a standing position. The pain is worse with activity and internal rotation of the hip. Pain is at the right PSIS when lying on his side. Lesague’s and hip abduction tests are positive.
What additional tests/movements would be observed in this condition
Passive external rotation of the hip produces pain
Pain with resisted active range of motion
Pain when palpating greater sciatic foramen
hibb’s test
test for hip
valsalva
disc
Piriformis is NOT involved with which ROM of the hip
Flexion, Extension
Milgram’s test
disc
A 34 year old male complains about pain in the right buttock that extends to the right foot. He can not sit on that buttock due to pain and the pain is increased when going from a sitting position to a standing position. The pain is worse with activity and internal rotation of the hip. Pain is at the right PSIS when lying on his side. Lesague’s and hip abduction tests are positive.
Treatment protocols include
Adjust sacrum
Stretch the piriformis
Trigger point therapy (any muscle spasm/issue)
A 34 year old male complains about pain in the right buttock that extends to the right foot. He can not sit on that buttock due to pain and the pain is increased when going from a sitting position to a standing position. The pain is worse with activity and internal rotation of the hip. Pain is at the right PSIS when lying on his side. Lesague’s and hip abduction tests are positive.
What is the dx
Piriformis syndrome
A 35 year old female presents with bilateral numbness in arms and hands. She also has severe neck pain. Shaking her hands makes them feel better but nothing relieves the neck pain. She has been a bank teller for 13 years. Decreased ROM in the cervical spine. Numbness in both arms. Wrights and Adsons tests are positive.
What is the likely etiology of this condition?
Congenital anomaly
Neurovascular bundle compromise
Pectoralis minor hypertonicity
A 35 year old female presents with bilateral numbness in arms and hands. She also has severe neck pain. Shaking her hands makes them feel better but nothing relieves the neck pain. She has been a bank teller for 13 years. Decreased ROM in the cervical spine. Numbness in both arms. Wrights and Adsons tests are positive.
What is the best management for this condition?
Stretch pectoralis muscles
Ergonomic evaluation
Stretch Scalene muscles
A 35 year old female presents with bilateral numbness in arms and hands. She also has severe neck pain. Shaking her hands makes them feel better but nothing relieves the neck pain. She has been a bank teller for 13 years. Decreased ROM in the cervical spine. Numbness in both arms. Wrights and Adsons tests are positive.
If there is no improvement after initial treatment what is the best advice?
Refer for surgical consultation
Order neurodiagnosis
NCV study (part of neurodiagnosis eval)
A 52 year old male presents with mid to low back pain. KEmp’s produces localized pain in every direction. Yeoman’s produced increased pain in the thoracolumbar junction and in the lumbar spine. Kemp’s test produced localized pain bilaterally. The patient also complains of hip pain and you note coxa vara bilaterally.
Which of the following is the most likely diagnosis?
Paget’s disease
Blastic metastasis
Hodgkin’s disease
A 52 year old male presents with mid to low back pain. KEmp’s produces localized pain in every direction. Yeoman’s produced increased pain in the thoracolumbar junction and in the lumbar spine. Kemp’s test produced localized pain bilaterally. The patient also complains of hip pain and you note coxa vara bilaterally.
Which of the following body parts is likely to be involved
Skull
Femur
Pelvis
A 52 year old male presents with mid to low back pain. KEmp’s produces localized pain in every direction. Yeoman’s produced increased pain in the thoracolumbar junction and in the lumbar spine. Kemp’s test produced localized pain bilaterally. The patient also complains of hip pain and you note coxa vara bilaterally.
Which of the following is the most likely sequelae?
Malignant degeneration
Tibial deformity
Pathological collapse
A 52 year old male presents with mid to low back pain. KEmp’s produces localized pain in every direction. Yeoman’s produced increased pain in the thoracolumbar junction and in the lumbar spine. Kemp’s test produced localized pain bilaterally. The patient also complains of hip pain and you note coxa vara bilaterally.
What is the condition?
Metastasis
A 10 year old boy presents with back pain. Upon inspection you note multiple, non-elevated, hyperpigmented lesions on his back. He has a left thoracic scoliosis and a right lumbar scoliosis. He also has a kyphosis present in the thoracic spine. Adam’s sign is negative.
What is the condition?
Neurofibromatosis
A 10 year old boy presents with back pain. Upon inspection you note multiple, non-elevated, hyperpigmented lesions on his back. He has a left thoracic scoliosis and a right lumbar scoliosis. He also has a kyphosis present in the thoracic spine. Adam’s sign is negative.
What radiographic signs do you expect to see?
Posterior body scalloping
Rib Deformity
Enlarged neural foramina
A 10 year old boy presents with back pain. Upon inspection you note multiple, non-elevated, hyperpigmented lesions on his back. He has a left thoracic scoliosis and a right lumbar scoliosis. He also has a kyphosis present in the thoracic spine. Adam’s sign is negative.
What are most likely associated findings
Neurological Deficit
Renal Abnormalitites
Deformity of limbs
A 10 year old boy presents with back pain. Upon inspection you note multiple, non-elevated, hyperpigmented lesions on his back. He has a left thoracic scoliosis and a right lumbar scoliosis. He also has a kyphosis present in the thoracic spine. Adam’s sign is negative.
Pick 3 that would be the most likely in the future to be a consequence?
Hypertension
Fibroma Mollosum
Spinal issues
A 43 year old female presents with pain and a burning sensation in both legs. Upon examination you note that she weights 175 lbs, and is 65” tall. Her BP is 158/78. She has a normal range of motion and 1+/4 DTR’s in the lower extremities. She also complains of a recent onset of visual disturbances.
What is the condition
Diabetes Type 2
A 43 year old female presents with pain and a burning sensation in both legs. Upon examination you note that she weights 175 lbs, and is 65” tall. Her BP is 158/78. She has a normal range of motion and 1+/4 DTR’s in the lower extremities. She also complains of a recent onset of visual disturbances
What are 3 other findings?
Insulin insensitivity
Polydipsia
Hyperglycemia
A 43 year old female presents with pain and a burning sensation in both legs. Upon examination you note that she weights 175 lbs, and is 65” tall. Her BP is 158/78. She has a normal range of motion and 1+/4 DTR’s in the lower extremities. She also complains of a recent onset of visual disturbances
3 best initial follow up steps
Low glycemic index diet
Chromium supplementation
Advise patient to walk
A 43 year old female presents with pain and a burning sensation in both legs. Upon examination you note that she weights 175 lbs, and is 65” tall. Her BP is 158/78. She has a normal range of motion and 1+/4 DTR’s in the lower extremities. She also complains of a recent onset of visual disturbances
Sequelae?
Retinopathy
Nephropathy
Arteriosclerosis
A 13 year old boy weighing 134 lbs presents with ankle pain for 1 day after an injury playing sports. It is worse with movement and better with rest. He experiences pain with all ROM. Drawer sign exhibits excessive motion anteriorly. Lateral stability was positive.
What is the condition?
Benign Bone Tumor - Simple Bone Cyst
A 13 year old boy weighing 134 lbs presents with ankle pain for 1 day after an injury playing sports. It is worse with movement and better with rest. He experiences pain with all ROM. Drawer sign exhibits excessive motion anteriorly. Lateral stability was positive.
