Part III Handouts Cleveland

CLEVELAND
NATIONAL BOARD REVIEW HANDOUTS
CHIROPRACTIC
PART III
COLLEGE
L OS ANGELES VERSION 1.0

CCCLA NATIONAL BOARD REVIEW

PART III – Version 1.0

TABLE OF CONTENTS

1. Extended Matching Case Questions p 3‐92 of 142

2. Compiled Fact Sheets p 93‐123 of 142

3. Miscellaneous Factoids p 124‐142 of 142

PATIENT INFORMATION
SEX: M AGE: 34
SUBJECTIVE FINDINGS:
CHIEF COMPLAINT: Right arm gets cold and hurts.
MECHANISM OF INJURY: Began insidiously 1 year ago
QUALITY OF PAIN: tingling, achy
SEVERITY OF PAIN: moderate
AGGRAVATING FACTORS: driving car; right lateral flexion of neck
ASSOCIATED SYMPTOMS: none
RELIEVING FACTORS: lying supine; left lateral flexion of neck
PAST MEDICAL HISTORY: non-contributory
FAMILY HISTORY: Mother had Hodgkin’s lymphoma
OBJECTIVE FINDINGS:
VITALS:
LEFT BP: 114/76 mmHg
RESP: 14 cpm
PULSE: 78 bpm
TEMP: 98.7ºF
RANGE OF MOTION:
Cervical ROM is WNL.
ORTHOPEDIC TESTING:
Cervical compression negative.
LABORATORY STUDIES:
N/A.
OTHER FINDINGS:
Right BP: 90/68 mmHg
Part III Handouts v.1.0 Page 3 of 142

Answer the following three (3) questions based on the patient
information provided on the previous page.
01 . Which orthopedic/neurologic tests do you expect to be positive? (CHOOSE 3)
A. Bracelet test E. Phalen
B. Adson test F. Costoclavicular test
C. Cervical distraction G. Hoffman sign
D. Wright test H. Babinski sign
02 . Which physical exam findings might you see? (CHOOSE 3)
A. Diminished pulses on right arm E. Hemoptysis
B. Edema of right arm F. Claw hand
C. Raynaud’s phenomenon G. Cough
D. Axillary lymphadenopathy H. Dyspnea
03 . Initial case management for this condition includes: (CHOOSE 3)
A. Referral to oncologist E. Run lab for CEA levels
B. Referral to cardiovascular specialist F. Cervical ROM exercises
C. Stretching of shortened muscles G. CMT
D. Cryotherapy H. Brugger’s postural exercise

01 . Which orthopedic/neurologic tests do you expect to be positive? (CHOOSE 3)
A. Bracelet test E. Phalen
B. Adson test F. Costoclavicular test
C. Cervical distraction G. Hoffman sign
D. Wright test H. Babinski sign
02 . Which physical exam findings might you see? (CHOOSE 3)
A. Diminished pulses on right arm E. Hemoptysis
B. Edema of right arm F. Claw hand
C. Raynaud’s phenomenon G. Cough
D. Axillary lymphadenopathy H. Dyspnea
03 . Initial case management for this condition includes: (CHOOSE 3)
A. Referral to oncologist E. Run lab for CEA levels
B. Referral to cardiovascular specialist F. Cervical ROM exercises
C. Stretching of shortened muscles G. CMT
D. Cryotherapy H. Brugger’s postural exercise

PATIENT INFORMATION
SEX: F AGE: 45
CHIEF COMPLAINT: Left shoulder pain and stiffness
MECHANISM OF INJURY: Insidious
QUALITY OF PAIN: Achy; sharp with movement
SEVERITY OF PAIN: 6/10
AGGRAVATING FACTORS: Movement; lying on either side
ASSOCIATED SYMPTOMS: Upper left arm pain
RELIEVING FACTORS: Moist heat
PAST MEDICAL HISTORY: fractured radius, age 7
FAMILY HISTORY: Diabetes; mother
OBJECTIVE FINDINGS:
VITALS: 45 y F
RESP: 14 cpm
PULSE: 80 bpm
TEMP: 98.6 F
RANGE OF MOTION:
Left shoulder abduction 60 degrees; external
rotation 5 degrees; flexion 60 degrees
ORTHOPEDIC TESTING:
Empty can and Lift-off unable to perform
LABORATORY STUDIES:
HbA1c 8.1 (elevated)
OTHER FINDINGS:
Left deltoid atrophy
L AP shoulder

01 . Select the three (3) best diagnoses for this patient. (CHOOSE 3)
A. Type 2 diabetes mellitus E. Rotator cuff syndrome
B. Disuse muscle atrophy F. Adhesive capsulitis
C. Iron deficiency anemia G. Shoulder dislocation
D. Clavicle fracture H. HADD
02 . Select the three (3) best case management strategies for this condition. (CHOOSE 3)
A. Cryotherapy E. Cold laser
B. Grade 5 mobilization of GH joint F. Iron supplements
C. Codman’s exercises G. Cardiovascular training
D. Wall-walking exercises H. Biceps curls
03 . Select the three (3) risk factors/causes for this shoulder condition. (CHOOSE 3)
A. Hypothyroidism E. Multiparity
B. Hypertension F. Hypercholesterolemia
C. Cervical myofascial pain syndrome G. Diabetes mellitus
D. Migraine headache H. Immobilization

01 . Select the three (3) best diagnoses for this patient. (CHOOSE 3)
A. Type 2 diabetes mellitus E. Rotator cuff syndrome
B. Disuse muscle atrophy F. Adhesive capsulitis
C. Iron deficiency anemia G. Shoulder dislocation
D. Clavicle fracture H. HADD
02 . Select the three (3) best case management strategies for this condition. (CHOOSE 3)
A. Cryotherapy E. Cold laser
B. Grade 5 mobilization of GH joint F. Iron supplements
C. Codman’s exercises G. Cardiovascular training
D. Wall-walking exercises H. Biceps curls
03 . Select the three (3) risk factors/causes for this shoulder condition. (CHOOSE 3)
A. Hypothyroidism E. Multiparity
B. Hypertension F. Hypercholesterolemia
C. Cervical myofascial pain syndrome G. Diabetes mellitus
D. Migraine headache H. Immobilization

PATIENT INFORMATION
SEX: F AGE: 44
CHIEF COMPLAINT: Pain over 3rd right metacarpal for 6 days.
MECHANISM OF INJURY: Pain occurred after striking back of hand on door knob.
QUALITY OF PAIN: Sharp ache.
SEVERITY OF PAIN: Mild-to-moderate.
AGGRAVATING FACTORS: Gripping objects, palpation of affected bone.
ASSOCIATED SYMPTOMS: Chronic joint pain/deformity, both hands. Ecchymosis over right hand.
RELIEVING FACTORS: None noted by patient.
PAST MEDICAL HISTORY: Patient has been a transient most of her adult life; little prior medical
contact.
FAMILY HISTORY: Mother is believed to also have had joint pains.
OBJECTIVE FINDINGS:
VITALS:
RESP: 17 cpm
PULSE: 80 bpm
TEMP: 99.0ºF
RANGE OF MOTION:
Reduced in both hands
and wrists.
ORTHOPEDIC TESTING:
Bracelet test positive bilateral.
LABORATORY STUDIES:
FTA-ABS positive. R
OTHER FINDINGS:
Generalized, firm, discrete,
non-tender lymphadenopathy.

01 . Which of the following diagnoses apply to this case? (CHOOSE 3)
A. Contusion of right hand E. Osteomalacia
B. Syphilis F. Rheumatoid arthritis
C. Sarcoidosis G. Ochronosis
D. Fracture of metacarpal H. Scleroderma
02 . Which of the following radiographic findings are seen? (CHOOSE 3)
A. Swan-neck deformity E. Juxta-articular erosions
B. Old gun shot wound F. Metacarpal fracture
C. Boutonniere deformity G. Chondrocalcinosis
D. Periarticular osteopenia H. Subchondral sclerosis
03 . What is appropriate initial management in this case? (CHOOSE 3)
A. Cold laser E. Fish oil supplementation
B. Ice water bath for hand F. Adjust thumbs
C. Referral to infectious disease specialist G. Splint hand
D. Referral to orthopedist for casting H. Myofascial release to dorsum of right hand

A. Contusion of right hand E. Osteomalacia
B. Syphilis F. Rheumatoid arthritis
C. Sarcoidosis G. Ochronosis
D. Fracture of metacarpal H. Scleroderma
02 . Which of the following radiographic findings are seen? (CHOOSE 3)
A. Swan-neck deformity E. Juxta-articular erosions
B. Old gun shot wound F. Metacarpal fracture
C. Boutonniere deformity G. Chondrocalcinosis
D. Periarticular osteopenia H. Subchondral sclerosis
03 . What is appropriate initial management in this case? (CHOOSE 3)
A. Cold laser E. Fish oil supplementation
B. Ice water bath for hand F. Adjust thumbs
C. Referral to infectious disease specialist G. Splint hand
D. Referral to orthopedist for casting H. Myofascial release to dorsum of right hand

PATIENT INFORMATION
SEX: M AGE: 32
CHIEF COMPLAINT: Right posterior leg pain to lower calf
MECHANISM OF INJURY: Started in 6th hour of 8 hours driving car
QUALITY OF PAIN: Sharp, shooting
AGGRAVATING FACTORS: Crossing right leg over left; walking
ASSOCIATED SYMPTOMS: Ache in right buttock, low back tightness
RELIEVING FACTORS: Lying supine
PAST MEDICAL HISTORY: Unremarkable
FAMILY HISTORY: Unremarkable
OBJECTIVE FINDINGS:
VITALS:
RESP: 14 cpm
PULSE: 78 bpm
TEMP: 97.7 F
RANGE OF MOTION:
Decreased internal rotation of right FAJ;
produces pain in leg.
ORTHOPEDIC TESTING:
Hibb test positive. Braggard positive.
Valsalva negative.
LABORATORY STUDIES:
ESR 2 mmHr (normal).
OTHER FINDINGS:
Extension restriction of right SI joint.
Scalp has reddened skin with greasy scales.

KEY
01 . Select the three appropriate diagnoses. (CHOOSE 3)
A. Lumbar disc herniation E. Psoriatic arthritis
B. Sciatic radiculitis F. Piriformis syndrome
C. Sacroiliac dysfunction G. Hip OA
D. Ankylosing spondylitis H. Hamstring strain
02 . Which of the following are appropriate outcome measure to use? (CHOOSE 3)
A. VAS E. Zung
B. Rheumatoid disability index F. IPSS
C. Oswestry G. Fiese disability index
D. Lower extremity functional scale H. COOP
03 . Select the appropriate initial management for this patient. (CHOOSE 3)
A. Strengthening of right hip external rotators E. Cat/camel exercises
B. Referral to rheumatologist F. Manipulation of right SI joint
C. Cox flexion-distraction G. Bed rest
D. Ultrasound to right buttock H. PIR to right piriformis

01 . Select the three appropriate diagnoses. (CHOOSE 3)
A. Lumbar disc herniation E. Psoriatic arthritis
B. Sciatic radiculitis F. Piriformis syndrome
C. Sacroiliac dysfunction G. Hip OA
D. Ankylosing spondylitis H. Hamstring strain
02 . Which of the following are appropriate outcome measure to use? (CHOOSE 3)
A. VAS E. Zung
B. Rheumatoid disability index F. IPSS
C. Oswestry G. Fiese disability index
D. Lower extremity functional scale H. COOP
03 . Select the appropriate initial management for this patient. (CHOOSE 3)
A. Strengthening of right hip external rotators E. Cat/camel exercises
B. Referral to rheumatologist F. Manipulation of right SI joint
C. Cox flexion-distraction G. Bed rest
D. Ultrasound to right buttock H. PIR to right piriformis

PATIENT INFORMATION
SEX: Male AGE: 65
CHIEF COMPLAINT: Neck pain
MECHANISM OF INJURY: unknown, insidious onset
QUALITY OF PAIN: achy, stiff
SEVERITY OF PAIN: mild to moderate
AGGRAVATING FACTORS: worse after periods of inactivity
ASSOCIATED SYMPTOMS: excessive stumbling and tripping
RELIEVING FACTORS: Advil
PAST MEDICAL HISTORY: unremarkable
FAMILY HISTORY: Father had multiple sclerosis
OBJECTIVE FINDINGS:
VITALS:
RESP: 16 cpm
PULSE: 92 bpm
TEMP: 98.3 F
RANGE OF MOTION:
Decreased cervical lateral flexion and rotation
bilaterally.
ORTHOPEDIC TESTING:
Increased neck pain with cervical compression.
Reduced neck pain with cervical distraction.
LABORATORY STUDIES:
CBC and Chem-7 unremarkable.
OTHER FINDINGS:
Loss of vibration and proprioception to the ankles
bilaterally.

1. Select the three (3) best differential diagnoses. (CHOOSE 3)
A. Diabetes mellitus E. Degenerative cervical spine stenosis
B. Multiple sclerosis F. Friedreich’s ataxia
C. DISH G. Paget’s disease of cervical spine
D. Myelopathy H. Cauda equina syndrome
2. What additional studies should be performed? (CHOOSE 3)
A. MRI of spine E. Serum alkaline phosphatase
B. EEG F. Sensory evoked potentials
C. Carotid angiography G. Femoral angiography
D. Serum HLA-B27 H. EMG
3. Which of the following are the most appropriate forms of management? (CHOOSE 3)
A. Calcium supplements E. Grade 3 mobilization of neck
B. Cervical ultrasound F. Cryotherapy
C. Cervical traction G. Referral to neurosurgeon
D. Cervical collar H. Cervical extension exercises

1. Select the three (3) best differential diagnoses. (CHOOSE 3)
A. Diabetes mellitus E. Degenerative cervical spine stenosis
B. Multiple sclerosis F. Friedreich’s ataxia
C. DISH G. Paget’s disease of cervical spine
D. Myelopathy H. Cauda equina syndrome
2. What additional studies should be performed? (CHOOSE 3)
A. MRI of spine E. Serum alkaline phosphatase
B. EEG F. Sensory evoked potentials
C. Carotid angiography G. Femoral angiography
D. Serum HLA-B27 H. EMG
3. Which of the following are the most appropriate forms of management? (CHOOSE 3)
A. Calcium supplements E. Grade 3 mobilization of neck
B. Cervical ultrasound F. Cryotherapy
C. Cervical traction G. Referral to neurosurgeon
D. Cervical collar H. Cervical extension exercises

PATIENT INFORMATION
SEX: F AGE: 37
CHIEF COMPLAINT: Right medial forearm pain down to 3rd, 4th and 5th digits.
MECHANISM OF INJURY: Insidious onset.
QUALITY OF PAIN: Pulling, tingling, numbness of affected digits.
SEVERITY OF PAIN: Moderate.
AGGRAVATING FACTORS: Driving, reading newspaper.
ASSOCIATED SYMPTOMS: Fingers on the right periodically become cold, pale, then cyanotic.
RELIEVING FACTORS: Neck and shoulder massage.
PAST MEDICAL HISTORY: Cholecystectomy, three years ago.
FAMILY HISTORY: Unremarkable.
OBJECTIVE FINDINGS:
VITALS:
RESP: 18 cpm
PULSE: 78 bpm
TEMP: 98.6 ºF
RANGE OF MOTION:
Reduced left lateral flexion and left
rotation of neck.
ORTHOPEDIC TESTING:
Jackson test negative bilaterally.
LABORATORY STUDIES:
None.
OTHER FINDINGS:
Upper thoracic hyperkyphosis with
intersegmental dysfunction at T3-T5.

