Exam 1 CR

What aspects of the PE should be done for back pain

Gen

CV and Pulm

MSK

Neuro (Motor, Sensation, Reflex)

Consider PV, Abdominal, and Rectal

Straight Leg Raise Test

An special MSK test done for lower back pain

Patient is placed supine with legs straight while examiner passively raises the leg and dorsiflexes the foot

Reproduction of pain = Lumbar radulopathy

FABER Test

A special test done for the hip

Patient is placed supine with leg in the 4-figure position (Flexed, abducted, and external rotation) while examiner stablizies opposing illium and apply downward pressure on the knee

Reproduction of pain = Hip Instability

Kemp’s Test

A special test for lumbar back pain

Patient is standing while examiner stabilizes the opposing illum then extends, lateral flexes, and rotates the upper body

Reproduction of pain = Facet Joint Pathology

Yeoman’s Test

A special test done for the lower back pain

Patient is placed prone while examiner pushes down on the SIJ and on the ipilateral leg, flexes the knee 90 degreee and extends the hip

Pain = SIJ instability

Criteria for Imaging for Lower Back Pain

Suspected caudia equina syndrome

Suspected malignancy

Suspected fracture

Suspected infection

No improvment after 6 weeks with conservative medical management and PT

Why is early MRI not used for radiculopathy with lower back pain

Increases number of surgeries and opioid use without benefits

What muscles support the SIJ

Gluteal muscles

Piriformis

What ligaments stabilize the SIJ

Iliolumbar Ligamnet

Sacrospinous

Sacrotuberous

Sacroiliac

Sacrococcygeal

Managment for SIJ Dysfunction

Activity as tolerated

Ice / Heat as tolerated

Should resolve in 4-6 weeks

Presentation of SIJ dysfunction

Painful gait

Discomfort with changing position (Sit to Stand)

Hypertonicity and tenderness of paraspinal and gluteal muscles

Pain on SIJ with limited ROM

Positive Yeoman’s Test

What medications can be SIJ instability

Topical Analgesics

Acetaminophen / NSAIDs

Muscle Relaxants

What is the education for chiropractic

Prerequisite 4 year degree

4 years of chiropractic program

What are the main subject areas for chiropractic programs

Gross anatomy

Neuro / Neuroanatomy

Nurition

Radiology and Advanced Imaging

Limited pharmacology

What are the parts of the board certification of chiropractic

Part 1: Basic Sciences

Part 2: Clinical Sciences

Part III: Clinical Competency

Part IV: Practical Skills

What must be done to maintain chiropractic license in PA

24 hours of CE for renewal

Professional liability insurance in minimum amount of $100k per occurance and $300k per annual aggregate