What are the radiographic signs
Metaphysis
Diaphysis
Geographic
A 13 year old boy weighing 134 lbs presents with ankle pain for 1 day after an injury playing sports. It is worse with movement and better with rest. He experiences pain with all ROM. Drawer sign exhibits excessive motion anteriorly. Lateral stability was positive.
Diagnosis?
Simple Bone Cyst
Sprain/Strain
Benign Bone Tumor
A 13 year old boy weighing 134 lbs presents with ankle pain for 1 day after an injury playing sports. It is worse with movement and better with rest. He experiences pain with all ROM. Drawer sign exhibits excessive motion anteriorly. Lateral stability was positive.
What would be the next step in this case?
Surgical Consultation
Evaluate for a splint
RICE (rest, ice, compression, elevation)
42 year old female presents with neck pain that occasionally radiates behind the right eye. She has suboccipital tension and paraspinal muscle spasm. She has a decreased ROM in all planes. The pain is worse with flexion of the neck and it comes and goes. She also experiences unilateral temporal pain.
Differential Diagnosis?
Common migraine headache
Tension headache
Cervicogenic headache
42 year old female presents with neck pain that occasionally radiates behind the right eye. She has suboccipital tension and paraspinal muscle spasm. She has a decreased ROM in all planes. The pain is worse with flexion of the neck and it comes and goes. She also experiences unilateral temporal pain.
3 additional clinical findings?
Sensitivity to light
Sensitivity to sound
Nausea
42 year old female presents with neck pain that occasionally radiates behind the right eye. She has suboccipital tension and paraspinal muscle spasm. She has a decreased ROM in all planes. The pain is worse with flexion of the neck and it comes and goes. She also experiences unilateral temporal pain.
3 best case management?
Adjust cervicals
Myofascial Therapy
Recommend stress management technique
45 year old male presents with back pain that started when he was shoveling snow 2 months ago. Bending forward and getting out of a chair causes pain down the back of the left leg. He walks into your office with an antalgic lean. Pain is from his calf to the big toe. Leaning to the right reproduced the calf pain. BP was 188/90. Minor’s sign is positive.
3 Ortho tests that are positive?
Milgram’s
Bowstring
Kemps
45 year old male presents with back pain that started when he was shoveling snow 2 months ago. Bending forward and getting out of a chair causes pain down the back of the left leg. He walks into your office with an antalgic lean. Pain is from his calf to the big toe. Leaning to the right reproduced the calf pain. BP was 188/90. Minor’s sign is positive.
Best initial follow up step
Spinal manipulation
Lumbar traction
Centralization of symptoms (distal point to become central)
45 year old male presents with back pain that started when he was shoveling snow 2 months ago. Bending forward and getting out of a chair causes pain down the back of the left leg. He walks into your office with an antalgic lean. Pain is from his calf to the big toe. Leaning to the right reproduced the calf pain. BP was 188/90. Minor’s sign is positive.
What if left untreated?
Gastrocnemius atrophy
Decreased Achilles reflex
Pain at the lateral foot
45 year old male presents with back pain that started when he was shoveling snow 2 months ago. Bending forward and getting out of a chair causes pain down the back of the left leg. He walks into your office with an antalgic lean. Pain is from his calf to the big toe. Leaning to the right reproduced the calf pain. BP was 188/90. Minor’s sign is positive.
What is the condition?
S1 nerve root
L5 disc issue
19 year old female woke up yesterday with neck pain and hypertonic posterior cervical muscles. The pain is dull and 3-7/10. There is decreased ROM in the Cspine due to pain in all ROM. Cervical distraction and compression tests increase the symptoms but do not produce radiation. There is normal bilateral sensation and motor function.
What are 3 likely additional clinical findings in this case?
SCM myospasm
Passive ROM greater than active ROM
Normal deep tendon reflexes
19 year old female woke up yesterday with neck pain and hypertonic posterior cervical muscles. The pain is dull and 3-7/10. There is decreased ROM in the Cspine due to pain in all ROM. Cervical distraction and compression tests increase the symptoms but do not produce radiation. There is normal bilateral sensation and motor function.
3 best follow up steps
Myofascial release
Adjust to patient tolerance
Trigger Point therapy
19 year old female woke up yesterday with neck pain and hypertonic posterior cervical muscles. The pain is dull and 3-7/10. There is decreased ROM in the Cspine due to pain in all ROM. Cervical distraction and compression tests increase the symptoms but do not produce radiation. There is normal bilateral sensation and motor function.
Patient continued to have a headache but also develops fever the next few days
Positive Kernig test
Increased WBCs positive CSF evaluation
Positive Brudzinski
44 year old female reports falling onto an outstretched arm 8 weeks ago. She reports that the pain is getting worse and that is radiates up to the shoulder. It is warm, red, and painful to the touch. The brachioradialis reflex could not be performed due to pain. All other DTRs in the upper extremities are normal. She reports a history of hypothyroid and that she is taking Synthroid. Provocative factors include emotional stress and increased activity.
What are the 3 most likely diagnosis?
Reflex Sympathetic Dystrophy
Complex regional pain syndrome
Sudeck’s Atrophy
44 year old female reports falling onto an outstretched arm 8 weeks ago. She reports that the pain is getting worse and that is radiates up to the shoulder. It is warm, red, and painful to the touch. The brachioradialis reflex could not be performed due to pain. All other DTRs in the upper extremities are normal. She reports a history of hypothyroid and that she is taking Synthroid. Provocative factors include emotional stress and increased activity.
3 best indicated clinical labs/studies
Triple Radionucleotide scan
Sympathetic Nerve BLock
Thermography
44 year old female reports falling onto an outstretched arm 8 weeks ago. She reports that the pain is getting worse and that is radiates up to the shoulder. It is warm, red, and painful to the touch. The brachioradialis reflex could not be performed due to pain. All other DTRs in the upper extremities are normal. She reports a history of hypothyroid and that she is taking Synthroid. Provocative factors include emotional stress and increased activity.
Long term sequelae?
Atrophic skin changes
Osteoporosis
Hyperesthesia
An 18 year old male presents with back pain. He has difficulty with lateral flexion to the right and less difficult to the left. (there were 2 x-rays) - scoliosis
Which 3 are most commonly associated with this condition?
Dorsal hemivertebra
Physiological short leg
Structural Scoliosis
An 18 year old male presents with back pain. He has difficulty with lateral flexion to the right and less difficult to the left. (there were 2 x-rays) - scoliosis
What 3 are systemic issues are likely associated with this case
Cardiac problems
Genitourinary problems
Progressive Scoliosis
An 18 year old male presents with back pain. He has difficulty with lateral flexion to the right and less difficult to the left. (there were 2 x-rays) - scoliosis
Management?
Chiropractic adjustments
Refer to Orthopedist for bracing
Spinal Rehab exercises
26 year old male presents with insidious onset of low back pain that started 3 weeks ago. Severity is 8-9/10. No palliative activity. Patient has a temperature of 99 degrees. Bilateral anterior thigh pain is also present.
What is the condition?
Discitis
26 year old male presents with insidious onset of low back pain that started 3 weeks ago. Severity is 8-9/10. No palliative activity. Patient has a temperature of 99 degrees. Bilateral anterior thigh pain is also present.