01 . What additional orthopedic tests are needed in this case? (CHOOSE 3)
A. Soto-Hall test E. Wright test
B. Allen test F. Schepelmann sign
C. Adson test G. Hawkin test
D. Valsalva maneuver H. Naffziger test
02 . Select the three most appropriate differential diagnoses. (CHOOSE 3)
A. Cervical discopathy with radiculopathy E. Pott’s disease
B. T4 syndrome F. Barrel chest
C. Raynaud’s phenomenon G. Cervical degenerative stenosis
D. Thoracic outlet syndrome H. Pancoast tumor
03 . Select the most appropriate initial management for this case. (CHOOSE 3)
A. McKenzie chin retractions E. Advise patient to stop smoking
B. Strengthen cervical erector spinae F. CMT to T3-T5
C. Ultrasound forearm G. Vitamin B12 supplements
D. CMT to midcervical spine H. Stretch scalenes and pecs

01 . What additional orthopedic tests are needed in this case? (CHOOSE 3)
A. Soto-Hall test E. Wright test
B. Allen test F. Schepelmann sign
C. Adson test G. Hawkin test
D. Valsalva maneuver H. Naffziger test
02 . Select the three most appropriate differential diagnoses. (CHOOSE 3)
A. Cervical discopathy with radiculopathy E. Pott’s disease
B. T4 syndrome F. Barrel chest
C. Raynaud’s phenomenon G. Cervical degenerative stenosis
D. Thoracic outlet syndrome H. Pancoast tumor
03 . Select the most appropriate initial management for this case. (CHOOSE 3)
A. McKenzie chin retractions E. Advise patient to stop smoking
B. Strengthen cervical erector spinae F. CMT to T3-T5
C. Ultrasound forearm G. Vitamin B12 supplements
D. CMT to midcervical spine H. Stretch scalenes and pecs

PATIENT INFORMATION
SEX: F AGE: 36
CHIEF COMPLAINT: Low back pain
MECHANISM OF INJURY: Moving boxes
QUALITY OF PAIN: Sharp, achy
SEVERITY OF PAIN: Severe
AGGRAVATING FACTORS: Sitting, coughing
ASSOCIATED SYMPTOMS: Sharp, shooting right leg pain to lateral foot
RELIEVING FACTORS: Lying down with knees bent
FAMILY HISTORY: RA, mother and sister
OBJECTIVE FINDINGS:
VITALS:
RESP: 20 cpm
PULSE: 92 bpm
TEMP: 98.7 F
RANGE OF MOTION:
Lumbar flexion 15 degrees, extension
5 degrees.
ORTHOPEDIC TESTING:
Positive SLR, Braggard, Valsalva.
LABORATORY STUDIES:
None.
OTHER FINDINGS:
Achilles reflex +1.

01 . Which three (3) additional ortho/neuro tests are expected to be positive? (CHOOSE 3)
A. L4 dermatome E. Hibb test
B. L5 dermatome F. Prone knee bend
C. Peronei muscle test G. Tibialis anterior muscle test
D. Kemp test H. Patellar reflex
02 . Select three (3) initial case management strategies. (CHOOSE 3)
A. McKenzie technique E. Cryotherapy
B. Hot pack F. Referral to orthopedic surgeon
C. 2 weeks bed rest G. Ultrasound (continuous mode)
D. SOT blocking H. Russian stim
03. Which three (3) outcome measures are most appropriate in this case? (CHOOSE 3)
A. Zung E. Duke health profile
B. Braden scale F. Visual analog scale
C. Rowland-Morris G. SF-36
D. COOP H. Oswestry

01 . Which three (3) additional ortho/neuro tests are expected to be positive? (CHOOSE 3)
A. L4 dermatome E. Hibb test
B. L5 dermatome F. Prone knee bend
C. Peronei muscle test G. Tibialis anterior muscle test
D. Kemp test H. Patellar reflex
02 . Select three (3) initial case management strategies. (CHOOSE 3)
A. McKenzie technique E. Cryotherapy
B. Hot pack F. Referral to orthopedic surgeon
C. 2 weeks bed rest G. Ultrasound (continuous mode)
D. SOT blocking H. Russian stim
03. Which three (3) outcome measures are most appropriate in this case? (CHOOSE 3)
A. Zung E. Duke health profile
B. Braden scale F. Visual analog scale
C. Rowland-Morris G. SF-36
D. COOP H. Oswestry

PATIENT INFORMATION
SEX: F AGE: 22
CHIEF COMPLAINT: Progressively severe unilateral wrist pain of 24 hr duration.
MECHANISM OF INJURY: While camping with new boyfriend; denies any trauma.
QUALITY OF PAIN: Deep ache.
SEVERITY OF PAIN: Severe; interrupts sleep.
AGGRAVATING FACTORS: Wrist movement.
ASSOCIATED SYMPTOMS: Progressive malaise and anorexia.
RELIEVING FACTORS: None.
PAST MEDICAL HISTORY: Noncontributory.
FAMILY HISTORY: Noncontributory.
OBJECTIVE FINDINGS:
VITALS:
RESP: 18 cpm
PULSE: 98 bpm
TEMP: 101 ºF
RANGE OF MOTION:
Involved wrist ROM severely restricted.
ORTHOPEDIC TESTING:
Bracelet test produces excruciating wrist pain.
LABORATORY STUDIES:
WBC count 11500.
OTHER FINDINGS:
Bilateral pustular eruptions on hands.
Mild pharyngeal injection.

01 . Which of the following are the most likely differential diagnoses? (CHOOSE 3)
A. Lyme disease, first stage E. Acute rheumatic fever
B. Disseminated gonococcal infection F. Wrist sprain
C. Streptococcal septic arthritis G. Wrist fracture
D. Reactive arthritis H. Psoriatic arthritis
02 . What additional clinical findings are expected in this case? (CHOOSE 3)
A. Purulent cervical discharge E. Cardiac murmur
B. Dysuria F. Subcutaneous nodules
C. Erythema migrans G. Bell’s palsy
D. Erythema marginatum H. Pelvic pain
03 . What additional exams, tests or imaging is indicated? (CHOOSE 3)
A. Echocardiogram E. Neurological exam
B. Chest x-ray F. Blood culture
C. Liver function tests G. Wrist xray
D. Pelvic exam H. HLA-B27

01 . Which of the following are the most likely differential diagnoses? (CHOOSE 3)
A. Lyme disease, first stage E. Acute rheumatic fever
B. Disseminated gonococcal infection F. Wrist sprain
C. Streptococcal septic arthritis G. Wrist fracture
D. Reactive arthritis H. Psoriatic arthritis
A. Purulent cervical discharge E. Cardiac murmur
B. Dysuria F. Subcutaneous nodules
C. Erythema migrans G. Bell’s palsy
D. Erythema marginatum H. Pelvic pain
03 . What additional exams, tests or imaging is indicated? (CHOOSE 3)
A. Echocardiogram E. Neurological exam
B. Chest x-ray F. Blood culture
C. Liver function tests G. Wrist xray
D. Pelvic exam H. HLA-B27

PATIENT INFORMATION
SEX: F AGE: 56
CHIEF COMPLAINT: Polyarticular joint pain and swelling in the hands bilaterally.
MECHANISM OF INJURY: Insidious, 36 years ago.
QUALITY OF PAIN: Aching and prolonged morning stiffness.
SEVERITY OF PAIN: 3-4/10.
AGGRAVATING FACTORS: Typing, opening jars.
ASSOCIATED SYMPTOMS: Recurrent oral ulcers and intermittent rash. Recurrent neck pain.
RELIEVING FACTORS: NSAIDs.
PAST MEDICAL HISTORY: Pleuritis 8 years ago, pericarditis 12 years ago.
FAMILY HISTORY: Mother had some type of arthritis.
OBJECTIVE FINDINGS:
VITALS:
RESP: 16 cpm
PULSE: 82 bpm
TEMP: 98.9 ºF
RANGE OF MOTION:
Finger flexion and extension
reduced bilaterally.
ORTHOPEDIC TESTING:
Bracelet test negative bilaterally.
LABORATORY STUDIES:
CBC: Normocytic anemia.
OTHER FINDINGS:
Raynaud’s phenomenon. (Exam
room is cold.)

01 . Which of the following cause ulnar deviation of the digits? (CHOOSE 3)
A. Osteoarthritis E. Gout
B. Scleroderma F. Reactive arthritis
C. Rheumatoid arthritis G. Ollier’s disease
D. Psoriatic arthritis H. Systemic lupus erythematosis
02 . Which of the following additional lab tests or imaging is needed. (CHOOSE 3)
A. Flexion-extension cervical films E. Serum electrolytes
B. Serum anti-nuclear antibody F. Bone scan
C. Serum uric acid G. Serum anti-dsDNA antibody
D. HLA-B27 H. Chest MRI
A. Lymphadenopathy E. Rheumatoid nodules
B. Endometriosis F. Glomerulonephritis
C. Photosensitivity G. Irritable bowel syndrome
D. Recurrent urinary tract infection H. Lipomas

01 . Which of the following cause ulnar deviation of the digits? (CHOOSE 3)
A. Osteoarthritis E. Gout
B. Scleroderma F. Reactive arthritis
C. Rheumatoid arthritis G. Ollier’s disease
D. Psoriatic arthritis H. Systemic lupus erythematosis
02 . Which of the following additional lab tests or imaging is needed. (CHOOSE 3)
A. Flexion-extension cervical films E. Serum electrolytes
B. Serum anti-nuclear antibody F. Bone scan
C. Serum uric acid G. Serum anti-dsDNA antibody
D. HLA-B27 H. Chest MRI
A. Lymphadenopathy E. Rheumatoid nodules
B. Endometriosis F. Glomerulonephritis
C. Photosensitivity G. Irritable bowel syndrome
D. Recurrent urinary tract infection H. Lipomas

PATIENT INFORMATION
SEX: M AGE: 28
CHIEF COMPLAINT: Right groin pain when consuming alcohol.
MECHANISM OF INJURY: Insidious 2 months ago.
QUALITY OF PAIN: Achy.
SEVERITY OF PAIN: Mild.
AGGRAVATING FACTORS: Consumption of alcohol.
ASSOCIATED SYMPTOMS: Night sweats, sporadic high fever.
PAST MEDICAL HISTORY: Treatment with phenytoin for grand mal seizures.
FAMILY HISTORY: SLE, mother.
OBJECTIVE FINDINGS:
VITALS:
RESP: 16 cpm
PULSE: 78 bpm
TEMP: 97.5 F
RANGE OF MOTION:
Right hip ROM within normal limits.
ORTHOPEDIC TESTING:
Patrick FABERE negative.
LABORATORY STUDIES:
Lymphocytopenia.
OTHER FINDINGS:
Left lower leg edema.

01 . Select three (3) additional lab test results that are expected in this case. (CHOOSE 3)
A. Thrombocytopenia E. Langerhans cells
B. Microcytic anemia F. Starry sky macrophages
C. Low TSH G. Hypercholesterolemia
D. Elevated ESR H. Reed-Sternberg cells
02 . Which of the following are possible consequences of treatment? (CHOOSE 3)
A. Breast cancer E. Multiple sclerosis
B. Stroke F. Lung cancer
C. Thyroid cancer G. HIV infection
D. Degenerative arthritis H. Chronic pancreatitis
03 . Select “red flag” findings for additional or follow-up assessment. (CHOOSE 3)
A. Hemoptysis E. Chest pain
B. Anxiety F. Sinusitis
C. Aphthous ulcers G. Constipation
D. Fordyce spots H. Mitral valve prolapse

01 . Select three (3) additional lab test results that are expected in this case. (CHOOSE 3)
A. Thrombocytopenia E. Langerhans cells
B. Microcytic anemia F. Starry sky macrophages
C. Low TSH G. Hypercholesterolemia
D. Elevated ESR H. Reed-Sternberg cells
02 . Which of the following are possible consequences of treatment? (CHOOSE 3)
A. Breast cancer E. Multiple sclerosis
B. Stroke F. Lung cancer
C. Thyroid cancer G. HIV infection
D. Degenerative arthritis H. Chronic pancreatitis
03 . Select “red flag” findings for additional or follow-up assessment. (CHOOSE 3)
A. Hemoptysis E. Chest pain
B. Anxiety F. Sinusitis
C. Aphthous ulcers G. Constipation
D. Fordyce spots H. Mitral valve prolapse

PATIENT INFORMATION
SEX: F AGE: 47
CHIEF COMPLAINT: Right second carpal digit DIP joint pain and swelling
QUALITY OF PAIN: Sharp ache
SEVERITY OF PAIN: Moderate
AGGRAVATING FACTORS: Prolonged inactivity, excessive activity
ASSOCIATED SYMPTOMS: Morning stiffness lasting 2 hours
RELIEVING FACTORS: NSAIDs
PAST MEDICAL HISTORY: Recurrent UTIs
FAMILY HISTORY: Non-contributory
OBJECTIVE FINDINGS:
VITALS:
RESP: 14 cpm
PULSE: 74 bpm
TEMP: 98.1 F
RANGE OF MOTION:
Mildly reduced at affected
joint.
ORTHOPEDIC TESTING:
None.
LABORATORY STUDIES:
None.
OTHER FINDINGS:
Rash.