What issues are treated with chiropratic

Back/Neck Pain

Radiculopathy

Headache

Pregnancy-related back pain

Sport and Work injury

What are the benefits of chiropractic care for lower back pain

Modest improvement to pain for acute

Improved funciton for acute

Reduces pain and improevs function for chronic

What are the modalities of chiropractic care

High-Velocity/Low-Amplitude CMT

Mobilization techniques

Instrument and Manually Assisted techniques

Myofascial Release

Traction and Distraction techniques

Physical Modalities

Rehabilitation and Exercise

What are the contraindications to using high velocity / low ampltiue CMT

Unstable fractures

Severe osteoporosis

Multiple myeloma

Osteomyelitis

Primary or metastatic bone tumors

Paget’s disease

Progressive or severe neurological deficit

Spinal cord tumors

Cauda equina syndrome and/or Myelopathy

Hyper mobile joints

Inflammatory phase ankylosing spondylitis

Reiter’s syndrome/Reactive Arthritis

Inadequate physical and spinal examination

Poor manipulative skills

What systems needs to be considered for chest pain

Cardiovascular

Pulmonary

Gastrointestinal

Dermatologic

Musculoskeletal

Psychiatric

What are the ddx for chest pain from cardiac

MI

Unstable angina

Thoracic aortic dissection

Stable angina

Pericarditis

What are the life threatening chest pain from cardiac

MI

Unstable angina

Thoracic aortic dissection

What are the ddx for chest pain from pulmonary

Tension pneumothorax

Pulmonary embolus

Bronchitis

Pneumonia

Simple pneumothorax

Lung cancer

What are the life threatening chest pain from pulm

Tension pneumothorax

Pulmonary embolus

What are the ddx for chest pain from GI

Boerhaave Syndrome

Esophageal spasm

Esophagitis

GERD

Gastritis

Peptic ulcer disease

Biliary tract disease

Pancreatitis

What are the life threatening chest pain from GI

Boerhaave Syndrome

What are the ddx for chest pain from derm

Herpes Zoster

What are the ddx for chest pain from MSK

Costochondritis

Muscle strain

Rib contusion/fracture

What are the ddx for chest pain from psych

Anxeity / Panic

Somatoform Disorder

What system is considered the dx of ex for chest pain

Psych

Aortic dissection

Tear between the intima & media layers of the aorta wall creates a false lumen

What are the regions of the thoracic aorta

Ascending

Arch

Descending

What are the layers of the aortic wall

Intima

Media

Adventitia

Where do aortic dissections most commonly occur

2cm above aortic root

At aortic arch

Just distal to left subclavian artery

DeBakey Classifications

The types of different aortic dissections

• DeBakey 1 = Involves ascending and descending

• DeBakey 2 = Ascending aorta only

• DeBakey 3 = Descending aorta only

What region of the thoracic aorta will usually require sugery for dissection

Ascending

What region of the thoracic aorta will usually be medically managed for dissection

Descending

All types of aortic dissections require what for inital management

Stabilizaiton

CT Surgery Consult

Standford Types

A typing system for aortic dissection

• Standford A = Any involvment of the ascending aorta

• Standford B = Desecnding aorta only

Risk Factors for Aortic Dissection

Uncontrolled HTN (#1)

Congenital aortic stenosis

Connective Tissue Disorders (Marfan/EDS)

Pregnant

Cocaine Use

FHx (First Degree Relative)

Presentation of Aortic Dissection

Sudden severe, tearing or ripping chest pain

Maximal severity at onset

radiates to the interscapular area

Neurologic symptoms

Abdominal pain

Extremity pain

BP is usually elevated

Asymmetric BP and Pulses between UE and LE

Aortic regurgitation

Pericardial tamponade

Work-Up for Aortic Dissections

CXR

EKG

CTA

TEE Beside

Study of Choice for Stable Aortic Dissections

CTA

Study of Choice for Unstable Aortic Dissections

TEE

What CXR findings can indicate aortic dissection

Blunting of the aortic knob

Apical cap

Pleural effusion

Tracheal deviation to the right

NG tube deviation to the right

Depression of the left mainstem bronchus

Benefits of CTA for Aortic Dissection

Indicates the location and extent of the dissection

Helps plan surgery

Risk of CTA for Aortic Dissection

Trransport of Potential Unstable Patient

IV Contrast Risks

What imaging study for aortic dissection can show aortic regurgitation and cardiac tamponde

TEE

Complications of Aortic Dissections

Rupture & exsanguination

Pericardial tamponade

Acute aortic regurgitation

Coronary artery dissection

Cerebral & spinal cord ischemia

Mesenteric, renal & limb ischemia

Managment of Aortic Dissection

Ascending = Medical then Surgical repair

Descending = Medical management

Manage effusions

What are complicating factors that increase severity of aortic dissection

Increasing size

Compromise of major aortic branches

Persistent pain

Bleeding into pleural cavity

Goal of Medical Management of Aortic Dissections

Decrease propagation of dissection

Decrease HR then BP rapidly

What are the goal vitals for aortic dissection

HR = 60

SBP = 100-120

What medications are given for aortic dissection

1st - Esomolol or Labetalol drip

2nd - Nitroprusside Drip

Why do we give esmolol before giving nitroprusside in aortic dissection

Prevention of reflex tachycardia

Why do we give morphine with nitroprusside for aortic dissection

Prevent pain-induced tachycardia and HTN

How are aortic dissections surgically managed

Patient placed on cardiopulmonary bypass

The affected layers of the aorta are sutured together

The aorta is reinforced with a Dacron graft

What increases likelihood of death during aortic repair for dissection

Aortic arch involvment

Where do we see aggression most commonly occur in healthcare

ED

Psych Units

Nursing Facility

Geriatrics

What is the best defense to agressive

Prevention

What can we do to prevent agressive incidients

Effective communication and active listening

Office / Unit Design

Recognition of high acuity

Crisis planning

Zero tolerance policy toward workplace violence

Controlled substance contracts

What should always be done at the start of every encounter

Visual assessment of your surroundings

What can the appearance of aggressive patients be?

Decline in grooming or bizarre dress indicating decompensation,

evidence of substance use,

getting red in the face

What can the behavior of aggressive patients be?

Uncooperative,

superficially cooperative with signs that there is a potential for escalation,

oppositional,

demanding

What can the eye contact of aggressive patients be?

Intese

What can the motor behavior of aggressive patients be?

