Week 1- Medical Screening & Cervicothoracic Region

Question 1

What is always the first component of the evaluation?

Answer 1

• Medical screening for red/yellow flags

Question 2

MSK conditions to screen for in the cervical spine

Answer 2

• Cervical fracture
• Cervical myelopathy
• Upper cervical ligamentous laxity
• Spinal infection

Question 3

Cardiovascular conditions to screen for in the cervical spine

Answer 3

• Cardiovascular event (myocardial infarction)

- Cervical arterial dysfunction

Question 4

Pulmonary conditions to screen for in the cervical spine

Answer 4

• Pulmonary event
• Pneumothorax
• Pulmonary embolism

Question 5

High-risk factors for cervical fracture

Answer 5

• > /= 65 y
• Dangerous MOA
• Upper extremity parasthesia

Question 6

What is considered a “dangerous MOA”?

Answer 6

• Fall from 3+ ft/5stairs
• Axial load
• MVC at 60+ mph, rollover/ejection
• Motorized rec vehicle accident
• Bike collosion

Question 7

What are low-risk factors for cervical fracture?

Answer 7

• Simple rear-end MVC
• Sitting position in external rotation
• Ambulatory at any time
• Delayed-onset neck pain
• Absence of midline C-spine tenderness

Question 8

What conditions need to be met to refer for imaging of cervical spine for fracture?

Answer 8

• “Yes” for high-risk factors
• “No” for low-risk factors
• Unable to rotate neck 45 degrees L/R

Question 9

What is cervical myelopathy?

Answer 9

-

Question 10

Mechanical causes of cervical myelopathy

Answer 10

• Trauma (ligament instability, fracture)
• Spinal cord compression
• Degenerative changes
• Bulging disks, thickened ligamentum flavum
• RA with subsequent atlanto-axial subluxation

Question 11

Cervical myelopathy systemic causes

Answer 11

• MS, ALS
• Guillain-Barre
• Multifocal motor myopathy

Question 12

5 tests included in cervical myelopathy CPR

Answer 12

• Gait deviation
• • Hoffman’s test
• Inverted supinator sign
• • Babinski test
• > 45 years

Question 13

What is considered a red flag for cervical myelopathy?

Answer 13

3/5 positive CPR tests

Question 14

Signs and symptoms for upper cervical ligamentous laxity

Answer 14

• Occipital headache & numbness
• Severe limitation during neck
  AROM in all directions
• Signs of cervical myelopathy

Question 15

Causes of upper cervical ligamentous laxity

Answer 15

• Trauma
• RA with atlanto-axial subluxation
• Down Syndrome
• Klippel-Feil
• Os odontoideum
• Odontoid fracture

Question 16

Signs and symptoms of a spinal infection

Answer 16

• Unrelenting spine pain
• Worse/severe pain at night (no change w/ positional changes)
• Hx of DM, SCI w/ neurogenic bladder, immune suppression
• Potential fever, chills, fatigue
• Concurrent infections or IV drug use
• Possible redness, swelling, warmth
• Local tenderness over spinous processes
• Spinal percussion painful

Question 17

What to do in case of a spinal infection

Answer 17

Refer for imaging and clinical lab tests

Question 18

Treatment for spinal infection

Answer 18

• Antibiotic therapy

- Surgical decompression

Question 19

Signs and symptoms for cardiovascular event

Answer 19

• Chest pain (gripping, pressure)
• Abdominal pain
• Shortness of breath
• Heart palpitations
• Irregular heartbeat
• Dizziness, nausea
• Peripheral edema
• Syncope

Question 20

MSK complaints indicating a cardiovascular event

Answer 20

• Jaw, neck, shoulder, arm, & back pain
• Myalgias, muscular fatigue, & muscle
  atrophy
• Weakness & fatigue
• Poor exercise tolerance

Question 21

5 D’s AND 3 N’s indicating arterial dysfunction

Answer 21

- Dizziness or lightheadedness	
related to neck movement
- Drop attacks
- Dysphagia
- Dysarthria
- Diplopia
- Ataxia
- Nausea
- Numbness
- Nystagmus

Question 22

Pain Descriptors for a Pulmonary Event

Answer 22

• Sharp, localized pain
• Aggravated by breathing,
  coughing, sneezing, laughing, etc.
• Better in upright/worse recumbent
• Better with auto splinting