01 . Which other anatomical sites can be affected in this condition? (CHOOSE 3)
A. DIP joints of toes E. Low back
B. Heart F. Pericardium
C. Nails G. Spleen
D. Eyes H. Oral mucosa
02 . Which three (3) radiology findings would you expect in this condition? (CHOOSE 3)
A. Symmetrical arthritis of carpal DIP joints E. Sudek atrophy
B. Resorption of terminal phalanges F. Asymmetric syndesmophytes
C. Hypertrophic osteophytes G. Subperiosteal new bone growth
D. Rat bite appearance H. Pencil in cup deformity
03 . Select the appropriate initial management of this patient. (CHOOSE 3)
A. Grade 5 mobilization of affected DIP joint E. Cross friction massage
B. Paraffin wax F. Hard cast
C. Hot pack G. Fish oil supplements
D. Referral to rheumatologist H. Subaqeous ultrasound (pulsed)

01 . Which other anatomical sites can be affected in this condition? (CHOOSE 3)
A. DIP joints of toes E. Low back
B. Heart F. Pericardium
C. Nails G. Spleen
D. Eyes H. Oral mucosa
02 . Which three (3) radiology findings would you expect in this condition? (CHOOSE 3)
A. Symmetrical arthritis of carpal DIP joints E. Sudek atrophy
B. Resorption of terminal phalanges F. Asymmetric syndesmophytes
C. Hypertrophic osteophytes G. Subperiosteal new bone growth
D. Rat bite appearance H. Pencil in cup deformity
03 . Select the appropriate initial management of this patient. (CHOOSE 3)
A. Grade 5 mobilization of affected DIP joint E. Cross friction massage
B. Paraffin wax F. Hard cast
C. Hot pack G. Fish oil supplements
D. Referral to rheumatologist H. Subaqeous ultrasound (pulsed)

PATIENT INFORMATION
SEX: M AGE: 78
QUALITY OF PAIN: Deep, boring
AGGRAVATING FACTORS: None
ASSOCIATED SYMPTOMS: Intermittent claudication
RELIEVING FACTORS: None
PAST MEDICAL HISTORY: MI, age 69
FAMILY HISTORY: CVA, father
OBJECTIVE FINDINGS:
VITALS:
RESP: 16 cpm
PULSE: 76 bpm
TEMP: 97.9 F
RANGE OF MOTION:
Mildly reduced lumbar ROM.
ORTHOPEDIC TESTING:
Pheasant test produces abdominal pain.
LABORATORY STUDIES:
Elevated LDL-C.
OTHER FINDINGS:
Pedal dusky rubor on dependency.

30 . Select the three (3) correct diagnoses. (CHOOSE 3)
A. Prostate carcinoma E. Systolic hypertension
B. Abdominal aortic aneurysm F. Spinal stenosis
C. Peripheral artery disease G. Fecal impaction of sigmoid colon
D. Appendicitis H. Cystic kidney disease
31 . Select three (3) risk factors for the patient’s condition shown on CT scan. (CHOOSE 3)
A. Hypertension E. Excessive dietary calcium
B. Hepatic cirrhosis F. Hypercholesterolemia
C. Hirschsprung disease G. Addison disease
D. Cigarette smoking H. Lymphoid hyperplasia
32 . Which of the following is appropriate long term management for this case? (CHOOSE 3)
A. Progressive walking program E. Monitor BP regularly
B. Increase alcohol consumption F. Shoulder range of motion exercises
C. Counsel patient on following DASH diet G. Regular orthopedic testing
D. Regular side posture adjusting H. Encourage limited physical activity

30 . Select the three (3) correct diagnoses. (CHOOSE 3)
A. Prostate carcinoma E. Systolic hypertension
B. Abdominal aortic aneurysm F. Spinal stenosis
C. Peripheral artery disease G. Fecal impaction of sigmoid colon
D. Appendicitis H. Cystic kidney disease
31 . Select three (3) risk factors for the patient’s condition shown on CT scan. (CHOOSE 3)
A. Hypertension E. Excessive dietary calcium
B. Hepatic cirrhosis F. Hypercholesterolemia
C. Hirschsprung disease G. Addison disease
D. Cigarette smoking H. Lymphoid hyperplasia
32 . Which of the following is appropriate long term management for this case? (CHOOSE 3)
A. Progressive walking program E. Monitor BP regularly
B. Increase alcohol consumption F. Shoulder range of motion exercises
C. Counsel patient on following DASH diet G. Regular orthopedic testing
D. Regular side posture adjusting H. Encourage limited physical activity

PATIENT INFORMATION
SEX: M AGE: 24
MECHANISM OF INJURY: Unknown; insidious
QUALITY OF PAIN: Achy
AGGRAVATING FACTORS: Rest, lifting
ASSOCIATED SYMPTOMS: Morning stiffness lasting 4 hours
RELIEVING FACTORS: NSAIDs
FAMILY HISTORY: Unremarkable
OBJECTIVE FINDINGS:
VITALS:
RESP: 16 cpm
PULSE: 70 bpm
TEMP: 99.0 F
RANGE OF MOTION:
Lumbar range of motion significantly reduced
in all ranges.
ORTHOPEDIC TESTING:
Positive Yeoman’s test.
LABORATORY STUDIES:
Elevated ESR.
OTHER FINDINGS:
None.

01 . Select three (3) x-ray findings. (CHOOSE 3)
A. Flowing osteophytes E. Hyperostosis
B. Trolley track sign F. Soft-tissue calcification
C. Porcelain gall bladder G. Loss of disc space
D. Non-marginal syndesmophytes H. Bilateral SI joint ankylosis
02 . Select three (3) additional orthopedic test that would be positive. (CHOOSE 3)
A. Valsalva maneuver E. Shepelmann sign
B. Fajersztajn test F. Adam sign
C. Shober test G. Belt test
D. Sicard test H. Patte test
03 . Select the three (3) most appropriate prognostic outcomes. (CHOOSE 3)
A. Prognosis is poor E. May produce dysphagia
B. Prognosis is good F. Iritis is possible
C. Condition is self-resolving G. Relapsing/remitting course
D. Will progress cephalically H. Poorer prognosis in females

01 . Select three (3) x-ray findings. (CHOOSE 3)
A. Flowing osteophytes E. Hyperostosis
B. Trolley track sign F. Soft-tissue calcification
C. Porcelain gall bladder G. Loss of disc space
D. Non-marginal syndesmophytes H. Bilateral SI joint ankylosis
02 . Select three (3) additional orthopedic test that would be positive. (CHOOSE 3)
A. Valsalva maneuver E. Shepelmann sign
B. Fajersztajn test F. Adam sign
C. Shober test G. Belt test
D. Sicard test H. Patte test
03 . Select the three (3) most appropriate prognostic outcomes. (CHOOSE 3)
A. Prognosis is poor E. May produce dysphagia
B. Prognosis is good F. Iritis is possible
C. Condition is self-resolving G. Relapsing/remitting course
D. Will progress cephalically H. Poorer prognosis in females

PATIENT INFORMATION
SEX: M AGE: 24
CHIEF COMPLAINT: Left knee pain
QUALITY OF PAIN: Deep, boring
AGGRAVATING FACTORS: Flexion, extension, of knee; walking, climbing stairs
ASSOCIATED SYMPTOMS: Cough
RELIEVING FACTORS: None; worse with rest, at night
OBJECTIVE FINDINGS:
VITALS:
RESP: 20 cpm
PULSE: 88 bpm
TEMP: 99.5 F
RANGE OF MOTION:
Left knee ROM reduced due to pain.
ORTHOPEDIC TESTING:
Ely sign positive on left.
LABORATORY STUDIES:
Elevated alkaline phosphatase.
OTHER FINDINGS:
Tender mass at left distal femur.

01 . What three (3) additional lab or imaging studies should be performed? (CHOOSE 3)
A. Liver biopsy E. Acid phosphatase
B. HLA-B27 F. Chest x-ray
C. Bone scan G. EMG
D. Right hip x-ray H. Chest CT scan
02 . Choose the three (3) most likely differential diagnoses. (CHOOSE 3)
A. Ewing sarcoma E. Osteosarcoma
B. Reticulum cell sarcoma F. Aneurysmal bone cyst
C. Myositis Ossificans G. Giant cell tumor
D. Fibrosarcoma H. Brodie’s abscess
03 . Choose the three (3) radiological findings seen on the film provided. (CHOOSE 3)
A. Onion skin appearance E. Lobulated appearance
B. Sunburst appearance F. Periosteal reaction
C. Ground glass appearance G. Spiculated appearance
D. Fallen fragment sign H. Shepherd’s crook deformity

01 . What three (3) additional lab or imaging studies should be performed? (CHOOSE 3)
A. Liver biopsy E. Acid phosphatase
B. HLA-B27 F. Chest x-ray
C. Bone scan G. EMG
D. Right hip x-ray H. Chest CT scan
02 . Choose the three (3) most likely differential diagnoses. (CHOOSE 3)
A. Ewing sarcoma E. Osteosarcoma
B. Reticulum cell sarcoma F. Aneurysmal bone cyst
C. Myositis Ossificans G. Giant cell tumor
D. Fibrosarcoma H. Brodie’s abscess
03 . Choose the three (3) radiological findings seen on the film provided. (CHOOSE 3)
A. Onion skin appearance E. Lobulated appearance
B. Sunburst appearance F. Periosteal reaction
C. Ground glass appearance G. Spiculated appearance
D. Fallen fragment sign H. Shepherd’s crook deformity

PATIENT INFORMATION
SEX: F AGE: 38
CHIEF COMPLAINT: Ptosis bilaterally.
MECHANISM OF INJURY: Developed after Salmonella enteritis.
QUALITY OF PAIN: None.
SEVERITY OF PAIN: N/A
AGGRAVATING FACTORS: Ptosis worsens as day progresses; worst in evening.
ASSOCIATED SYMPTOMS: Muscle weakness after activity; improves with rest.
RELIEVING FACTORS: Rest, sleep.
PAST MEDICAL HISTORY: Thyrotoxicosis; resolved with treatment.
FAMILY HISTORY: Mother, 68, has hypothyroidism.
OBJECTIVE FINDINGS:
VITALS:
RESP: 14 cpm
PULSE: 74 bpm
TEMP: 98.0 ºF
RANGE OF MOTION:
Unremarkable.
ORTHOPEDIC TESTING:
Repetitive squats produces +3 hip girdle weakness.
LABORATORY STUDIES:
Serum vitamin B12 normal.
OTHER FINDINGS:
Slurred speech with prolonged speaking.

01 . Which of the following additional lab tests or imaging should be ordered? (CHOOSE 3)
A. ANA E. Cervical spine x-rays
B. CBC F. Chest CT
C. KUB G. ECG
D. HLA-B27 H. Serum electrolytes
02 . Select three correct precipitating factors for this patient’s condition. (CHOOSE 3)
A. Smoking E. TB
B. Hyperthyroidism F. Meningioma
C. Asbestos exposure G. Infection
D. Surgery H. Alcoholism
03 . What additional clinical findings can be expected in this condition? (CHOOSE 3)
A. Dysphagia/choking E. Malar rash
B. Dullness on lung percussion F. Normal DTRs
C. Respiratory failure G. Arm pain
D. Hearing deficit H. Dermatomal numbness

01 . Which of the following additional lab tests or imaging should be ordered? (CHOOSE 3)
A. ANA E. Cervical spine x-rays
B. CBC F. Chest CT
C. KUB G. ECG
D. HLA-B27 H. Serum electrolytes
02 . Select three correct precipitating factors for this patient’s condition. (CHOOSE 3)
A. Smoking E. TB
B. Hyperthyroidism F. Meningioma
C. Asbestos exposure G. Infection
D. Surgery H. Alcoholism
03 . What additional clinical findings can be expected in this condition? (CHOOSE 3)
A. Dysphagia/choking E. Malar rash
B. Dullness on lung percussion F. Normal DTRs
C. Respiratory failure G. Arm pain
D. Hearing deficit H. Dermatomal numbness

PATIENT INFORMATION
SEX: M AGE: 27
CHIEF COMPLAINT: Left upper quadrant abdominal discomfort
MECHANISM OF INJURY: None.
QUALITY OF PAIN: Pressure, fullness, mild ache
SEVERITY OF PAIN: 1-2/10
AGGRAVATING FACTORS: Palpation in LUQ
ASSOCIATED SYMPTOMS: Can’t take deep breaths; dysphagia with reflux
PAST MEDICAL HISTORY: Pharyngitis 3 months ago
OBJECTIVE FINDINGS:
VITALS:
RESP: 20 cpm
PULSE: 82 bpm
TEMP: 99.6 ºF
RANGE OF MOTION:
Thoracic range of motion normal.
ORTHOPEDIC TESTING:
N/A
LABORATORY STUDIES:
Total cholesterol: 267 mg/dL.
OTHER FINDINGS:
Cervical lymphadenopathy.

01 . Select the appropriate additional lab tests needed in this case. (CHOOSE 3)
A. Serum fasting glucose E. Epstein-Barr virus antibody
B. WBC count with differential F. Mono-spot test
C. Bone marrow biopsy G. Throat culture
D. Lymph node biopsy H. Urinalysis
A. Pericardial friction rub E. Urinary tract infection
B. Fatigue F. Murphy’s punch positive
C. Hepatomegaly G. Productive cough
D. Peripheral edema H. Splenomegaly
03 . Which of the following clinical impressions/diagnoses apply? (CHOOSE 3)
A. Rheumatic fever E. Sickle-cell disease
B. Chronic fatigue syndrome F. Gastric ulcer
C. Infectious mononucleosis G. Hypercholesterolemia
D. Plasmacytoid lymphocyte H. Non-Hodgkins lymphoma

01 . Select the appropriate additional lab tests needed in this case. (CHOOSE 3)
A. Serum fasting glucose E. Epstein-Barr virus antibody
B. WBC count with differential F. Mono-spot test
C. Bone marrow biopsy G. Throat culture
D. Lymph node biopsy H. Urinalysis
A. Pericardial friction rub E. Urinary tract infection
B. Fatigue F. Murphy’s punch positive
C. Hepatomegaly G. Productive cough
D. Peripheral edema H. Splenomegaly
03 . Which of the following clinical impressions/diagnoses apply? (CHOOSE 3)
A. Rheumatic fever E. Sickle-cell disease
B. Chronic fatigue syndrome F. Gastric ulcer
C. Infectious mononucleosis G. Hypercholesterolemia
D. Plasmacytoid lymphocyte H. Non-Hodgkins lymphoma

PATIENT INFORMATION
SEX: F AGE: 54
CHIEF COMPLAINT: Pain in right lateral forefoot.
MECHANISM OF INJURY: Sudden, while walking 5 miles to work.
QUALITY OF PAIN: Cramp-like.
SEVERITY OF PAIN: 5/10.
AGGRAVATING FACTORS: Standing, walking, palpation.
ASSOCIATED SYMPTOMS: Edema of foot and ankle.
RELIEVING FACTORS: Rest, elevation of foot.
PAST MEDICAL HISTORY: Premature menopause (age 39).
FAMILY HISTORY: Non-contributory.
OBJECTIVE FINDINGS:
VITALS:
RESP: 16 cpm
PULSE: 77 bpm
TEMP: 97.6 ºF
RANGE OF MOTION:
ROM of toes and ankle WNL.
ORTHOPEDIC TESTING:
Metatarsal squeeze produces pain in
right lateral forefooot.
LABORATORY STUDIES:
None.
OTHER FINDINGS:
Superficial lower leg varicosities bilaterally.