Which of the following is most likely Etiology for the general population?
IV drug use
Discopathy
Urinary Tract Infection
26 year old male presents with insidious onset of low back pain that started 3 weeks ago. Severity is 8-9/10. No palliative activity. Patient has a temperature of 99 degrees. Bilateral anterior thigh pain is also present.
What are the lab tests?
Neutrophilia
Increased ESR
Increased WBC count
26 year old male presents with insidious onset of low back pain that started 3 weeks ago. Severity is 8-9/10. No palliative activity. Patient has a temperature of 99 degrees. Bilateral anterior thigh pain is also present.
Most likely sequelae if condition goes untreated?
Recurrent infections
Inguinal lymphadenopathy
Arthritic Changes
19 year old female with low back pain and morning stiffness. She is getting progressively worse with fatigue over a long period of time. She further complains about sensitivity to sunlight. Murphy’s punch is positive, decreased ROM in the wrist. There is ulnar deviation of the phalanges which can be straightened out with her hand on the table. Positive Bechterew’s test and Positive kemps test. cellular casts, blood and protein are found in the urine.
What is the condition?
SLR - Lupus
19 year old female with low back pain and morning stiffness. She is getting progressively worse with fatigue over a long period of time. She further complains about sensitivity to sunlight. Murphy’s punch is positive, decreased ROM in the wrist. There is ulnar deviation of the phalanges which can be straightened out with her hand on the table. Positive Bechterew’s test and Positive kemps test. cellular casts, blood and protein are found in the urine.
3 labs
ANA
Anti-DNA
Thrombocytopenia
19 year old female with low back pain and morning stiffness. She is getting progressively worse with fatigue over a long period of time. She further complains about sensitivity to sunlight. Murphy’s punch is positive, decreased ROM in the wrist. There is ulnar deviation of the phalanges which can be straightened out with her hand on the table. Positive Bechterew’s test and Positive kemps test. cellular casts, blood and protein are found in the urine.
What else would you expect to find
malar rash
discoid lesion
alopecia
19 year old female with low back pain and morning stiffness. She is getting progressively worse with fatigue over a long period of time. She further complains about sensitivity to sunlight. Murphy’s punch is positive, decreased ROM in the wrist. There is ulnar deviation of the phalanges which can be straightened out with her hand on the table. Positive Bechterew’s test and Positive kemps test. cellular casts, blood and protein are found in the urine.
Proper case management
Chiropractic Care
Avoid the sun
Activities to tolerance
54 year old female presents with bouts of low back pain for the past several months. She explaisn that the pain is worse with lumbar extensions. THere is no radiating pain. Kemps test reveals localized low back pain in all directions.
What are the best 3 differential diagnosis
Degenerative Spondylolisthesis
Facet Syndrome
Lower Cross Syndrome
54 year old female presents with bouts of low back pain for the past several months. She explaisn that the pain is worse with lumbar extensions. THere is no radiating pain. Kemps test reveals localized low back pain in all directions.
3 additional findings
Meniscoid entrapment
Weak core muscles
Decrease disc height
54 year old female presents with bouts of low back pain for the past several months. She explaisn that the pain is worse with lumbar extensions. THere is no radiating pain. Kemps test reveals localized low back pain in all directions.
Management?
Knee to chest streatches
SPECT test (test for spondylo)
Williams exercises
a 43 year old male presents with a history of diabetes and obesity. Upon examination you find negative anterior drawer test. Lachman’s test and McMurray’s test. Positive Apley’s compression test (pain in the knee)
X-ray of the knee (calcium seen between femur and tibia)
Diagnosis?
CPPD
Pseudogout
Chondrocalcinosis
a 43 year old male presents with a history of diabetes and obesity. Upon examination you find negative anterior drawer test. Lachman’s test and McMurray’s test. Positive Apley’s compression test (pain in the knee)
X-ray of the knee (calcium seen between femur and tibia)
Radiographic findings
Sharp Tibial Plateau
Subchondral Cyst
Calcificaiton in the joint line
a 43 year old male presents with a history of diabetes and obesity. Upon examination you find negative anterior drawer test. Lachman’s test and McMurray’s test. Positive Apley’s compression test (pain in the knee)
X-ray of the knee (calcium seen between femur and tibia)
Diagnosis test
joint aspiration (this takes out crystals)
Biopsy of the articular cartilage
MRI
50 year old male patient with hip pain. The pain is 6-7/10. Hibb’s test is positive and so is Anvil Test. (there is an x-ray of femur and part of hip)
Diagnosis?
Primary neoplasm
Hematopoietic disease
Multiple Myeloma
50 year old male patient with hip pain. The pain is 6-7/10. Hibb’s test is positive and so is Anvil Test. (there is an x-ray of femur and part of hip)
Radiographic signs
Osteolytic lesion
Osteopenia
Metaphyseal lesion
50 year old male patient with hip pain. The pain is 6-7/10. Hibb’s test is positive and so is Anvil Test. (there is an x-ray of femur and part of hip)
Future sequelae?
Anemia
Increased occurence of infections
Unexplained weight loss
32 year old. tingling in the legs, intermittent weakness and balance problems. Ortho tests negative.
Follow up tests?
MRI of brain
Visual Evoked Potentials
CSF for proteins
32 year old. tingling in the legs, intermittent weakness and balance problems. Ortho tests negative.
Most likely associated signs
Visual disturbances
Postiive L’Hermittes
Hyperreflexia
32 year old. tingling in the legs, intermittent weakness and balance problems. Ortho tests negative.
Sequelae?
Speech impairment
Cognitive impairment
Spastic paralysis
50 yo female. x-ray of L5 disc degeneration.
Differential
Facet syndrome
Disc narrowing
Canal stenosis
50 yo female. x-ray of L5 disc degeneration.
Additional findings
Lying prone knees to chest palliative
50 yo female. x-ray of L5 disc degeneration.
Course of action
Williams exercises
Adjust
Myofascial release
16 yo male presents with bilateral rounding of the shoulders and anterior head carriage. He complains of thoracic spine pain that is worse when active and is better with rest but never completely goes away.
UCS and Scheuermann’s disase as seen on x-ray.
X-ray findings?
End plate irregularities
anterior body wedging
hyperkyphosis
schmorl’s node defect
16 yo male presents with bilateral rounding of the shoulders and anterior head carriage. He complains of thoracic spine pain that is worse when active and is better with rest but never completely goes away.
UCS and Scheuermann’s disase as seen on x-ray.
Treatment
suspend athletic activities
adjust P-A in supine position
back extension exercises
16 yo male presents with bilateral rounding of the shoulders and anterior head carriage. He complains of thoracic spine pain that is worse when active and is better with rest but never completely goes away.
UCS and Scheuermann’s disase as seen on x-ray.
Initial treatment
Kinesio-tape
Adjust
Stop athletic activity
16 yo male presents with bilateral rounding of the shoulders and anterior head carriage. He complains of thoracic spine pain that is worse when active and is better with rest but never completely goes away.
UCS and Scheuermann’s disase as seen on x-ray.
3 clinical findings
intermittent pain hyperlordosis in the lumbar muscle stiffness and fatigue increased cervical lordosis hyperkyphosis anterior pelvic tilt
16 yo male presents with bilateral rounding of the shoulders and anterior head carriage. He complains of thoracic spine pain that is worse when active and is better with rest but never completely goes away.