Restless,

pacing,

squirming or shifting in seat,

tremor (withdrawal),

clenching fists

What can the speech behavior of aggressive patients be?

Loud, rapid,

pressured,

slurred,

changes such as starting to stutter

What can the thought process behavior of aggressive patients be?

Perseverative,

concrete,

illogical

What can the thought content behavior of aggressive patients be?

Cognitive distortions,

repeat themselves either due to perseveration or feeling as if they aren’t being heard,

starting to make accusations or indicate that they feel they aren’t being heard or don’t like something about the way they are being treated,

SI/HI,

hallucinations

persecutory delusions

What is your role with aggressive patients

Maintain safety

Minimize external stimuli

Be a calming, confident, reassuring, and non-judgmental presence

What is a safe distance from an agitated person

6 feet

Empathy-

the action of understanding, being aware of, and being sensitive to another’s emotions

Paraphrasing-

summarizing or restating what they said

Reflection-

pick up on an emotion they are expressing and reflect on this

When do you use open vs closed questions

Open- allow the person to vent and express themselves

Closed- allow you to elicit direct and concise answers when important information is needed

Broken record technique can help with what

there is important information you need to convey or something you need them to do

establishing limits/boundaries and making your position on a subject clear

How can you manage a patient in psychosis

You can validate their experience, offer assistance and even safety.

It’s okay to indicate you don’t hear voices.

Regarding delusions, you can indicate you don’t share their view, but are willing to help.

Generally, take a neutral but supportive stance.

How can you manage a patient in mania

Be clear, concise, and consistent in your communication.

Ask specific, concrete, and usually closed-ended questions when information is needed.

Redirect if possible.

Disengage if needed.

How can you manage a patient with sucidial/homicidal ideation

Active listening, empathy, reassurance, validation for feelings

Emphasize the temporary time-frame of crisis

Generate/suggest alternatives

Offer help and hope

How can you manage a patient with unreasonable demands

Be clear, concise, and consistent in your communication.

Set and maintain your limits/boundaries.

Redirect if possible.

Defer to office/hospital policy, DEA regulations, etc.

Defer to others involved (office manager, team meetings to discuss discharge, etc.)

Disengage if needed.

How can you manage a patient with AMS

Be clear, concise, and consistent in your communication.

Be patient and repeat yourself if needed.

Attempt to provide orientation.

Explain everything you are doing, especially if entering their space to provide medical care.

What are the manifestionation of COPD

Chronic Bronchitis

Emphysema

What characteristics make COPD more likely than asthma

Occurs later in adulthood & worsens with age

Strong link to smoking

Often symptomatic & abnormal exam between exacerbations

Limited reversibility

May be complicated by pulmonary hypertension & cor pulmonale

Much more likely to have CXR & EKG changes

Most common cause of COPD

Smoking

What are the characteristics of chronic bronchitis

Chronic productive cough- at least 3 months annually for 2 consecutive years

Excess mucus production (bronchorrhea), bronchospasm, & bronchial wall thickening

Initially reversible

Pulmonary hypertension leads to right heart failure

What are the characteristics of emphysema

Irreversible alveolar wall destruction leads to bleb/bullae formation simulating pneumothoraces

Results in tissue hypoxia & cachexia

What conditions mimics emphysema

Alpha-1-antitryspin deficinec

Presentation of COPD (Generally)

gradually over years- patients often compensate

Morning cough; sputum production;

chest tightness; dyspnea

Accessory muscle use/tripod position

Pursed lip breathing

What S/S are seen with chronic bronchitis COPD

Obese

JVD

Peripheral Edema

Hepatomegaly

What S/S are seen with emphysema COPD

Cachexia

Barrel Chest

Distant heart sounds

What CXR finding can indicate COPD

Hyperinflation

Long narrow heart

Flattened hemidiaphargms

Increased retrosternal air space

Blebs and bullae

What EKG findings are suspicious for COPD

Multi-focal Atrial Tachycardia

Right Axis deviation

RBBB

Right Atrial Enlargement

Right Ventricular Hypertrophy

Low Voltage

Multi-focal tachycardia

narrow complex, irregularly, irregular, tachycardia with at least 3 distinct p wave morphologies

How does MAT differ from A-fib

P waves are present and changing shape

What is the cornerstone of COPD dx

Spirometry

What value on spirometry screens for COPD

FEV1/FVC

At what level does FEV1/FVC indicate COPD

< 0.7

What value on spirometry indicates severity of COPD

FEV1 %

How do we gauge reversiblity of COPD

Perform spirometry pre and post bronchodilator