01 . What additional lab tests or imaging is needed? (CHOOSE 3)
A. CBC E. Pituitary function tests
B. Doppler ultrasound of lower leg veins F. Chest x-ray
C. DEXA G. Serum fasting glucose
D. Serum electrolytes H. Foot radiographs
02 . Select the 3 correct clinical impressions for this case. (CHOOSE 3)
A. Suspected hypopituitarism E. Suspected March fracture
B. Atherosclerotic vascular disease F. Plantar fasciitis
C. Chronic venous insufficiency G. Morton’s neuroma
D. Suspected osteoporosis H. Suspected diabetes mellitus, type 2
03 . What is appropriate initial case management for this patient? (CHOOSE 3)
A. Eliminate weight bearing on affected foot E. Referral to neurosurgeon
B. Ultrasound underwater to foot F. Referral to orthopedic surgeon
C. Manipulate metatarsals G. Supplementation with calcium & vitamin

D
D. Plantar fascia stripping H. Low glycemic diet

01 . What additional lab tests or imaging is needed? (CHOOSE 3)
A. CBC E. Pituitary function tests
B. Doppler ultrasound of lower leg veins F. Chest x-ray
C. DEXA G. Serum fasting glucose
D. Serum electrolytes H. Foot radiographs
02 . Select the 3 correct clinical impressions for this case. (CHOOSE 3)
A. Suspected hypopituitarism E. Suspected March fracture
B. Atherosclerotic vascular disease F. Plantar fasciitis
C. Chronic venous insufficiency G. Morton’s neuroma
D. Suspected osteoporosis H. Suspected diabetes mellitus, type 2
03 . What is appropriate initial case management for this patient? (CHOOSE 3)
A. Eliminate weight bearing on affected foot E. Referral to neurosurgeon
B. Ultrasound underwater to foot F. Referral to orthopedic surgeon
C. Manipulate metatarsals G. Supplementation with calcium & vitamin D
D. Plantar fascia stripping H. Low glycemic diet

PATIENT INFORMATION
SEX: M AGE: 43
CHIEF COMPLAINT: Recurrent headaches over right eye
MECHANISM OF INJURY: None
QUALITY OF PAIN: Sharp ache, stabbing
SEVERITY OF PAIN: severe
AGGRAVATING FACTORS: alcohol
ASSOCIATED SYMPTOMS: Ipsilateral ptosis and forehead sweating
RELIEVING FACTORS: self-limiting in about 1 hour
PAST MEDICAL HISTORY: Tonsillectomy, age 6
FAMILY HISTORY: patient is adopted
OBJECTIVE FINDINGS:
VITALS:
RESP: 20 cpm
PULSE: 86 bpm
TEMP: 97.8ºF
RANGE OF MOTION:
Normal cervical ROM
ORTHOPEDIC TESTING:
Brudzinski negative
LABORATORY STUDIES:
RBC count elevated
OTHER FINDINGS:
Cough due to smoking

01 . Which of the following includes appropriate long term management? (CHOOSE 3)
A. Avoid alcohol E. Stop smoking
B. Anti-histamines F. Meditation
C. Avoid allergens G. Melatonin
D. Short-wave diathermy over sinuses H. Aerobic exercise
02 . Select the appropriate diagnoses for this case. (CHOOSE 3)
A. Leukemia E. Sinus headache
B. Secondary polycythemia F. Hypertension
C. Migraine headache G. Pre-hypertension
D. Cluster headache H. Iritis
03 . Select appropriate risk factors for this headache. (CHOOSE 3)
A. Male E. Female
B. Family history F. Meningitis
C. High salt intake G. Diabetes mellitus
D. High sugar intake H. Smoking

01 . Which of the following includes appropriate long term management? (CHOOSE 3)
A. Avoid alcohol E. Stop smoking
B. Anti-histamines F. Meditation
C. Avoid allergens G. Melatonin
D. Short-wave diathermy over sinuses H. Aerobic exercise
02 . Select the appropriate diagnoses for this case. (CHOOSE 3)
A. Leukemia E. Sinus headache
B. Secondary polycythemia F. Hypertension
C. Migraine headache G. Pre-hypertension
D. Cluster headache H. Iritis
03 . Select appropriate risk factors for this headache. (CHOOSE 3)
A. Male E. Female
B. Family history F. Meningitis
C. High salt intake G. Diabetes mellitus
D. High sugar intake H. Smoking

PATIENT INFORMATION
SEX: M AGE: 64
CHIEF COMPLAINT: Bilateral leg pain
MECHANISM OF INJURY: None
QUALITY OF PAIN: Heaviness, aching, tingling, numbness
SEVERITY OF PAIN: Mild-to-moderate
AGGRAVATING FACTORS: Walking, standing, swimming
ASSOCIATED SYMPTOMS: Urinary hesitancy, urgency, frequency, dribbling
RELIEVING FACTORS: Sitting down to rest
PAST MEDICAL HISTORY: Multiple disc herniations
FAMILY HISTORY: Father: MI and CVA
OBJECTIVE FINDINGS:
VITALS:
RESP: 18 cpm
PULSE: 78 bpm
TEMP: 98.5ºF
RANGE OF MOTION:
Lumbar ROM restricted globally
ORTHOPEDIC TESTING:
Stoop test positive
LABORATORY STUDIES:
Urinalysis and routine chemistry panel WNL
OTHER FINDINGS:
Impaired vibratory sense bilaterally in feet

01 . Select the most appropriate diagnoses for this patient. (CHOOSE 3)
A. Diabetes mellitus E. Acute disc herniation
B. UTI F. Prostatic hypertrophy
C. Vascular claudication G. Neurogenic claudication
D. Central canal stenosis H. Deep vein thrombosis
02 . Which of the additional clinical findings can be expected? (CHOOSE 3)
A. Bruit E. Hyporeflexia in the legs
B. Diminished peripheral pulses F. Babinski sign
C. Elevated plasma glucose G. Diminished pinprick sensation in feet
D. Elevated PSA H. Positive Homan sign
03 . Which of the following are appropriate for long term management? (CHOOSE 3)
A. Flexion-Distraction technique E. McKenzie extension exercises
B. Niacin F. Weekly ultrasound to low back
C. Williams exercises G. Abdominal strengthening
D. Low glycemic diet H. Bed rest

01 . Select the most appropriate diagnoses for this patient. (CHOOSE 3)
A. Diabetes mellitus E. Acute disc herniation
B. UTI F. Prostatic hypertrophy
C. Vascular claudication G. Neurogenic claudication
D. Central canal stenosis H. Deep vein thrombosis
02 . Which of the additional clinical findings can be expected? (CHOOSE 3)
A. Bruit E. Hyporeflexia in the legs
B. Diminished peripheral pulses F. Babinski sign
C. Elevated plasma glucose G. Diminished pinprick sensation in feet
D. Elevated PSA H. Positive Homan sign
03 . Which of the following are appropriate for long term management? (CHOOSE 3)
A. Flexion-Distraction technique E. McKenzie extension exercises
B. Niacin F. Weekly ultrasound to low back
C. Williams exercises G. Abdominal strengthening
D. Low glycemic diet H. Bed rest

PATIENT INFORMATION
SEX: F AGE: 69
CHIEF COMPLAINT: Acute low back pain.
MECHANISM OF INJURY: Bending to tie shoes.
QUALITY OF PAIN: Ache, sharp at times.
SEVERITY OF PAIN: Severe.
AGGRAVATING FACTORS: Upright position, flexion.
ASSOCIATED SYMPTOMS: Constipation.
RELIEVING FACTORS: Recumbency.
PAST MEDICAL HISTORY: Exertional dyspnea for last 12 years from heavy smoking.
FAMILY HISTORY: Mother, stroke.
OBJECTIVE FINDINGS:
VITALS:
RESP: 20 cpm
PULSE: 88 bpm
TEMP: 98.4 ºF
RANGE OF MOTION:
Lumbar range of motion severely restricted.
ORTHOPEDIC TESTING:
Unable to perform due to pain.
LABORATORY STUDIES:
Normal serum calcium.
OTHER FINDINGS:
Tympanic abdomen with < 5 bowel sounds/min.
Increased AP chest diameter.

01 . Select the radiologic findings that can be seen on the x-ray. (CHOOSE 3)
A. Traumatic compression fracture E. Post-menopausal osteoporotic

compression fracture
B. Pathologic compression fracture F. Decreased bone density
C. Retrolisthesis of L4 G. Anterolisthesis of L5
D. Benign tumor H. Hyperlordosis
02 . Select the three other diagnosis that this patient has. (CHOOSE 3)
A. Adynamic ileus E. Blastic metastasis
B. Metastatic breast cancer F. Multiple myeloma
C. Hyperparathyroidism G. Platyspondyly
D. Hypertension H. COPD
03 . Which of the following is appropriate initial case management? (CHOOSE 3)
A. Lumbar brace E. Cox flexion-distraction
B. Spinal manipulation F. Ultrasound
C. Refer to oncologist G. Referral for pain control
D. Vitamin D and calcium H. Extension exercises

01 . Select the radiologic findings that can be seen on the x-ray. (CHOOSE 3)
A. Traumatic compression fracture E. Post-menopausal osteoporotic compression

fracture
B. Pathologic compression fracture F. Decreased bone density
C. Retrolisthesis of L4 G. Anterolisthesis of L5
D. Benign tumor H. Hyperlordosis
02 . Select the three other diagnosis that this patient has. (CHOOSE 3)
A. Adynamic ileus E. Blastic metastasis
B. Metastatic breast cancer F. Multiple myeloma
C. Hyperparathyroidism G. Platyspondyly
D. Hypertension H. COPD
03 . Which of the following is appropriate initial case management? (CHOOSE 3)
A. Lumbar brace E. Cox flexion-distraction
B. Spinal manipulation F. Ultrasound
C. Refer to oncologist G. Referral for pain control
D. Vitamin D and calcium H. Extension exercises

PATIENT INFORMATION
SEX: F AGE: 35
CHIEF COMPLAINT: Urinary urgency, frequency.
SEVERITY OF PAIN: N/A.
AGGRAVATING FACTORS: Drinking a lot of coffee.
ASSOCIATED SYMPTOMS: Constipation.
PAST MEDICAL HISTORY: Diagnosed with SLE at age 26.
FAMILY HISTORY: Mother, 74, has diabetes mellitus.
OBJECTIVE FINDINGS:
VITALS:
RESP: 18 cpm
PULSE: 86 bpm
TEMP: 98.8 ºF
RANGE OF MOTION:
N/A.
ORTHOPEDIC TESTING:
N/A.
LABORATORY STUDIES:
BUN, creatinine, ESR WNL.
OTHER FINDINGS:
Murphy’s punch negative bilaterally.

01 . What additional lab tests or imaging is needed in this case? (CHOOSE 3)
A. Lumbar x-rays E. Pelvic ultrasound
B. HbA1c F. Colonoscopy
C. PSA G. Serum electrolytes
D. UA H. ANA
02 . Select the most appropriate differential diagnoses for this patient. (CHOOSE 3)
A. Interstitial cystitis E. Pyelonephritis
B. Lupus nephropathy F. Hypercalcemia
C. Diabetes mellitus G. Proctitis
D. Chronic renal failure H. Endometriosis
03 . What is the long-term management for the most likely diagnosis? (CHOOSE 3)
A. Referral to rheumatologist E. Referral for antibiotics
B. Weight loss F. Low glycemic diet
C. Referral to urologist G. Adjust atlas
D. Referral to endocrinologist H. Vegetarian diet

01 . What additional lab tests or imaging is needed in this case? (CHOOSE 3)
A. Lumbar x-rays E. Pelvic ultrasound
B. HbA1c F. Colonoscopy
C. PSA G. Serum electrolytes
D. UA H. ANA
02 . Select the most appropriate differential diagnoses for this patient. (CHOOSE 3)
A. Interstitial cystitis E. Pyelonephritis
B. Lupus nephropathy F. Hypercalcemia
C. Diabetes mellitus G. Proctitis
D. Chronic renal failure H. Endometriosis
03 . What is the long-term management for the most likely diagnosis? (CHOOSE 3)
A. Referral to rheumatologist E. Referral for antibiotics
B. Weight loss F. Low glycemic diet
C. Referral to urologist G. Adjust atlas
D. Referral to endocrinologist H. Vegetarian diet

PATIENT INFORMATION
SEX: M AGE: 77
CHIEF COMPLAINT: Cough and chest pain on the right.
QUALITY OF PAIN: Sharp, stabbing.
SEVERITY OF PAIN: Moderately severe.
AGGRAVATING FACTORS: Deep breathing, moving trunk.
ASSOCIATED SYMPTOMS: Purulent, blood-streaked sputum production.
RELIEVING FACTORS: Shallow breathing, rest.
PAST MEDICAL HISTORY: Post-traumatic splenectomy, 1999.
OBJECTIVE FINDINGS:
VITALS:
RESP: 26 cpm
PULSE: 120 bpm
TEMP: 102.4 ºF
RANGE OF MOTION:
Restricted and painful thoracic
flexion and extension.
ORTHOPEDIC TESTING:
Schepelmann’s sign: pain on the
right when bending to the left.
LABORATORY STUDIES:
WBC count: 13500
Neutrophils: 77%
Lymphocytes: 12%
OTHER FINDINGS:
Muscle splinting in right upper-to-mid
rib cage.