UCS and Scheuermann’s disase as seen on x-ray.
Recommendations
strengthen erector spinae
stretch hamstrings
strenghten rectus femoris
50 yo male that played college football presents with right shoulder pain. He has a previous skin cancer on his forehead. He reports he hit his head on a shelf. He has a positive shoulder deprossor test on the right, pain adn decreased ROM of the C spine, numbness in lower extremities. Positive Babinski’s sign, weakenss in the legs, 4+/5 DTR in the lower extremities.
unable to toe walk, weakness with toe walking
Diagnosis
canal stenosis
UMNL
Central disc herniation
50 yo male that played college football presents with right shoulder pain. He has a previous skin cancer on his forehead. He reports he hit his head on a shelf. He has a positive shoulder deprossor test on the right, pain adn decreased ROM of the C spine, numbness in lower extremities. Positive Babinski’s sign, weakenss in the legs, 4+/5 DTR in the lower extremities.
unable to toe walk, weakness with toe walking
Signs?
clonus
hyperreflexia in the lower extremity
hyperspasticityf
50 yo male that played college football presents with right shoulder pain. He has a previous skin cancer on his forehead. He reports he hit his head on a shelf. He has a positive shoulder deprossor test on the right, pain adn decreased ROM of the C spine, numbness in lower extremities. Positive Babinski’s sign, weakenss in the legs, 4+/5 DTR in the lower extremities.
unable to toe walk, weakness with toe walking
complications?
weakness in the lower extremity
inability to heel walk or toe walk
paraplegia
50 yo male that played college football presents with right shoulder pain. He has a previous skin cancer on his forehead. He reports he hit his head on a shelf. He has a positive shoulder deprossor test on the right, pain adn decreased ROM of the C spine, numbness in lower extremities. Positive Babinski’s sign, weakenss in the legs, 4+/5 DTR in the lower extremities.
DX
canal stenosis
posterior longitudinal ligament hypertrophy
ligamentum flavum hypertrophy
50 yo male that played college football presents with right shoulder pain. He has a previous skin cancer on his forehead. He reports he hit his head on a shelf. He has a positive shoulder deprossor test on the right, pain adn decreased ROM of the C spine, numbness in lower extremities. Positive Babinski’s sign, weakenss in the legs, 4+/5 DTR in the lower extremities.
signs?
clonus
hyperreflexia in the lower extremity
hyperspasticity
50 yo male that played college football presents with right shoulder pain. He has a previous skin cancer on his forehead. He reports he hit his head on a shelf. He has a positive shoulder deprossor test on the right, pain adn decreased ROM of the C spine, numbness in lower extremities. Positive Babinski’s sign, weakenss in the legs, 4+/5 DTR in the lower extremities.
complications?
weakness in the lower extremity
paralysis
balance disorders
43 yo male with diabetes and positive apley’s compression. X-ray of knee showing CPPD.
Dx
CPPD
Chondrocalcinosis
Pseudogout
43 yo male with diabetes and positive apley’s compression. X-ray of knee showing CPPD.
X-ray findings
sharp tibial plateau
calcification of joint line
subchondral cyst
43 yo male with diabetes and positive apley’s compression. X-ray of knee showing CPPD.
diagnostic tests
joint aspiration
biopsy
MRI
24 yo female history of headaches. Agenesis of C1 posterior arch on X-ray
Diagnosis
agenesis of posterior arch of C1
anterior tubercle sclerosis
congenital anomaly
24 yo female history of headaches. Agenesis of C1 posterior arch on X-ray
secondary problems
atlantooccipital instability
neurological deficits
spina bifida occulta
24 yo female history of headaches. Agenesis of C1 posterior arch on X-ray
best tx or next step
flex/ext x-rays
neuro evaluation
avoid adjusting upper cervical area
21 yo male with shoulder pain. very obvious AC joint separation on x-ray.
Diagnosis?
coracoclavicular ligament sprain
AC separation
AC sprain
21 yo male with shoulder pain. very obvious AC joint separation on x-ray.
treatment
cryotherapy
sling
refer for surgery
21 yo male with shoulder pain. very obvious AC joint separation on x-ray.
future consequences
early onset OA
rotator cuff tendinopathy
impingement syndrome
35 yo with Bell’s Palsy.
Dx
LMNL
facial nerve inflammation
CN7 pathology
35 yo with Bell’s Palsy.
If unresolved?
decreased vision
decreased ability to speak
lacrimation while eating
35 yo with Bell’s Palsy.
treatemnt
co-treat with neurologist
artificial tears
adjust
55 yo male with AAA.
Exam findings:
abdominal bruit
abdominal pulsation
abdominal pain upon exertion
55 yo male with AAA.
Case Hx findings
hx smoking
family hx of CV disease
familial hyperlipidemia
55 yo male with AAA.
Management
diagnostic US
defer chiro care
refer to ER
35 yo female with bilateral numbness in upper extremity and neck pain. Wrights and Adsons’ positive.
Etiology?
cervical ribs
scalenes
neurovascular compromise
35 yo female with bilateral numbness in upper extremity and neck pain. Wrights and Adsons’ positive.
management
stretch pectoralis muscle
stretch scalenes
neck retraction exercises
35 yo female with bilateral numbness in upper extremity and neck pain. Wrights and Adsons’ positive.
if no improvement
NCV study
surgical consultation
neuro diagnosis
35 yo has low back pain with lifting. Pain into the big toe. Weak heel walk. decreased sensation to the top of the foot.
what would be affected?
L5 nerve root
L4 disc
Weak toe extension
35 yo has low back pain with lifting. Pain into the big toe. Weak heel walk. decreased sensation to the top of the foot.
Treatment
chiropractic adjustments
flexion/distraction
mckenzie exercises???
35 yo has low back pain with lifting. Pain into the big toe. Weak heel walk. decreased sensation to the top of the foot.
if unresolved
cauda equina syndrome (all 3 were QE findings)
Inability to void
urinary incontinence
32 yo findings of MS.
Follow up?
MRI of brain
CSF for protein
Electrodiagnosis
32 yo findings of MS.
Associated signs?
visual disturbances
hyperreflexia
fasciculations
32 yo findings of MS.
sequelae?
vertigo
urinary incontinence
tonic/clonic seizures
32 yo female who is a secretary and she types all day long. Bilateral finger and hand pain and tingling.
dx?
carpal tunnel syndrome
median nerve entrapment
pronator teres syndrome
32 yo female who is a secretary and she types all day long. Bilateral finger and hand pain and tingling.
How do you know it’s worsening?
decrease dynamometer
thenar atrophy
inability to perform pincer grip
32 yo female who is a secretary and she types all day long. Bilateral finger and hand pain and tingling.
treatment
adjust lunate
transverse friction massage pronator teres
ergonomic training
71 yo female with low back pain while gardening 18 hours ago, sudden onset of low back pain. Sharp pain. X-ray of compression fracture.
dx?
Osteoporotic fracture
stable fracture
step defect
71 yo female with low back pain while gardening 18 hours ago, sudden onset of low back pain. Sharp pain. X-ray of compression fracture.
treatment
refer to orthopedic surgeon
modify ADL’s
cryotherapy
71 yo female with low back pain while gardening 18 hours ago, sudden onset of low back pain. Sharp pain. X-ray of compression fracture.
progression of condition
postural changes
altered biomechanics
increase rate of degeneration
45 yo female. Hx describes upper and lower cross syndrome. X-ray of a hemangioma.