Question 23

Signs and Symptoms for Pulmonary Event

Answer 23

• Dyspnea/shortness of breath (at rest or exertional)
• Persistent cough
• Fevers, chills, general malaise
• Weak, rapid pulse with fall in BP (pneumothorax)
• Cyanosis

Question 24

Signs and Symptoms of a Pneumothorax

Answer 24

• Shortness of breath, dry cough
• Acute onset sharp pain in the chest (upper & lateral chest wall)
• Can refer to ipsilateral shoulder/upper trapezius region, across chest, to the scapular region, and to the abdomen
• Change in respiratory movements
• Drop in blood pressure, increased venous distension in neck
• More pain in recumbent positions/better in sitting

Question 25

Predictor variables for pulmonary embolism

Answer 25

- Clinical signs and symptoms of DVT (3.0) - No alternative diagnosis (3.0) - Heart rate >100 bpm (1.5) - Immobilization following surgery in the past 4 weeks (1.5) - Previous DVT/PE (1.5) - Hemoptysis (1.0) - Malignancy (treated currently, in the last 6 months, or palliative) (1.0)

Question 26

Levels of risk and probability of pulmonary embolism

Answer 26

- >2.0 pts = Low Risk = 3.6% probability - 2.0 - 6.0 pts = Moderate Risk = 20.5% probability - >6.0 pts = High Risk = 66.7% probability

Question 27

Where will pancreas issues refer to?

Answer 27

- Left shoulder - Anterior central abdomen - Posterior thoracic region

Question 28

Where are issues if there is pain in the posterior thoracic region?

Answer 28

Issues in the esophagus, liver, gallbladder, common bile duct, and pancreas

Question 29

Where are issues if there is pain in the right shoulder region?

Answer 29

Issues in the stomach, duodenum, liver, gallbladder, and common bile duct

Question 30

Signs and symptoms for stomach, duodenal, or pancreatic conditions

Answer 30

- Gnawing, cramping, burning, “heartburn”, aching - Constant or sudden onset, weight loss, nausea, vomiting, fever, malaise - May have pain in waves or may be related to eating or drinking in timing - Early satiety, black “tarry” or light colored stools (pancreatic cancer)

Question 31

Causes of stomach, duodenal, and pancreatic conditions

Answer 31

- Gastric, pyloric, or duodenal ulcers | - Stomach cancer

Question 32

Where will kidney/renal issues refer to?

Answer 32

- Left inguinal region - Posterior QL region - Left shoulder

Question 33

Where is the common site of metastases?

Answer 33

Skeleton - 60% thoracic - 40% lumbosacral - Rare in C-spine

Question 34

What is the "lead kettle" mnemonic?

Answer 34

PB KTLL - Prostate - Breast - Kidney - Thyroid - Lung - Lymphoma

Question 35

Cancers most commonly affecting the cervico-thoracic spine

Answer 35

- Thyroid & esophageal cancer - Hodgkin's lymphoma - Pancoast's tumor - Multiple myeloma - Breast cancer - Other organ cancers that can refer to the T-spine

Question 36

What predicts cancer in patients?

Answer 36

- Age >/= 50 - Unexplaiined weight loss - Previous Hx of cancer - Failure to improve over 1 month - 100% sensitive

Question 37

Common Risk Factors for Depression

Answer 37

- Current/past hx of major depression - Family hx of major depressions (first degree relative) - Hx of MI, CA, CVA, substance abuse/dependency, obesity, CHF, dementia, or DM - Currently suffering from significant loss or change in social status - Pregnant or post-partum - Fatigue or sleep disturbance, fatigue, weight change - Women > men - Chronic pain or 2+ chronic diseases

Question 38

Depression screen questions?

Answer 38

- Over past 2 weeks, have you felt down, depressed, or hopeless? - Over past 2 weeks, have you felt little interest or pleasure in doing things? - Do you want help?

Question 39

Suicide risk factors

Answer 39

- Family hx of suicide attempts - Sense of hopelessness - Previous attempt or plan - Hx of chronic progressive illness - Recent significant loss - Unemployment - Widowed, divorced, or living alone - Hx of psychiatric illness - Sex (males higher rate of completion; females higher attempt rate) - Recent interpersonal struggle - Presence of firearms in home (for teens)