KEY
A. Decreased tactile fremitus E. Positive Soto-Hall
B. Dullness on percussion F. Pericardial friction rub
C. Hyperresonance on percussion G. Crackles
D. Egophony H. Flow murmur
05 . Which radiology findings/impressions are present in the film provided? (CHOOSE 3)
A. Costophrenic angle blunting E. Lung cancer
B. Cardiomegaly F. Granuloma
C. Lobar consolidation G. Normal left lung
D. Hiatal hernia H. Pneumothorax
A. Congestive heart failure E. Pleural effusion
B. Pneumococcal pneumonia F. Tuberculosis
C. Coxackievirus pneumonia G. Hypertension
D. Myoplasma pneumonia H. Acute pericarditis

A. Decreased tactile fremitus E. Positive Soto-Hall
B. Dullness on percussion F. Pericardial friction rub
C. Hyperresonance on percussion G. Crackles
D. Egophony H. Flow murmur
05 . Which radiology findings/impressions are present in the film provided? (CHOOSE 3)
A. Costophrenic angle blunting E. Lung cancer
B. Cardiomegaly F. Granuloma
C. Lobar consolidation G. Normal left lung
D. Hiatal hernia H. Pneumothorax
A. Congestive heart failure E. Pleural effusion
B. Pneumococcal pneumonia F. Tuberculosis
C. Coxackievirus pneumonia G. Hypertension
D. Myoplasma pneumonia H. Acute pericarditis

PATIENT INFORMATION
SEX: F AGE: 30
CHIEF COMPLAINT: Headache
QUALITY OF PAIN: Throbbing
AGGRAVATING FACTORS: Exertion, straining, recumbent position
ASSOCIATED SYMPTOMS: Weight gain, polyuria
RELIEVING FACTORS: Rest in sitting position
FAMILY HISTORY: Duodenal ulcer, father
OBJECTIVE FINDINGS:
VITALS:
RESP: 18 cpm
PULSE: 84 bpm
TEMP: 97.5 F
RANGE OF MOTION:
Unremarkable.
ORTHOPEDIC TESTING:
Valsalva aggravates headache.
LABORATORY STUDIES:
Elevated serum sodium,
Decreased serum potassium.
OTHER FINDINGS:
Abdominal straie

01 . Choose three (3) other lab or imaging studies required in this case. (CHOOSE 3)
A. Fasting blood glucose E. Thyroid panel
B. Abdominal MRI F. Urinary 5-HIAA
C. 24 hour urinary cortisol G. Bone scan
D. Upper GI study H. Liver function tests
02 . Select three (3) complications that can be expected with this condition. (CHOOSE 3)
A. Rheumatoid arthritis E. Osteosarcoma
B. Hypothyroidism F. Osteoporosis
C. Diabetes mellitus G. Deafness
D. Malabsorption syndrome H. Renal calculi
03 . Select the three (3) possible etiologic organs for this condition. (CHOOSE 3)
A. Kidney E. Heart
B. Anterior pituitary F. Liver
C. Posterior pituitary G. Lung
D. Adrenal gland H. Brain

01 . Choose three (3) other lab or imaging studies required in this case. (CHOOSE 3)
A. Fasting blood glucose E. Thyroid panel
B. Abdominal MRI F. Urinary 5-HIAA
C. 24 hour urinary cortisol G. Bone scan
D. Upper GI study H. Liver function tests
02 . Select three (3) complications that can be expected with this condition. (CHOOSE 3)
A. Rheumatoid arthritis E. Osteosarcoma
B. Hypothyroidism F. Osteoporosis
C. Diabetes mellitus G. Deafness
D. Malabsorption syndrome H. Renal calculi
03 . Select the three (3) possible etiologic organs for this condition. (CHOOSE 3)
A. Kidney E. Heart
B. Anterior pituitary F. Liver
C. Posterior pituitary G. Lung
D. Adrenal gland H. Brain

PATIENT INFORMATION
SEX: F AGE: 31
CHIEF COMPLAINT: Suprapubic pain when urinating
MECHANISM OF INJURY: Insidious 2 months ago
QUALITY OF PAIN: Burning
SEVERITY OF PAIN: Moderate
AGGRAVATING FACTORS: Urination, palpation in suprapubic area
ASSOCIATED SYMPTOMS: Dysmenorrhea, dyspareunia
PAST MEDICAL HISTORY: First onset of dysmenorrhea at age 27
OBJECTIVE FINDINGS:
VITALS:
RESP: 16 cpm
PULSE: 76 bpm
TEMP: 97.9 F
RANGE OF MOTION:
Lumbar ROM within normal limits.
ORTHOPEDIC TESTING:
Patrick FABERE negative bilaterally.
LABORATORY STUDIES:
RBC count low, MCV low, hemoglobin low;
Ferritin low.
UA: negative for nitrites, leukocyte esterase
and blood.
OTHER FINDINGS:
Suprapubic tenderness.

01 . Which of the following need to be included in the diagnosis? (CHOOSE 3)
A. Iron deficiency E. Microcytic anemia
B. Urinary tract infection F. Macrocytic anemia
C. Urolithiasis G. Pelvic inflammatory disease
D. Endometriosis H. Proctitis
02 . What additional studies should be performed on this patient? (CHOOSE 3)
A. Gynecological exam E. Serum iron
B. Pelvic MRI F. Serum folate
C. O & P G. Aortic angiography
D. Laparoscopic biopsy H. Inguinal hernia exam
03 . What additional signs or symptoms may be seen with this condition? (CHOOSE 3)
A. Colonic polyps E. Lymphadenopathy
B. Palpable pelvic mass F. Uterine fibroids
C. Abdominal bloating G. Infertility
D. Rheumatoid arthritis H. Bladder carcinoma

01 . Which of the following need to be included in the diagnosis? (CHOOSE 3)
A. Iron deficiency E. Microcytic anemia
B. Urinary tract infection F. Macrocytic anemia
C. Urolithiasis G. Pelvic inflammatory disease
D. Endometriosis H. Proctitis
02 . What additional studies should be performed on this patient? (CHOOSE 3)
A. Gynecological exam E. Serum iron
B. Pelvic MRI F. Serum folate
C. O & P G. Aortic angiography
D. Laparoscopic biopsy H. Inguinal hernia exam
03 . What additional signs or symptoms may be seen with this condition? (CHOOSE 3)
A. Colonic polyps E. Lymphadenopathy
B. Palpable pelvic mass F. Uterine fibroids
C. Abdominal bloating G. Infertility
D. Rheumatoid arthritis H. Bladder carcinoma

PATIENT INFORMATION
SEX: M AGE: 67
CHIEF COMPLAINT: Midback pain
QUALITY OF PAIN: Stiff, achy
SEVERITY OF PAIN: Mild
AGGRAVATING FACTORS: Lying spine
ASSOCIATED SYMPTOMS: Exertional dyspnea, morning cough
RELIEVING FACTORS: Resting in lounge chair
PAST MEDICAL HISTORY: Lumbar disc herniation, age 33
FAMILY HISTORY: Father, emphysema
OBJECTIVE FINDINGS:
VITALS:
LEFT BP: 158/94
RESP: 20 cpm
PULSE: 90 bpm, irregular
TEMP: 98.4ºF
RANGE OF MOTION:
Decreased cervical flexion
ORTHOPEDIC TESTING:
None performed
LABORATORY STUDIES:
None performed
OTHER FINDINGS:
Upper thoracic extension absent

01 . Select the 3 other expected findings in this case. (CHOOSE 3)
A. Prolonged expiration E. Scoliosis
B. Thoracic intersegmental fixations F. Murmur
C. Hyperresonant percussion G. Epigastric tenderness
D. Anemia H. Pleural friction rub
02 . What additional lab or imaging is needed in this case? (CHOOSE 3)
A. Hgb A1c E. Electrocardiogram
B. Sputum culture F. Cervical spine radiographs
C. Blood culture G. Bone densitometry
D. Pulmonary function tests H. Serum electrolytes
03 . Select the appropriate radiology findings. (CHOOSE 3)
A. Aortic aneurysm E. Enlarged pulmonary arteries
B. Increased AP chest diameter F. Flattening of the diaphragm
C. Gynecomastia G. Sternal fracture
D. Blunted costophrenic sulci H. Mitral annular calcification

01 . Select the 3 other expected findings in this case. (CHOOSE 3)
A. Prolonged expiration E. Scoliosis
B. Thoracic intersegmental fixations F. Murmur
C. Hyperresonant percussion G. Epigastric tenderness
D. Anemia H. Pleural friction rub
02 . What additional lab or imaging is needed in this case? (CHOOSE 3)
A. Hgb A1c E. Electrocardiogram
B. Sputum culture F. Cervical spine radiographs
C. Blood culture G. Bone densitometry
D. Pulmonary function tests H. Serum electrolytes
03 . Select the appropriate radiology findings. (CHOOSE 3)
A. Aortic aneurysm E. Enlarged pulmonary arteries
B. Increased AP chest diameter F. Flattening of the diaphragm
C. Gynecomastia G. Sternal fracture
D. Blunted costophrenic sulci H. Mitral annular calcification

PATIENT INFORMATION
SEX: M AGE: 29
CHIEF COMPLAINT: Elbow, wrist, knee and ankle pain, and chills.
MECHANISM OF INJURY: None; insidious.
QUALITY OF PAIN: Achy.
SEVERITY OF PAIN: Mild.
AGGRAVATING FACTORS: None.
ASSOCIATED SYMPTOMS: Fatigue, weight loss, left flank pain.
RELIEVING FACTORS: Aleve.
PAST MEDICAL HISTORY: Mitral valve prolapse, chlamydial urethritis.
OBJECTIVE FINDINGS:
VITALS:
RESP: 20 cpm
PULSE: 92 bpm
TEMP: 100.8 ºF
RANGE OF MOTION:
Affected joints have painful ROM but no
restrictions.
ORTHOPEDIC TESTING:
None.
LABORATORY STUDIES:
WBC count: 13400.
OTHER FINDINGS:
Costovertebral angle tenderness on the left.
Mitral holosystolic murmur.

01 . What additional clinical findings can expected in this case? (CHOOSE 3)
A. Splinter hemorrahges E. Erythema marginatum
B. Subcutaneous nodules F. Night sweats
C. Tophi G. Melena
D. Splenomegaly H. Positive Lachman test
02 . What additional lab tests or imaging is required in this case? (CHOOSE 3)
A. CBC E. Serum electrolytes
B. Blood cultures F. Bone scan
C. UA G. Echocardiogram
D. Liver function tests H. MRI of chest
03 . What complications or sequelae can be expected in this case? (CHOOSE 3)
A. Rheumatoid arthritis E. Renal infarction
B. Nephrolithiasis F. Congestive heart failure
C. Fatal GI bleeding G. Hepatoma
D. Stroke H. Glaucoma

01 . What additional clinical findings can expected in this case? (CHOOSE 3)
A. Splinter hemorrahges E. Erythema marginatum
B. Subcutaneous nodules F. Night sweats
C. Tophi G. Melena
D. Splenomegaly H. Positive Lachman test
02 . What additional lab tests or imaging is required in this case? (CHOOSE 3)
A. CBC E. Serum electrolytes
B. Blood cultures F. Bone scan
C. UA G. Echocardiogram
D. Liver function tests H. MRI of chest
03 . What complications or sequelae can be expected in this case? (CHOOSE 3)
A. Rheumatoid arthritis E. Renal infarction
B. Nephrolithiasis F. Congestive heart failure
C. Fatal GI bleeding G. Hepatoma
D. Stroke H. Glaucoma

PATIENT INFORMATION
SEX: M AGE: 44
CHIEF COMPLAINT: Weight loss.
SEVERITY OF PAIN: Not applicable.
AGGRAVATING FACTORS: Reduced food intake.
ASSOCIATED SYMPTOMS: Productive cough.
PAST MEDICAL HISTORY: Excessive high-calorie food intake
FAMILY HISTORY: Asthma, brother.
OBJECTIVE FINDINGS:
VITALS:
RESP: 22 cpm
PULSE: 90 bpm
TEMP: 99.9 F
RANGE OF MOTION:
Not relevant.
ORTHOPEDIC TESTING:
Adam’s test negative.
LABORATORY STUDIES:
Elevated WBC count, 14,000
Elevated PMN and monocyte count
PPD positive, 22 mm
OTHER FINDINGS:
Crackles in right upper lobe.

01 . Select the three (3) most common extra-pulmonary sites of involvement. (CHOOSE 3)
A. Kidney E. Penis
B. Vertebrae F. skin
C. Lymph nodes G. Small intestine
D. Eye H. Brain
02 . Which of the following are risk factors for the condition presented. (CHOOSE 3)
A. Bronchial asthma E. HIV infection
B. Alcoholism F. Hyperthyroidism
C. Rib fractures G. Diabetes mellitus
D. Vegetarianism H. Congestive heart failure
03 . What additional clinical findings can be expected to appear? (CHOOSE 3)
A. Rhinitis E. Diarrhea
B. Constipation F. Anorexia
C. Hearing loss G. Pleural effusion
D. Night sweats H. Atrial fibrillation

01 . Select the three (3) most common extra-pulmonary sites of involvement. (CHOOSE 3)
A. Kidney E. Penis
B. Vertebrae F. skin
C. Lymph nodes G. Small intestine
D. Eye H. Brain
02 . Which of the following are risk factors for the condition presented. (CHOOSE 3)
A. Bronchial asthma E. HIV infection
B. Alcoholism F. Hyperthyroidism
C. Rib fractures G. Diabetes mellitus
D. Vegetarianism H. Congestive heart failure
03 . What additional clinical findings can be expected to appear? (CHOOSE 3)
A. Rhinitis E. Diarrhea
B. Constipation F. Anorexia
C. Hearing loss G. Pleural effusion
D. Night sweats H. Atrial fibrillation

PATIENT INFORMATION
SEX: F AGE: 70
CHIEF COMPLAINT: Paresthesias in first three digits of both hands
QUALITY OF PAIN: Tingling; pins and needles
SEVERITY OF PAIN: Mild
AGGRAVATING FACTORS: Sleep
ASSOCIATED SYMPTOMS: Fatigue
RELIEVING FACTORS: Shaking out hands
PAST MEDICAL HISTORY: Hodgkin’s disease, age 37
FAMILY HISTORY: Addison disease, mother
OBJECTIVE FINDINGS:
VITALS:
RESP: 14 cpm
PULSE: 58 bpm
TEMP: 96.7 F
RANGE OF MOTION:
Within normal limits.
ORTHOPEDIC TESTING:
Positive Tinel test at wrists.
LABORATORY STUDIES:
Elevated TSH.
OTHER FINDINGS:
Delayed relaxation phase of deep tendon
reflexes.