Dx?
hemangioma
vascular neogenesis
benign bone tumor
45 yo female. Hx describes upper and lower cross syndrome. X-ray of a hemangioma.
What else could happen
verteebral body collapse
vertebral expansion
canal stenosis
45 yo female. Hx describes upper and lower cross syndrome. X-ray of a hemangioma.
treatment
adjust to tolerance
refer to an orthopedist
ADL’s remain normal
46 yo female administrative assistant presents with neck pain and headaches that have been getting progressively worse over the past six months. The pain is dull and 3-6/10. She reports using the computer and writing makes it worse and ice makes it better. She has a slight decrease in flexion and extension fo the C spine. She has hypertonic cervical extensor cervical muscles as well as suboccipital muscles. She also has an anterior head carriage. Describes UCS. X-ray shows a block vertebrae.
X-ray findings?
wasp waist
rudimentary disc
congenital synostosis
46 yo female administrative assistant presents with neck pain and headaches that have been getting progressively worse over the past six months. The pain is dull and 3-6/10. She reports using the computer and writing makes it worse and ice makes it better. She has a slight decrease in flexion and extension fo the C spine. She has hypertonic cervical extensor cervical muscles as well as suboccipital muscles. She also has an anterior head carriage. Describes UCS. X-ray shows a block vertebrae.
differential diagnosis?
tension headache
Congenital Block
Postural syndrome
46 yo female administrative assistant presents with neck pain and headaches that have been getting progressively worse over the past six months. The pain is dull and 3-6/10. She reports using the computer and writing makes it worse and ice makes it better. She has a slight decrease in flexion and extension fo the C spine. She has hypertonic cervical extensor cervical muscles as well as suboccipital muscles. She also has an anterior head carriage. Describes UCS. X-ray shows a block vertebrae.
treatment
ergonomic training
strengthen deep neck flexors
chiropractic adjustments.
32 yo male soccer player presents with knee pain. He injured his knee while playing soccer 2 days ago. Along with the knee pain he has swelling, popping and locking of the knee. no ortho tests could be done due to swelling and pain.
What tests would be positive?
bounce home
apley’s compression and distraction
McMurray’s
32 yo male soccer player presents with knee pain. He injured his knee while playing soccer 2 days ago. Along with the knee pain he has swelling, popping and locking of the knee. no ortho tests could be done due to swelling and pain.
what would be the initial treatment
recommend crutches to remove weight
refer to an orthopedist
recommend bracing the knee
32 yo male soccer player presents with knee pain. He injured his knee while playing soccer 2 days ago. Along with the knee pain he has swelling, popping and locking of the knee. no ortho tests could be done due to swelling and pain.
what is the best course of action in the subacte phase?
progress to weight bearing
derotation knee brace
proprioceptive training (not open chain quad exercises with resistance because this is just rehab phase)
56 yo female presents with neck pain for the past month. The pain radiates to the left arm into the thumb and index finger. The patient has weak wrist extensors. Cervical compression and distraction is positive. X-ray of military neck.
What is the condition?
C6 nerve entrapmetn
56 yo female presents with neck pain for the past month. The pain radiates to the left arm into the thumb and index finger. The patient has weak wrist extensors. Cervical compression and distraction is positive. X-ray of military neck.
Additional clinical findings
positive bakody test
hyporeflexia of brachioradialis
decreased sensation over lateral forearm
56 yo female presents with neck pain for the past month. The pain radiates to the left arm into the thumb and index finger. The patient has weak wrist extensors. Cervical compression and distraction is positive. X-ray of military neck.
Diagnosis?
peripheral nerve entrapment
C6 nerve root lesion
C5/6 IVF encroachment
56 yo female presents with neck pain for the past month. The pain radiates to the left arm into the thumb and index finger. The patient has weak wrist extensors. Cervical compression and distraction is positive. X-ray of military neck.
Management
perform cervical traction with slight flexion
adjust
Order NCV study
55 yo male comes to you with back and abdominal pain. Abdominal pain occurs when his grandson sits on his abdomen. He has difficulty sitting up. The SLR test causes pain reproduction at 85 degrees.
What is the condition?
AAA
55 yo male comes to you with back and abdominal pain. Abdominal pain occurs when his grandson sits on his abdomen. He has difficulty sitting up. The SLR test causes pain reproduction at 85 degrees.
physical exam?
abdominal auscultation on abdomen
abdominal pulsations over
abdominal pain upon exertion
55 yo male comes to you with back and abdominal pain. Abdominal pain occurs when his grandson sits on his abdomen. He has difficulty sitting up. The SLR test causes pain reproduction at 85 degrees.
case history
long history of smoking
hyperlipidemia
male gender
55 yo male comes to you with back and abdominal pain. Abdominal pain occurs when his grandson sits on his abdomen. He has difficulty sitting up. The SLR test causes pain reproduction at 85 degrees.
management
refer to an ER
Evaluation with diagnostic US
Defer chiropractic care.
55 yo male comes to you with back and abdominal pain. Abdominal pain occurs when his grandson sits on his abdomen. He has difficulty sitting up. The SLR test causes pain reproduction at 85 degrees.
3 ways to confirm diagnosis
send to vascular specialist
send out for MRA
send out for CT scan
22 yo with back pain. Right rib humping and lower right PSIS. There is no change in the curve with forward flexion.
Causes?
hemivertebra
vertebral bar
physiological short leg
22 yo with back pain. Right rib humping and lower right PSIS. There is no change in the curve with forward flexion.
likely clinical findings
genitourinary problems
gastrointestinal problems
cardiac problems
22 yo with back pain. Right rib humping and lower right PSIS. There is no change in the curve with forward flexion.
what would be associated if the curve was switched to the left
arnold chiari formation
syringomyelia
spinal cord tumor
32 yo male with low back pain following surgery 2 weeks ago. Nothing has been palliative. Temperature of 100.6. X-ray of discitis.
Differential diagnosis?
Osteomyelitis
discitis
post surgical infection
32 yo male with low back pain following surgery 2 weeks ago. Nothing has been palliative. Temperature of 100.6. X-ray of discitis.
Labs?
increased ESR
increased WBC
Increased CRP
32 yo male with low back pain following surgery 2 weeks ago. Nothing has been palliative. Temperature of 100.6. X-ray of discitis.
sequelae?
pyemic abscess
septicemia
septic arthritis
24 yo male with LBP after throwing a bag of cement over his right shoulder. Experiencing bilateral leg weakenss and difficulty voiding. Worse with flexion and standing 8-9/10. 1+/4 patellar reflexes.
Positive orthopedic tests?
Bilateral SLR
Milgrams
D’s triad
(no tests are unilateral because this is a bilateral problem)
24 yo male with LBP after throwing a bag of cement over his right shoulder. Experiencing bilateral leg weakenss and difficulty voiding. Worse with flexion and standing 8-9/10. 1+/4 patellar reflexes.