01 . Which three (3) additional clinical manifestations would you expect? (CHOOSE 3)
A. Loss of lateral eyebrows E. Heat intolerance
B. Cold intolerance F. Diarrhea
C. Hyperhidrosis G. Anxiety
D. Hypercalcemia H. Coarse, sparse, dry hair
02 . Choose three (3) additional ortho/neuro tests that should be performed. (CHOOSE 3)
A. Bunnel-Littler test E. Biceps reflex
B. Swallowing test F. Upper limb tension test
C. Phalen test G. Dermatome testing
D. Cozen test H. Neer test
03 . Which three (3) diagnoses does the patient have? (CHOOSE 3)
A. Recurrent Hodgkin disease E. Carpal tunnel syndrome
B. Cardiomyopathy F. Cervical disc herniation
C. Primary Hypothyroidism G. Cubital tunnel syndrome
D. Primary Hyperthyroidism H. Hypertension

01 . Which three (3) additional clinical manifestations would you expect? (CHOOSE 3)
A. Loss of lateral eyebrows E. Heat intolerance
B. Cold intolerance F. Diarrhea
C. Hyperhidrosis G. Anxiety
D. Hypercalcemia H. Coarse, sparse, dry hair
02 . Choose three (3) additional ortho/neuro tests that should be performed. (CHOOSE 3)
A. Bunnel-Littler test E. Biceps reflex
B. Swallowing test F. Upper limb tension test
C. Phalen test G. Dermatome testing
D. Cozen test H. Neer test
03 . Which three (3) diagnoses does the patient have? (CHOOSE 3)
A. Recurrent Hodgkin disease E. Carpal tunnel syndrome
B. Cardiomyopathy F. Cervical disc herniation
C. Primary Hypothyroidism G. Cubital tunnel syndrome
D. Primary Hyperthyroidism H. Hypertension

PATIENT INFORMATION
SEX: M AGE: 4
CHIEF COMPLAINT: Left anteromedial knee pain
MECHANISM OF INJURY: Gradual
QUALITY OF PAIN: Achy
SEVERITY OF PAIN: moderate
AGGRAVATING FACTORS: activity, jumping, running
ASSOCIATED SYMPTOMS: left groin tenderness
RELIEVING FACTORS: rest
PAST MEDICAL HISTORY: unremarkable
FAMILY HISTORY: non-contributory
OBJECTIVE FINDINGS:
VITALS:
RESP: 24 cpm
PULSE: 108 bpm
TEMP: 99.7ºF
RANGE OF MOTION:
Left hip ROM is reduced in abduction and
internal rotation
ORTHOPEDIC TESTING:
Negative Clarke test
LABORATORY STUDIES:
None performed
OTHER FINDINGS:
Child limps

01 . What additional tests should be performed on this patient? (CHOOSE 3)
A. CBC E. Valsalva maneuver
B. Patrick FABERE F. Opthalmoscopic exam
C. Bone scan G. Apley’s distraction and compression
D. Lumbar spine x-rays H. Goldthwaite test
02 . What are correct regarding the etiology of this condition? (CHOOSE 3)
A. Obesity E. Due to infection
B. Idiopathic F. More common in males
C. Most common onset in puberty G. More common in females
D. Osteonecrosis H. Due to knee trauma
03 . What are the radiology findings that you will see in this condition? (CHOOSE 3)
A. Mushroom cap sign E. Ice cap appearance
B. Increased medial joint space F. Decreased joint space
C. Smaller femoral head G. Cat bite lesion
D. Compression H. Putti’s triad

01 . What additional tests should be performed on this patient? (CHOOSE 3)
A. CBC E. Valsalva maneuver
B. Patrick FABERE F. Opthalmoscopic exam
C. Bone scan G. Apley’s distraction and compression
D. Lumbar spine x-rays H. Goldthwaite test
02 . What are correct regarding the etiology of this condition? (CHOOSE 3)
A. Obesity E. Due to infection
B. Idiopathic F. More common in males
C. Most common onset in puberty G. More common in females
D. Osteonecrosis H. Due to knee trauma
03 . What are the radiology findings that you will see in this condition? (CHOOSE 3)
A. Mushroom cap sign E. Ice cap appearance
B. Increased medial joint space F. Decreased joint space
C. Smaller femoral head G. Cat bite lesion
D. Compression H. Putti’s triad

PATIENT INFORMATION
SEX: F AGE: 35
MECHANISM OF INJURY: Unexplained acute exacerbation of existing low back pain
QUALITY OF PAIN: Sharp
AGGRAVATING FACTORS: Lumbar extension
ASSOCIATED SYMPTOMS: Nausea and vomiting; urinary frequency
RELIEVING FACTORS: slight relief with lumbar flexion
PAST MEDICAL HISTORY: undiagnosed low back pain following weight lifting injury in school
FAMILY HISTORY: Mother: breast cancer
OBJECTIVE FINDINGS:
VITALS:
RESP: 20 cpm
PULSE: 90 bpm
TEMP: 100.7ºF
RANGE OF MOTION:
Decreased lumbar flexion
ORTHOPEDIC TESTING:
Ely’s heel-to-buttock produces low back pain
LABORATORY STUDIES:
Microscopic hematuria
OTHER FINDINGS:
Costovertebral angle tenderness

01 . Select the most appropriate differential diagnoses. (CHOOSE 3)
A. Acute low back strain E. Perforated peptic ulcer
B. Facet syndrome F. Acute lumbar disc prolapse
C. Ruptured abdominal aortic aneurysm G. Nephrolithiasis
D. Spondylolisthesis H. PID
02 . What is the most appropriate initial case management? (CHOOSE 3)
A. Effleurage E. Lumbar McKenzie extension exercises
B. Vigorous oral hydration F. Referral to urologist
C. Referral to vascular surgeon G. Recommend NSAIDs for pain
D. Take lumbar radiographs H. Referral to internist
03 . What is the most appropriate long term case management? (CHOOSE 3)
A. Core stabilization exercises E. Diet modification
B. Avoid manipulation in extension F. Regular preventative Graston to low back
C. Russian stim to erector spinae G. Weekly supportive spinal manipulation
D. Use condoms to prevent recurrences H. Monitor blood pressure

01 . Select the most appropriate differential diagnoses. (CHOOSE 3)
A. Acute low back strain E. Perforated peptic ulcer
B. Facet syndrome F. Acute lumbar disc prolapse
C. Ruptured abdominal aortic aneurysm G. Nephrolithiasis
D. Spondylolisthesis H. PID
02 . What is the most appropriate initial case management? (CHOOSE 3)
A. Effleurage E. Lumbar McKenzie extension exercises
B. Vigorous oral hydration F. Referral to urologist
C. Referral to vascular surgeon G. Recommend NSAIDs for pain
D. Take lumbar radiographs H. Referral to internist
03 . What is the most appropriate long term case management? (CHOOSE 3)
A. Core stabilization exercises E. Diet modification
B. Avoid manipulation in extension F. Regular preventative Graston to low back
C. Russian stim to erector spinae G. Weekly supportive spinal manipulation
D. Use condoms to prevent recurrences H. Monitor blood pressure

Part III EMCQ fact sheets CCCLA National Board Review
CONDITION: Abdominal Aortic Aneurysm
Relevant anatomy:
! Most AAAs occur between the renal arteries and the aortic bifurcation (L1-L4).
Risk factors and causes:

! Smoking, hypertension, male, increasing age.
Clinical findings: ! Most are asymptomatic until rupture. May have steady, deep,
boring lumbosacral pain. Palpable enlarged aneurysm may be felt. A bruit may be
heard. At rupture: Severe abdominal and/or LBP, hypotension, tachycardia,
lightheadedness, syncope, leg pain and weakness.
Ortho/neuro tests positive:

! None.
Lab tests positive:

! None.
Radiology findings:
! DUS, CT.
Red flags for additional assessment/referral:

! Signs of rupture (see above).
Complications or sequelae:
! Death, renal failure, MI, CVA.
Outcome assessments:
!
Prognosis/expected progression:
! Without treatment: fatal. With treatment, fair chance of survival.
Initial case management:

! Call 911.
Long-term case management:

! Control BP, quit smoking.
Home-instruction/work ergonomics:
! Proper diet, low in cholesterol: DASH diet.
1
CONDITION: Adhesive Capsulitis
Relevant anatomy:
! The glenohumeral joint capsule develops adhesions/fibrosis.

! Trauma, immobilization of shoulder, DM, RSDS.
Clinical findings:
! Initially, pain with progressive restriction, eventually becoming less painful with
typical capsular pattern of restriction greatest in abduction, external rotation, and flexion.

! Apley scratch test, Mazion shoulder rock maneuver
Lab tests positive:

! Fasting blood glucose to R/O DM if necessary.
Radiology findings:
!

!
!
! ROM, upper extremity functional scale
! Good with treatment; takes months to recover

! Passive mobilization, stretching, USD

! Continued stretching; strengthening of atrophied muscles
! Codmanʼs exercises, wall-walking exercises
2
CONDITION: Ankylosing spondylitis
Relevant anatomy:
! Axial joints, typically starting with SI joints, become inflamed, then ankylose.

! Male, caucasian, young adults.
Clinical findings:
! Low back pain and stiffness. Stiffness worst in morning (>1 hr duration), and after
prolonged inactivity. Back pain worse at night. May have low grade fever, anorexia, weight loss,
fatigue. Decreased spinal ROM, initially in low back, but progressive cephalad as ankylosis
advances up the spine. May cause decreased chest expansion (<2” for males or <1½” for
females). May develop uveitis. Peripheral joints may be involved as well.

! Iliac compression, gapping, Elyʼs heel to buttock, Gillet.
Lab tests positive:

! HLA-B27, ESR.
Radiology findings:
! Initially widening of SI joints eventually followed by ankylosis. Vertebral column can
demonstrate any number of findings, including marginal syndesmophytes, dagger sign, trolley
track sign, shiny corner sign, Romanus lesion, bamboo spine, barrel vertebra, squared off
vertebra.

! Acute back pain following trauma--high risk of fracture of ankylosed segments. Be ware
of ADI instability.
!
! Monitor spinal ROM; disability scores (ie Oswestry, Rowland-Morris).
! Not curable. Can slow or halt progression.

! Refer to rheumatologist. Anti-inflammatory PT; gentle mobilization.

! Exercises to maintain posture and strength, continued mobilization.
! Perform home exercises; emphasize fish, fruits and vegetables.
3
CONDITION: Cervical spondylotic myelopathy
Relevant anatomy:
! Cervical DJD, disc herniation, or tumor is compressing spinal cord (and most
likely also cervical nerve roots).

! Increasing age, prior trauma.
Clinical findings:
! Neck pain with possible arm radiation with numbness, weakness and
hyporeflexia in arm(s), along with long tract signs in the lower extremities (Babinski,
hyperreflexia, spasticity, loss of vibration and proprioception--abnormal gait--, and
abnormal pain and temp sensation).

! See above for neuro; orthos: cervical compression and distraction positive;
possibly Soto-Hall.
Lab tests positive:

!
Radiology findings:
! Cervical DJD; MRI or CT may show disc herniation or tumor.

! Bowel or bladder dysfunction, suggesting severe cord compression.
! Permanent loss of neurological function in lower extremities.
! Monitor neurologic status.
! Fair to good with appropriate management.

! Refer to neurosurgeon.

!
!
4
CONDITION: Cluster headache
Relevant anatomy:
!

! Men who smoke. 20-40 years old. Alcohol triggers HA.
Clinical findings:
! HA usually occurs at same time each day, often in the middle of the night.
Excruciating sudden pain, usually over eye with nasal congestion, lacrimation, facial
flushing, Hornerʼs syndrome. The patient is agitated and restless. Resolves in 30-60
min. Recurs daily for a while, then abates. Diagnosis is based on Sx characteristics.

!
Lab tests positive:

!
Radiology findings:
!

!
!
!
! Relapsing/remitting.

! Melatonin. Referral.

!
! Avoid alcohol; stop smoking.
5
CONDITION: COPD
Relevant anatomy:
! Consists of chronic obstructive bronchitis and emphysema. Chronic bronchitis becomes chronic
obstructive bronchitis when spirometric evidence of airflow obstruction develops. The bronchial walls are
narrowed, swollen and inflammed, and contain sputum. Emphysema is destruction of lung parenchyma
leading to loss of elastic recoil and alveolar septa.

! Most cases are due to cigarette smoking.
Clinical findings:
! Productive cough, progressive dyspnea, recurrent acute lung infections, prolonged expiration with
pursed lip breathing, barrel chest, wheezing and rhonchi.

! N/A
Lab tests positive:

! Spirometry: reduced FEV1 and FVC (forced expiratory volume in 1 second and forced vital
capacity)
Radiology findings:
! Flattening of diaphragm, narrow heart, rapid tapering of hilar vessel, peribronchial cuffing, and
widening of retrosternal space.

! Increased work of breathing, esp with cyanosis, somnolence, low O2 saturation on pulse
oximetry, chest x-ray indicative of pneumonia or pneumothorax.
! Pneumonia, spontaneous pneumothorax, acute exacerbation of bronchitis, cor pulmonale (right
ventricular enlargement and failure).
! Periodic spirometry.
! Mortality increases with decreasing FEV1. Death can also occur with acute pneumonia or cardiac
disease. Progression of COPD will continue if patient continues to smoke.

! Referral to pulmonologist.

! Smoking cessation; medical.
! Encourage smoking cessation.
6
CONDITION: Cushingʼs
Relevant anatomy:
! Excessive adrenal cortisol production.