Diagnosis
cauda equina
central lesion
LMNL
24 yo male with LBP after throwing a bag of cement over his right shoulder. Experiencing bilateral leg weakenss and difficulty voiding. Worse with flexion and standing 8-9/10. 1+/4 patellar reflexes.
Signs and symptoms
fasiculations
saddle paresthesia
decreased sensation over the medial malleoli
60 yo male presents with dull achy low back pain. Has increased alkaline phosphatase, normal calcium and protein levels. 2 x-rays provided - one was a missing pedicle.
Diagnosis?
Lytic metastasis
Osteopenia
Multiple Myeloma
60 yo male presents with dull achy low back pain. Has increased alkaline phosphatase, normal calcium and protein levels. 2 x-rays provided - one was a missing pedicle.
Radiological findings
Missing pedicle
anterior body height loss
loss of post body height (goes with CA)
infection (possibly due to one of the -xrays and ruling out the other answers)
60 yo male presents with dull achy low back pain. Has increased alkaline phosphatase, normal calcium and protein levels. 2 x-rays provided - one was a missing pedicle.
future problems of this disease?
nocturnal pain
splenomegaly
normocytic normochromic anemia
34 yo male presents with pain in the right buttock that radiates to the right foot. HE cannot sit due to the pain. Pain is worse with activity and internal rotation. Patella reflex is 2+.
What is your diagnosis?
piriformis syndrome
sciatica
nerve entrapment
34 yo male presents with pain in the right buttock that radiates to the right foot. HE cannot sit due to the pain. Pain is worse with activity and internal rotation. Patella reflex is 2+.
what will increase the pain?
hip internal rotation
sitting
adducting the hip
34 yo male presents with pain in the right buttock that radiates to the right foot. HE cannot sit due to the pain. Pain is worse with activity and internal rotation. Patella reflex is 2+.
treatment
adjust sacrum
trigger point therapy
myofascial release
43 yo male with buttock pain that the outside right toe for the past 2 days. Bechterew’s positive. Toe walk on the right positive. Adams produces pain both in supported and unsupported. well-leg, valsalva, and braggards are positive.
X-ray shows DJD throughout lumbar spine.
Initial treatment?
cryotherapy
trial of adjusting
extension exercises
43 yo male with buttock pain that the outside right toe for the past 2 days. Bechterew’s positive. Toe walk on the right positive. Adams produces pain both in supported and unsupported. well-leg, valsalva, and braggards are positive.
X-ray shows DJD throughout lumbar spine.
associated clinical findings
weak foot eversion
weak achilles reflex
weak big toe plantarflexion
43 yo male with buttock pain that the outside right toe for the past 2 days. Bechterew’s positive. Toe walk on the right positive. Adams produces pain both in supported and unsupported. well-leg, valsalva, and braggards are positive.
X-ray shows DJD throughout lumbar spine.
if untreated what neurological signs will be present
atrophy of the gastrocnemius
fasciculations in the gastrocnemius
absent ankle reflex
36 yo male presents with headaches and neck pain that is getting worse 3-6/10. Has slightly decreased ROM and anterior head carriage. X-ray of occipitalization and congenital block of C2/3.
radiological findings?
occipitalization
congenital block
rudimentary disc
36 yo male presents with headaches and neck pain that is getting worse 3-6/10. Has slightly decreased ROM and anterior head carriage. X-ray of occipitalization and congenital block of C2/3.
Additional clinical findings?
Tension headache
Wasp waist deformity
Hypertonic pectoralis muscle
36 yo male presents with headaches and neck pain that is getting worse 3-6/10. Has slightly decreased ROM and anterior head carriage. X-ray of occipitalization and congenital block of C2/3.
treatment?
Ergonomics re-training
Postural exercises
Myofascial release
24 yo male. Hand x-ray showing multiple lytic expansile lesions.
Differential Diagnosis?
Benign bone tumor
Multiple Enchondromas
Ollier’s disease
24 yo male. Hand x-ray showing multiple lytic expansile lesions. D
Radiographical findings?
Geographical lesions
Cortical thickening
Expansion
24 yo male. Hand x-ray showing multiple lytic expansile lesions.
Sequalae
Malignant degeneration
Pathological fracture
45 yo female over weight, findings of diabetes. Unsteady on feet.
Associated clinical findings?
Ketones in the urine
Glucosuria
Polyuria
45 yo female over weight, findings of diabetes. Unsteady on feet.
Other findings
Decreased wound healing
Increased vaginal infections
45 yo female over weight, findings of diabetes. Unsteady on feet.
Advice you would give the patient
Co-treat with an endocrinologist
Low glycemic diet
Swimming for exercise (b/c unsteady on her feet so increase physical activity and exercise is NOT the answer)
17 yo swimmer with shoulder pain between 70-100 degrees abduction. Patient has cafe-au-lait spots on the back of her shoulder. X-ray shows eccentric lesion in the proximal humerus.
Differential Diagnosis?
Fibrous dysplasia
Benign bone tumor
Supraspinatus tendinitis
17 yo swimmer with shoulder pain between 70-100 degrees abduction. Patient has cafe-au-lait spots on the back of her shoulder. X-ray shows eccentric lesion in the proximal humerus.
Management?
Refer to an orthopedist
Treat only with symptoms
Exercises to strengthen the shoulder
17 yo swimmer with shoulder pain between 70-100 degrees abduction. Patient has cafe-au-lait spots on the back of her shoulder. X-ray shows eccentric lesion in the proximal humerus.
Sequelae?
Bone deformity
Skin lesions
Adhesive capsulitis
210 lbs male 5’5” insidious onset of burning pain in the lateral thigh. Reflexes are 2+ bilaterally.
Differential diagnosis?
Peripheral entrapment
Lateral femoral cutaneous nerve involvement
L2 neuropathy
L1 neuropathy
210 lbs male 5’5” insidious onset of burning pain in the lateral thigh. Reflexes are 2+ bilaterally.
Initial recommendations
Wear losser fitting clothing
Weight loss
Chiropractic adjustments
210 lbs male 5’5” insidious onset of burning pain in the lateral thigh. Reflexes are 2+ bilaterally.
If there is a decrease in DTR pick 3 differential diagnosis
Nerve root encroachment
Disc lesion
Polyneuropathy
30 yo male with insidious low back pain that has gradually increased over the last 3 months. Has pain in the calcaneal tendon, red eyes, and a lesion in the mouth. X-ray showing sacroiliitis.
Differential diagnosis?
Reiters
Reactive arthritis
Polyarthritis
30 yo male with insidious low back pain that has gradually increased over the last 3 months. Has pain in the calcaneal tendon, red eyes, and a lesion in the mouth. X-ray showing sacroiliitis.
Follow up tests
HLA-B27
ESR
Chlamydia culture
30 yo male with insidious low back pain that has gradually increased over the last 3 months. Has pain in the calcaneal tendon, red eyes, and a lesion in the mouth. X-ray showing sacroiliitis.
Sequelae
Knee arthritis Genital lesions Aphthous stomatitis Red painful nodules on the hands and feet Anterior uveitis (an initial finding)
22 yo x-ray of AS
Radiographical findings?
Shiny corner sign
Trolley track
Dagger sign
22 yo x-ray of AS
Differential diagnosis
Ankylosing spondylitis Psoriatic arthritis Enteropathic arthritis (AS with diarrhea) Osteitis condensans ilii Reactive arthritis
22 yo x-ray of AS
Progression
Anderson lesion
Carrot stick fracture
Anterior uveitis
41 yo female with chronic shoulder pain. Positive Apleys scratch and impingement. Pain with overhead activities. X-ray shows multiple soft tissue calcification in the shoulder.
Diagnosis?
Supraspinatus calcification
Impingement syndrome
HADD
Osteochondrosis
41 yo female with chronic shoulder pain. Positive Apleys scratch and impingement. Pain with overhead activities. X-ray shows multiple soft tissue calcification in the shoulder.
What would be observed?
Positive Empty can
Positive codman’s
Pain and swelling around shoulder joint
Positive Neers
41 yo female with chronic shoulder pain. Positive Apleys scratch and impingement. Pain with overhead activities. X-ray shows multiple soft tissue calcification in the shoulder.
What would be done in the REHAB phase
Codmans exercises Strengthen external rotators Transverse friction massage Continuous US (in SUBACUTE) Strengthen deltoid
62 yo male with low back pain adn has difficulty initiating urination and reports polyuria at night. X-ray ivory VB
Labs?
Increased PSA
Increased Acid Phosphatase
Increased Alkaline Phosphatase
62 yo male with low back pain adn has difficulty initiating urination and reports polyuria at night. X-ray ivory VB
Most likely cause
Pagets
Blastic mets
Hodgkins
62 yo male with low back pain adn has difficulty initiating urination and reports polyuria at night. X-ray ivory VB
Best follow up
Refer to oncologist
MRI prostate
Radionucleide scan
CT spine
24 yo female malar rash…scleroderma findings. X-ray Calcinosis cutis.
Diagnosis?
Calcinosis cutis
Systemic sclerosis
Acro-osteolysis
24 yo female malar rash…scleroderma findings. X-ray Calcinosis cutis.
Associated conditions
Raynaud phenomenon
Skin hardening
+ANA
24 yo female malar rash…scleroderma findings. X-ray Calcinosis cutis.
Sequela
Gastroesophageal problems
Pulmonary fibrosis
Dysphagia
Neurogenic arthropathy
19 yo SLE.
Labs?
ANA Anti-DNA Thrombocytopenia Leukopenia Urobilinogen
19 yo SLE.
Other findings
Malar rash
Discoid lesion
Alopecia
Telangectasia
19 yo SLE.
Case management
Chiropractic adjustments
Avoid sun
Activities to tolerance
14 yo female, 2 month history of LBP, worse after playing volleyball. Ice makes it feel better. Hyperlordosis is present. X-ray Spondy
3 other tests expected to be positive
Kemps
Yeoman
Standing stork
(All extension)
14 yo female, 2 month history of LBP, worse after playing volleyball. Ice makes it feel better. Hyperlordosis is present. X-ray Spondy
3 best Initial treatment options
Anti-lordotic bracing
Cryotherapy
Temporarily restrict activity
14 yo female, 2 month history of LBP, worse after playing volleyball. Ice makes it feel better. Hyperlordosis is present. X-ray Spondy
3 muscles to strengthen to prevent further injury
Hamstrings
Rectus abdominus
Obliques
(Want to stretch psoas, erectors, and quads0
46 yo typist progressively worse headaches and neck pain. Decreases flex ext in cervicals and anterior head carriage. X-ray congenital block
3 relevant radiographical findings
Wasp waist
Rudimentary disc
Congenital stenosis
46 yo typist progressively worse headaches and neck pain. Decreases flex ext in cervicals and anterior head carriage. X-ray congenital block
3 best diagnosis
Tension headache
Congenital block
Postural syndrome
46 yo typist progressively worse headaches and neck pain. Decreases flex ext in cervicals and anterior head carriage. X-ray congenital block
3 best treatments
Ergonomic retraining
Strengthen deep neck flexors
Adjust C spine
17 yo male with neck stiffness
X-ray osteoblastoma obliterating C2 spinous
Most likely diagnosis?
ABC
Osteoid osteoma
Osteoblastoma
17 yo male with neck stiffness
X-ray osteoblastoma obliterating C2 spinous
Likely associated signs
Decreased ROM
Muscle splinting
Painful scoliosis
17 yo male with neck stiffness.
X-ray osteoblastoma obliterating C2 spinous
Likely sequelae
Hyperreflexia
Spinal canal stenosis
Decreased dorsal column function
19 yo female with vertigo. Less symptoms when seated, worse with standing. Very low BP 107/70. No overt neuro findings. Feels better overall when not moving.
Differential diagnosis
Menderes disease
Benign positional vertigo
Vertebral basilar artery insufficiency
19 yo female with vertigo. Less symptoms when seated, worse with standing. Very low BP 107/70. No overt neuro findings. Feels better overall when not moving.
Initial treatments
Perform Epley maneuver
Rule out intercranial pathology
Canalith repositioning
19 yo female with vertigo. Less symptoms when seated, worse with standing. Very low BP 107/70. No overt neuro findings. Feels better overall when not moving.
Associated signs of this condition
Nausea
Loss of balance
Horizontal nystagmus
30 yo female with insidious onset of right knee pain, popliteal fossa pain, inflammations, swelling, no history of trauma. Additionally there is swelling/redness in the PIP joints bilaterally. MRI - gnarly knee with lots of fluid.
Most likely dx
Bakers cyst
RA
Inflammatory arthritis
30 yo female with insidious onset of right knee pain, popliteal fossa pain, inflammations, swelling, no history of trauma. Additionally there is swelling/redness in the PIP joints bilaterally. MRI - gnarly knee with lots of fluid.
Additional tests
RA latex
Hand films
Joint aspiration
(DO NOT take a flex/ext on every RA latex patient unless have neck complaint)
30 yo female with insidious onset of right knee pain, popliteal fossa pain, inflammations, swelling, no history of trauma. Additionally there is swelling/redness in the PIP joints bilaterally. MRI - gnarly knee with lots of fluid.
Most appropriate treatment
Knee brace
Lap swimming in warm water
Co-manage with rheumatologist
42 yo male slams foot in door. Red swollen and has shiny skin. X-ray of a foot (CRPS)
Which of the following is responsible in this case
RCPS (sudeck’s atrophy)
Peripheral vascular disease
Disuse atrophy
42 yo male slams foot in door. Red swollen and has shiny skin. X-ray of a foot (CRPS)
Best treatment
Sympathetic nerve block
TENs for pain
Corticosteroids
42 yo male slams foot in door. Red swollen and has shiny skin. X-ray of a foot (CRPS)
3 additional findings
Hyperesthesia Hypertrichosis Muscle weakness Severe burning pain Swelling Atrophy go skin over affeced area Localized osteopenia
30 yo male shoulder pain after pitching cattle feed out of his truck 1 week ago. Previous supraspinatus surgery 2 years ago. Shoulder abduction at >90 decreased pain. Limited F/E. Positive speeds test, 4/5 muscle test, negative yergasons, empty can and wrights.
Differential diagnosis
Biceps tendinitis
Subdeltoid bursitis
SLAP lesion
30 yo male shoulder pain after pitching cattle feed out of his truck 1 week ago. Previous supraspinatus surgery 2 years ago. Shoulder abduction at >90 decreased pain. Limited F/E. Positive speeds test, 4/5 muscle test, negative yergasons, empty can and wrights.