! There are three organic causes of Cushingʼs: most cases are due to a pituitary tumor produces
excess ACTH. This type is called Cushingʼs disease. A second cause is an adrenal tumor producing
excess cortisol. The third cause is ectopic ACTH production, most often by lung cancers. These second
two are called Cushingʼs syndrome.
Clinical findings:
! Moon facies with a plethoric appearance, truncal obesity with proximal muscle atrophy and
weakness (potato on toothpicks appearance), suprclavicular and cervicodorsal fat pads (buffalo hump),
thin atrophic skin with purple striae, easy bruising and poor wound healing, hypertension, mental
disturbances, menstrual irregularities, frontal balding, and hirsutism.

!
Lab tests positive:

! Hyperglycemia. In Cushingʼs disease and ectopic ACTH production, ACTH and cortisol are
elevated. In Cushingʼs syndrome due to adrenal tumor, ACTH is low and cortisol is elevated.
Radiology findings:
! Osteoporosis. Possible renal calculi.

!
!
!
! Good to poor.

! Referral.

! Medical.
!
7
CONDITION: Endometriosis
Relevant anatomy:
! Functioning endometrial tissue is implanted outside the uterine cavity. In most cases, it is
confined to the peritoneal cavity, especially the ovaries, broad ligaments, posterior cul-de-sac, and
uterosacral ligaments. Less commonly, it may implant on the serosal surfaces of the intestines, ureters,
bladder, vagina, cervix, pleura and pericardium. Bleeding from the tissues causes inflammation and
subsequent adhesions.

! Ectopic tissue results from retrograde flow of menstrual tissue through the fallopian tubes.
Clinical findings:
! Common: pelvic pain, especially during menses, pelvic mass, altered menses, infertility,
dyspareunia. The onset of dysmenorrhea after years of painfree menses is a particularly important
diagnostic clue. Other possible symptoms depend on sites of implantation: abdominal bloating, painful
defecation, painful urination, rectal bleeding, etc.

!
Lab tests positive:

! Definitive Dx is by laparoscopic biopsy.
Radiology findings:
! CT/MRI may show lesions.

!
!
!
! Good to poor, depending on severity.

! Referral.

! Medical.
!
8
CONDITION: Gonococcal arthritis
Relevant anatomy:
! Most often affects small joints of hands, wrists, elbows, knees, and ankles.

! Unprotected sex with infected individual. Usually adolescents or young adults.
Clinical findings:
! Fever, chills, skin rash (pustules/papules), migratory tenosynovitis and arthritis
which settles in one or a few joints. May or may not have genitourinary symptoms.

!
Lab tests positive:

! Positive genitourinary culture, positive synovianalysis, increased WBC count,
ESR, blood cultures.
Radiology findings:
! Soft tissue swelling, synovial effusion, eventually joint destruction may occur).

!
! Permanent joint destruction (uncommon).
!
! Good with appropriate antibiotics.

! Refer.

!
! Counsel patient on sexual protection.
9
CONDITION: Hodgkinʼs lymphoma
Relevant anatomy:
! Malignant proliferation of lymphoreticular system.

! Males slightly more common than females, 15-40 yr old.
Clinical findings:
! Painless cervical lymphadenopathy, but pain may occur immediately after alcohol
consumption. Pruritus may occur. Fever, night sweats, weight loss. Splenomegaly.
(Fever may be a Pel-Ebstein fever: days of high fever alternating with days of low or
normal temperature).

!
Lab tests positive:

! Lymph node biopsy: Reed-Sternberg cells. Anemia, lymphocytopenia,
eosinophilia, increased alkaline phosphatase and ESR.
Radiology findings:
! Ivory vertebra. Mediastinal lymphadenopathy on CXR.

!
! Most complications are those of treatment, however, the disease can be fatal.
!
! Cure in >75%.

! Refer.

!
!
10
CONDITION: Hypothyroidism (myxedema)
Relevant anatomy:
! Most cases are primary hypothyroidism, however, 10% are secondary. More
common in women.

! Primary hypothyroidism is almost always due to Hashimotoʼs thyroiditis
(autoimmune); in the US, iodine deficency is no longer a common cause; secondary is
due to hypopituitarism.
Clinical findings:
! Cold intolerance, constipation, forgetfulness, slow mentation, modest weight
gain, carpal tunnel syndrome, amenorrhea, hoarse voice, slow speech, facial puffiness,
loss of lateral eyebrows, sparse hair, coarse, dry skin, bradycardia, enlarged tongue,
possible pleural effusion.

! Delayed relaxation phase of deep tendon reflexes (pathognomonic).
Lab tests positive:

! In primary hypothyroidism: Elevated TSH, low T4 and T3; in secondary: low TSH,
T4, and T3. Possible anemia on CBC.
Radiology findings:
!

! Coma.
! Myxedema coma.
!
! Good with thyroid hormone replacement.

! Referral.

! Medical.
11
CONDITION: Infectious mononucleosis
Relevant anatomy:
! Involves cervical lymph nodes, upper respiratory tract, and spleen.

! Spread of EBV by kissing.
Clinical findings:
! Fatigue, lasting days to weeks, followed by fever, pharyngitis, and
lymphadenopathy. Fever peaks in afternoon or early evening. Splenomegaly occurs in
50% of cases.

!
Lab tests positive:

! CBC (lymphocytosis) and heterophil antibody test, (Mono-spot). Possible
elevated liver enzymes.
Radiology findings:
!

! Signs of complications (see below).
! Meningitis, encephalitis, Guillian-Barre syndrome, cranial nerve palsies, splenic
rupture. EBV increases risk of Burkittʼs lymphoma.
!
! Usually self-limited.

! Supportive.

!
! Avoid heavy lifting and contact sports to prevent splenic rupture.
12
CONDITION: Infective endocarditis
Relevant anatomy:
! Infection of the endocardial layer and valves of the heart.

! IV drug abuse, valvular disease, prosthetic valves, immunocompromise are
common risk factors. Staph aureus and strep viridans are common causes, the former
from IV drug use, the latter from dental work.
Clinical findings:
! Fever and a murmur. Also can experience fatigue, dyspnea, and bacterial
embolic phenomena: stroke, splinter hemorrhages in nailbeds, Oslerʼs nodes (painful
nodules on finger pads and toe pads), Janeway lesions (painless reddish-brown spots
on palms and soles), splenic enlargement and pain (abscesses), petechial hemorrhages
in conjunctivae, Roth spots (retinal).

! N/A
Lab tests positive:

! Positive blood cultures, increased WBC count, increased ESR.
Radiology findings:
!

! LUQ pain, RUQ pain (splenic or hepatic abscess), stroke, signs of CHF, MI.
! Stroke and other organ ischemic necrosis due to emboli.
! Negative blood cultures.
! Good with aggressive antibiotic treatment.

! Referral.

! Medical.
13
! CONDITION: Isthmic spondylolisthesis
Relevant anatomy:
! Slippage anteriorly of a vertebra. Most commonly for isthmic spondys is L5, while
L4 is most commonly involved in degererative spondy. Isthmic is most common type of
spondylolisthesis.

! Usually occurs in adolescence. Often due to minimal trauma with disruption of
the pars (spondylolysis), and subsequent anterior slippage (spondylolisthesis).
Clinical findings:
! Low back pain, worse in extension, or when straightening from a stooped
posture.

! Pheasant, Stork standing
Lab tests positive:

!
Radiology findings:
! Break in pars with anterior slippage of vertebra. Graded via Meyerding, and
Ullmanʼs line.

! Cauda equina syndrome
! Instability, neurological compromise
! Oswestry; monitor degree of slippage.
! Fair to good with treatment.

! Flexion-distraction, supine sacral pull spondylo adjustment

! Rehab for core stability
!
14
CONDITION: Legg-Calve-Perthesʼ disease
Relevant anatomy:
! Affects the femoral head in children.

! Boys > girls; 4-10 yrs old. Idiopathic aseptic necrosis of femur head.
Clinical findings:
! Hip and/or anteromedial knee pain, gait disturbance of gradual onset and slow
progression. Worse with activity and weight bearing. Abduction and internal rotation of
hip is most significantly reduced.

! Patrick FABERE
Lab tests positive:

!
Radiology findings:
! Flattening and opacification of femoral head. Diagnosis is confirmed with bone
scan or MRI.

!
! Residual distortion of femoral head, and subsequent development of DJD.
!
! Without treatment, self-resolving in 2-3 years. With treatment, sequelae are less
severe.

! Prolonged bed rest, referral.

! Mobile traction, slings and splints, abduction plaster casts.
!
15
CONDITION: Lumbar disc herniation
Relevant anatomy:
! Protrusion of a lumbar disc, most commonly L4 or L5. L4 disc (between L4 and L5)
affects the L5 nerve root. The L5 disc affects the S1 nerve root.

! Lifting, flexion with twisting, sedentary lifestyle, truck driver, prior back trauma, smoking.
Clinical findings:
! Acute LBP, accompanied by sciatic leg pain, often to the foot, aggravated by sitting and
flexion, less severe with standing, relieved by lying down. Dejerineʼs triad. May have loss of
neurologic function in affected nerve root (paresthesia or numbness, hyporeflexia, weakness).

! SLR, Braggard, WLR and Fajersztajn if medial disc, Valsalva, Kemp, Turyn. For L5
nerve root: weak great toe extensor or heel walk, or tibialis posterior, and sensory over dorsum
of foot and anterolateral lower leg. For S1 nerve root: weak toe walk or peroneii, Achillesʼ reflex,
and sensory over lateral/plantar foot.
Lab tests positive:

!
Radiology findings:
! MRI, or CT evidence of disc herniation.

! Cauda equina syndrome (perineal numbness with loss of bowel/bladder function).
! Permanent loss of neurologic function if cauda equina is not treated promptly.
! Monitor neurologic status, orthopedic tests; outcome measures (Oswestry, Rowland-
Morris, or Bournemouth).
! Good with proper treatment.

! McKenzie protocol, flexion-distraction, analgesic and anti-inflammatory modalities. Refer
immediately if cauda equina syndrome is present. Refer to spine surgeon if patientʼs condition
deteriorates or fails to improve.

! Ergonomic assessment and education, back rehab exercises.
! Avoid sitting, flexion, lifting, instruct in icing and home exercises.
16
CONDITION: March fracture (metatarsal stress fracture)
Relevant anatomy:
! Metatarsal stress fracture, most commonly the second metatarsal.

! Poorly conditioned runners or individuals who suddenly begin long distance
walking, or begin carrying heavy packs (soldiers). Risk factors include pes cavus,
osteoporosis, female triathletes.
Clinical findings:
! Forefoot pain that occurs after long workout which lessens shortly after activity is
stopped. With subsequent exercise, onset of pain is progressively earlier. Eventually
pain is severe enough to prevent activity.

! Forefoot squeeze (not recommended).
Lab tests positive:

!
Radiology findings:
! Standard foot series reveals fracture.

!
!
!
! Will take up to 12 weeks to heal.

! Crutches, wooden shoes or supports. Casts rarely required.

!
! Rest.
17
CONDITION: Myasthenia gravis
Relevant anatomy:
! Autoimmune attack of acetylcholine receptors at the myoneural junction.

! Young women and older men. Precipitating factors: infections, surgery, drugs.
Clinical findings:
! Weakness and easy fatiguability of muscles. Bulbar muscles are affected first,
espcially muscles of eye (diplopia, strabismus, ptosis). Symptoms worsen as day goes
on. Other facial muscles, masticatory muscles, swallowing muscles, and tongue are
affected. Eventually other muscles can be affected, including respiratory muscles. Little
muscle atrophy is seen, and DTRs are preserved. May have thymoma.

! Weakness of affected muscles.
Lab tests positive:

! Positive Tensilon test. Abnormal EMG.
Radiology findings:
!

! Respiratory difficulty.
! Respiratory failure.
!
! Poor.

! Refer.

!
!
18
CONDITION: Nephrolithiasis, Urolithiasis
Relevant anatomy:
! Nearly 80% of kidney stones are composed of calcium oxalate, 10% are
composed of uric acid, 2% are cystine, and the rest are struvite (magnesium ammonium
phosphate).

! For calcium oxalate stones, the main risk factors are hypercalciuria (hereditary),
or hyperoxaluria caused by excess ingestion of oxalate-rich foods (rhubarb, spinach,
chocolate). Uric acid stones are formed in patients with hyperuricemia, gout, and
excessive consumption of high-purine foods.
Clinical findings:
! Excruciating back pain with radiation across abdomen into groin, nausea and
vomiting, and hematuria. Urinary frequency and urgency are common.

! Murphyʼ punch produces costovertebral angle tenderness.
Lab tests positive:

! Hematuria.
Radiology findings:
! Calcium containing stones can be visible on plain film. Noncontrast spiral CT is
the diagnostic imaging modality of choice.

! High fever, and shaking chills, indicating infection proximal to stone.
! Kidney infection and sepsis.
!
! Good with proper treatment.

! Referral.

! Diet modification to prevent recurrence.
19
CONDITION: Osteoporosis
Relevant anatomy:
! Cortical and trabecular (cancellous) bone loss occurs. Cortices becomes thinned and trabeculae are
decreased in number.

! 95% is primary, 5% is secondary. There are 3 types of primary osteoporosis: 1. Idiopathic (uncommon,
occurs in children and young adults), 2. Post-menopausal (51-75 years of age), 3. Involutional or senile (due to
decreased osteoblast activity associated with aging--seen after 60 years of age). Primary osteoporosis is more
common in women. Risk factors include: smoking, excessive caffeine and alcohol consumption, and sedentary
lifestyles. Recent evidence suggests that life-long vitamin D deficiency plays an important role. Secondary
osteoporosis is due to an underlying disease.
Clinical findings:
! None, until fracture occurs, at which time bone pain will be present. Vertebral compression fractures below
T6 are common, as are fractures of the femoral neck. Multiple thoracic compression fractures can lead to a
dowagerʼs hump.

! Integrity of the nervous system should be assessed in cases of spinal fractures to rule out nerve root or
spinal cord compression. Numbness and weakness indicate such lesions. Hyperreflexia and Babinski signs indicate
spinal cord compression.
Lab tests positive:

! Serum calcium and phosphorus will be normal in primary osteoporosis. Many patients with osteoporosis will
have low 25-OH vitamin D levels, however.
Radiology findings:
! Plain radiographs demonstrate osteopenia with decreased bone density and pencil thin cortices, but not until
at least 30% of bone mass has been lost. Fractures, if present, will also be seen. The gold standard for measuring
bone density is the DEXA (dual-energy x-ray absorptiometry). Screening is recommended for women over 65

! Signs of underlying disease, suggesting secondary osteoporosis. Common causes of secondary
osteoporosis include chronic renal failure, COPD, corticosteroid use, Cushingʼs, hyperparathyroidism, malabsorption
syndrome, RA, and malignancy.
! Fracture.
! Track DEXA scores.
! The goal of treatment is to preserve bone mass. The rate of bone loss can be slowed with aggressive
treatment.