Initial follow up
MRI (b/c previous surgery)
Biceps isometric exercises
Limit overhead movement
30 yo male shoulder pain after pitching cattle feed out of his truck 1 week ago. Previous supraspinatus surgery 2 years ago. Shoulder abduction at >90 decreased pain. Limited F/E. Positive speeds test, 4/5 muscle test, negative yergasons, empty can and wrights.
How to prevent in the future
Isometric curls
Strengthen rotator cuff
Ergonomic education
45 male ecchymosis, pain, swelling, decreased ROM, rolled ankle 2 weeks ago. X-ray foot with fx at 5th metatarsal (jones/dancers fx)
Initial treatment
Refer to an orthopedist
Ice
Crutches
45 male ecchymosis, pain, swelling, decreased ROM, rolled ankle 2 weeks ago. X-ray foot with fx at 5th metatarsal (jones/dancers fx)
Rehab?
Wobble board
Eversion exercise
Orthotics
45 male ecchymosis, pain, swelling, decreased ROM, rolled ankle 2 weeks ago. X-ray foot with fx at 5th metatarsal (jones/dancers fx)
Complications
Non-union fracture
Peroneus brevis weakness
Excessive bony deformity
67 yo female swollen hot painful joints, gradual onset. Worse with activity past 3 weeks. X-ray of DIP and PIP involvement.
Differentials
Inflammatory OA
Erosive OA
DJD
67 yo female swollen hot painful joints, gradual onset. Worse with activity past 3 weeks. X-ray of DIP and PIP involvement.
Radiographic findings
Gull wing
Sclerosis
Osteopenia
67 yo female swollen hot painful joints, gradual onset. Worse with activity past 3 weeks. X-ray of DIP and PIP involvement.
Initial management
Paraffin bath
Immobilization
Recommend glucosamine and chondroitin sulfate
82 yo female sudden LBP while gardening. Palliative ice. 8/10. X-ray of lateral lumbar with calcified aorta (smaller than VB)
Radiographical findings
DJD
Atherosclerotic plaquing
Osteopenia
82 yo female sudden LBP while gardening. Palliative ice. 8/10. X-ray of lateral lumbar with calcified aorta (smaller than VB)
Initial tests
DEXA
CT
Abdominal US
82 yo female sudden LBP while gardening. Palliative ice. 8/10. X-ray of lateral lumbar with calcified aorta (smaller than VB)
Treatment
Elastic lumbar support
Adjust lumbars
Limit some physical activities
56 yo male lower thoracic pain started 1 year ago made worse with activity. X-ray of DISH on lateral thoracic.
Radiographic findings
Osteophyte bridging
ALL calcification
DISH
56 yo male lower thoracic pain started 1 year ago made worse with activity. X-ray of DISH on lateral thoracic.
Sequelae
Dysphagia and hoarseness
Peripheral neuropathy
Ketonuria
56 yo male lower thoracic pain started 1 year ago made worse with activity. X-ray of DISH on lateral thoracic.
Next step or follow up
Monitor glucose levels
Corticosteroids
Strengthen erector spinae muscles
32 yo female bilateral leg weakness, vertigo, recent bladder problem. Hx of smoking 10 years. Positive babinski. Negative SLR. Positive L’Hermittes. ROM WNL.
Follow up
Refer to neurologist
CSF exam
Brain MRI
32 yo female bilateral leg weakness, vertigo, recent bladder problem. Hx of smoking 10 years. Positive babinski. Negative SLR. Positive L’Hermittes. ROM WNL.
Associated signs
+3 DTR
Visual disturbances
Fasciculations (this is the only UMNL you’ll see this with)
32 yo female bilateral leg weakness, vertigo, recent bladder problem. Hx of smoking 10 years. Positive babinski. Negative SLR. Positive L’Hermittes. ROM WNL.
Sequelae
Scanning speech Intention tremors Nystagmus Tonic clonic seizures Cognitive impairment
27 yo female insidious foot pain after wearing new shoes. Dull ache 4-7/10 pain at 3rd metatarsal head and swelling. X-ray of foot with sclerotic 3rd MTP.
Diagnosis
Freiburgs disease
Osteochondritis (aka AVN)
Bone infarction
27 yo female insidious foot pain after wearing new shoes. Dull ache 4-7/10 pain at 3rd metatarsal head and swelling. X-ray of foot with sclerotic 3rd MTP.
Initial treatment
Weight unloading
Immobilization
Boot cast
27 yo female insidious foot pain after wearing new shoes. Dull ache 4-7/10 pain at 3rd metatarsal head and swelling. X-ray of foot with sclerotic 3rd MTP.
Sequelae
Chronic metatarsalgia
Joint degeneration
Foot deformity
32 yo female with neck pain and bilateral suboccipital headache. Made worse with emotional stress and worse. She has AHC.
Differential diagnosis
Cervicogenic headache
Tension headache
Upper cross syndrome
32 yo female with neck pain and bilateral suboccipital headache. Made worse with emotional stress and worse. She has AHC.
WOTF muscles needs to be strengthened
Longus colli
Serratus anterior
Rhomboids
32 yo female with neck pain and bilateral suboccipital headache. Made worse with emotional stress and worse. She has AHC.
WOTF muscles needs to be stretched
Pectoralis major
Levator scapulae
Scalene
42 yo male LBP, diabetic taking metformin. Kemps produces localized low back pain in every direction. X-ray 3 blastic vertebrae;, cloudy appearance where the pancreas should be.
Labs you would expect to be positive?
Alkaline phosphatase
Lipase
Amylase
42 yo male LBP, diabetic taking metformin. Kemps produces localized low back pain in every direction. X-ray 3 blastic vertebrae;, cloudy appearance where the pancreas should be.
Sequelae
Jaundice
Neuropathy
Metastatic disease
42 yo male LBP, diabetic taking metformin. Kemps produces localized low back pain in every direction. X-ray 3 blastic vertebrae;, cloudy appearance where the pancreas should be.
Follow up
Chemotherapy
Therapeutic radiation
Specific pancreases treatment
31 yo female with neck pain and weakness in the upper extremity. Recently involved in an MVA where she was rearended at 50 mph. No ROM due to pain. Positive shoulder depressor and jacksons. felt like running water going down her upper shoulders during pinwheel examination. Normal vibration and joint sense. X-ray of a tear drop fracture.
Diagnosis
Tear drop fracture
Whiplash associated disorder
Anterior cord syndrome
31 yo female with neck pain and weakness in the upper extremity. Recently involved in an MVA where she was rearended at 50 mph. No ROM due to pain. Positive shoulder depressor and jacksons. felt like running water going down her upper shoulders during pinwheel examination. Normal vibration and joint sense. X-ray of a tear drop fracture.
Treatment
Refer to ER
Cervical collar
NSAIDs
31 yo female with neck pain and weakness in the upper extremity. Recently involved in an MVA where she was rearended at 50 mph. No ROM due to pain. Positive shoulder depressor and jacksons. felt like running water going down her upper shoulders during pinwheel examination. Normal vibration and joint sense. X-ray of a tear drop fracture.
Associated cervical findings
Can’t feel hot/cold in forearms
4/5 muscle strength
Paraspinal muscle splinting