! Calcium (1000 mg per day) and vitamin D (1000 IU per day). Referral for bisphosphonate prescription, which
significantly can increase bone mass. If fracture has occurred, appropriate treatment is required.

! Continued supplement and medication. Rehabilitation post-fracture may be required.
! Regular exercise (if no fracture) to encourage bone formation. If fresh compression fracture, avoid bending
and lifting, use back brace.
20
CONDITION: Osteosarcoma
Relevant anatomy:
! Most commonly involves the metaphysis, most common at the knee.

! 10-20 year olds.
Clinical findings:
! Bone pain, often deep, worse at night, unrelenting, constant.

!
Lab tests positive:

! Dx requires biopsy.
Radiology findings:
! Sunburst, spiculated periosteal appearance, Codmanʼs triangle, soft-tissue mass.
Do chest x-ray since lung met is common.

! Cough.
! Lung metastasis or other distant mets.
!
! Poor.

! Refer to oncologist.

!
!
21
CONDITION: Piriformis syndrome
Relevant anatomy:
! Spasm of piriformis muscle, often entrapping sciatic nerve.

! Overuse, SIJ disorders, trochanteric disease, fibrous adhesions.
Clinical findings:
! Sciatica beginning in the buttock with positive SLR aggravated with leg in internal
rotation compared to external rotation. Piriformis taut and tender. Low back pain usually
absent.

! May have motor or sensory deficits in the leg. Positive LLTT.
Lab tests positive:

!
Radiology findings:
! In the elderly, consider imaging to rule out spinal stenosis.

!
!
! Appropriate outcome measures.
! Good in most cases.

! May need to treat underlying cause. Various methods of stretching muscle, e-
stim, US, CMT to SIJ if appropriate.

! Rehab may be appropriate.
! Stretching exercises.
22
CONDITION: Community acquired pneumonia
Relevant anatomy:
! Infection of lung parenchyma.

! Causes include bacterial, viral, or fungal. The most common bacterial causes are: Strep
pneumoniae, Hemophilus influenzae, Chlamydia pneumoniae, and Mycoplasma pneumoniae. The most
common viral causes are: Respiratory syncytial virus (RSV), adenovirus, influenza virus, parainfluenza
virus. The most common fungal causes are Histoplasma and Coccidioides.
Clinical findings:
! Vary somewhat due to infectious agent. Generally, will produce malaise, cough, dyspnea, and
chest pain. Sputum production may be seen, especially later in course of infection. Fever, tachypnea and
tachycardia, crackles, bronchial breath sounds and egophony, and dullness to percussion may be found.
Pleural effusion may be present.

! N/A
Lab tests positive:

! Increased WBC count; increased PMN with bacterial, increased lymphocytes with viral, increased
monocytes with fungal. Sputum culture may be positive.
Radiology findings:
! Chest x-ray almost always demonstrates some degree of infiltrate after the first 24-48 hours.
Pleural effusion may be seen.

! Presence of cyanosis, tachypnea greater than 32 breaths per minute, low O2 saturation on pulse
oximetry.
! Death.
!
! Pneumococcal pneumonia accounts for 66% of all fatal cases of community acquired pneumonia
in the elderly or infants. Otherwise, prognosis tends to be good with proper treatment.

! Referral; antibiotics if appropriate.

! Medical.
! Rest.
23
CONDITION: Psoriatic arthritis
Relevant anatomy:
! Involves skin, nails, and joints, esp DIPs.

! AIDS, HLA-B27.
Clinical findings:
! Skin and nail involvement may precede or follow onset of arthritis. Typically is
asymmetrical involvement of DIPs of hands and feet, but can involve other joints, SI
joints and spine. Rheumatoid nodules are absent.

!
Lab tests positive:

! ESR and CRP increased, HLA-B27 positive in many; possible increase in uric
acid.
Radiology findings:
! In spine, asymmetric non-marginal syndesmophytes. Hand: bilateral but
asymmetrical, marginal jt erosion, fluffy periostitis (mouse ears), pencil-in-cup,
telescoping of digits leading to opera glass hand deformity; Spine: non-marginal
syndesmophytes--comma shaped, bagpipe shaped, Bywater-Dixon or floating type

!
!
!
! Most are controllable with medication.

! Refer to rheumatologist.

!
24
CONDITION: Rheumatoid arthritis
Relevant anatomy:
! Symmetrical inflammatory arthritis of peripheral joints.

! Female, 35-50 years, smoking.
Clinical findings:
! Symmetrical joint pain, swelling, stiffness lasting more than 1 hr, involving the
wrists, MCPs, and PIPs, most commonly. Symptoms worse in the morning. Low grade
fever, fatigue, anorexia. May also involve feet, elbows, ankles, and upper cervical spine.
Fingers may exhibit ulnar deviation, swan-neck and boutonniere deformities.
Rheumatoid nodules may be present.

!
Lab tests positive:

! Positive rheumatoid factor, elevated ESR.
Radiology findings:
! Soft tissue swelling, rat bite erosions, juxta-articular erosions, periarticular
osteopenia, uniform jt space narrowing, ulnar deviation of digits, swan neck and
boutonneire deformities, Terry Thomas sign, Lanois deformity

! Remember to assess ADI for atlantodental instability.
! See red flags.
! There are rheumatoid specific outcome measures.
! Unpredictable. Life-expectancy is reduced by 3-7 years.

! Fish oil, anti-inflammatory PT, rest, referral to rheumatologist.

! Maintain muscle strength and mobility with exercises, as tolerated.
25
CONDITION: SLE
Relevant anatomy:
! Multisystem, inflammatory autoimmune disorder.

! Female of child-bearing age, Black > White.
Clinical findings:
! Fever, polyarthritis which is typically non-destructive but may cause ulnar drift or
swan-neck deformities, malar rash, photosensitivity, oral ulcers, serositis, renal
disorders, leukopenia, headache or stroke or neuropathy or personality changes--any or
all.

!
Lab tests positive:

! ANA, anti-DNA, anti-SM antibodies positive, low WBC, high ESR.
Radiology findings:
! Soft-tissue swelling, vascular calcification, relative preservation of jt space, ulnar
deviation of digits, swan neck and boutonneire deformities, osteonecrosis.

! Stroke, acute nephritis, sudden worsening of symptoms.
!
!
! Relapsing and remitting.

! Refer to rheumatologist.

!
!
26
CONDITION: Degenerative ;umbar spinal stenosis
Relevant anatomy:
! Narrowing of the central canal and often, the lateral recesses.

! Degenerative. Risk of symptoms increase in congenitally small canals.
Clinical findings:
! Possible low back pain and morning stiffness lasting less than 1 hr. Unilateral,
bilateral, or alternating leg pain, radiculopathy, neurogenic claudication, possible
bowel/bladder involvement.

! Pheasant test, stoop test, bicycle test.
Lab tests positive:

!
Radiology findings:
! Possible degenerative spondylolisthesis, lipping and spurring, facet hypertrophy,
positive Eisensteinʼs measurement. Need CT or MRI to adequately evaluate.

!
!
! Oswestry or similar.
! Fair. Can be managed in many cases, not cured without surgery.

! Flexion distraction, Williams flexion exercises

! Continue flexion exercises; postural correction.
! Avoid prolonged extension.
27
CONDITION: Type 2 diabetes mellitus
Relevant anatomy:
! Beta islet cells initially secrete high levels of insulin due to insulin receptor resistance, but eventually insulin
production falls, further exacerbating the hyperglycemia.

! Obesity, American Indians, Hispanics, Asians.
Clinical findings:
! Polyuria, polydipsia, excessive thirst. Fatigue, weakness. Often asymptomatic. May present with signs and
symptoms of complications.

!
Lab tests positive:
! Elevated fasting glucose, elevated HbA1c.
Radiology findings:
!
! Signs and symptoms of complications. (See below).
1. Diabetic retinopathy. This is the most common cause of blindness in the US. Characterized by retinal
microaneurysms, macular edema, neovascularization, cotton-wool spots, and retinal detachment.
2. Diabetic nephropathy. This is the most common cause of renal failure in the US. Characterized by systemic
hypertension, albuminuria, and nephrotic syndrome, with wide-spread edema.
3. Diabetic neuropathy. This is the most common cause of peripheral polyneuropathy in the US.
Characterized by glove and stocking paresthesia, loss of proprioception. May also have
mononeuropathies, especially of median, peroneal, femoral. May also develop autonomic neuropathy,
characterized by gastroparesis and bezoar formation, orthostatic hypotension, diarrhea, and abnormal
sweating patterns.
4. MI, CHF, CVA, PAD.
5. Foot ulcers and gangrene. DM is the most common cause of gangrene in the US.
6. Infection. Diabetics are more prone to infection than non-diabetics.
7. Dupuytrenʼs contracture, adhesive capsulitis
8. Necrobiosis lipoidica diabeticorum, acanthosis nigricans.
! Daily blood glucose monitoring.
! Without proper treatment, prognosis is poor; with proper treatment, development of complication is reduced
and prognosis is fair.

! Referral. Diet.

! Medical and dietary.
! Encourage proper blood glucose monitoring, dietary adherence, and exercise.
28
CONDITION: Tuberculosis
Relevant anatomy:
! Mycobacterial infection most commonly affecting the lungs. In HIV negative patients, it most
typically affects the lung apex. In HIV positive patients, it may affect any portion of lungs, and may have a
miliary distribution.

! The most significant risk factor is HIV infection. Other risk factors include homelessness, living in
crowded living conditions, alcoholism, malnutrition, recent immigration from high-prevalence countries:
Southeast Asia, Central America, Africa.
Clinical findings:
! Progressive cough, eventually productive of purulent sputum, eventually containing blood; chest
pain, esp pleuritic, weight loss, night sweats, fever, crackles.

! N/A
Lab tests positive:

! Positive PPD (purified protein derivative skin test); elevated WBC count, esp monocytes; positive
sputum stain for acid-fast bacilli and culture.
Radiology findings:
! Varies. Multinodular infiltrate above or posterior to clavicle, middle or lower lung infiltrate, upper
lobe lung cavitation (classic), pleural effusion.

! Additional assessment required if there is a suggestion of extra-pulmonary involvement.
! Complications include: renal involvement, spinal involvement (Pott disease), lymph node
involvement, or meningitis, peritonitis, and pericarditis.
!
! Generally good with proper treatment, although MDRTB (multi-drug resistant TB) may be more
challenging to cure.

! Referral.

! Medical.
! Reinforce need to continue with antibiotic regimen as instructed by physician.
29
CONDITION: Thoracic outlet syndrome
Relevant anatomy:
! Entrapment of neurovascular bundle in thoracic outlet.

! Entrapping structure may be scalenus anticus, cervical rib, clavicle (postural), pec minor,
tumor of lung apex of lymph nodes.
Clinical findings:
! May have neck or shoulder pain with radiation down the arm. If primarily brachial plexus
is entrapped, will see paresthesia/numbness, possible weakness, and decreased DTRs.
Raynaudʼs may be seen. If primarily the subclavian artery and/or vein is entrapped, will see
color changes (pallor or cyanosis), cold extremity, Raynaudʼs, weak pulses, swelling in hand.
Neurologic entrapment is much more common.

! Adsonʼs, costoclavicular, Wrightʼs/hyperabduction, Allen
Lab tests positive:

!
Radiology findings:
! Cervical films to rule out cervical rib; CXR and apical lordotic if Pancoast tumor is
suspected.

! Lymphadenopathy, history of smoking.
! In severe cases of vascular involvement, may see gangrene of fingertips. In neurologic
involvement, may see wasting in intrinsic muscles of hand.
! Upper extremity functional scale.
! Poor, to fair to good, depending on cause.

! Determine cause, and whether referral is required. Treat underlying musculoskeletal
fault, including stretching, myofascial release, CMT.

! Postural correction and exercises.
! See above.
30
CONDITION: Urinary tract infection (UTI)
Relevant anatomy:
! Can involve urethra, bladder, prostate, kidney.

! Female gender. Diabetes mellitus, catheterization, prostate enlargement. Most common
infectious organisms: E. Coli.
Clinical findings:
! Urethritis: dysuria, urethral discharge.
! Cystitis: sudden onset of frequency, urgency, and painful voiding of small volumes of urine.
Hematuria may be present.
! Prostatitis: suprapubic or rectal pain, urethral discharge, frequency, urgency, difficulty stopping,
dribbling.
! Pyelonephritis: low back or flank pain. Urinary frequency and dysuria is seen in 33%. Chills, fever,
nausea and vomiting are typical. Murphyʼs punch reveals costovertebral angle tenderness.

!
Lab tests positive:

! Urinalysis: culture and sensitivity reveals organism; positive nitrite and leukocyte esterase
indicates presence of infection.
Radiology findings:
!

! Signs of pyelonephritis (the most severe form of UTI).
!
!
! Good.

! Referral.

! Cranberry juice daily can reduce risk of recurrence.
! Cranberry juice.
31
PART III Miscellaneous Factoids! CCCLA National Board Review
Worst-case causes of acute abdominal pain
Children:! ! Appendicitis
! ! ! Intussusception
! ! ! Reyeʼs syndrome
Young women:! Appendicitis

! ! ! Ectopic pregnancy
! ! ! PID
Young men:! ! Appendicitis

! ! ! Testicular torsion
Midlife adults:! Acute MI

! ! ! Perforated ulcer
Elderly adults:! Acute intestinal ischemia

! ! ! Necrotic bowel
! ! ! Bowel obstruction
! ! ! Ruptured abdominal aortic aneurysm
1
Features of inflammatory vs mechanical back pain

Mechanical Inflammatory
Onset acute gradual
Age at onset any age usually < 40
(years)
Effect of worse better
exercise
Effect of rest better worse
Morning + +++
stiffness
Pain radiation nerve root diffuse
irritation/ tension
signs- L4, L5, S1
Sleep +/– +++
disturbance
Tenderness, local diffuse
spasm
Scoliosis + –
Deficit in asymmetrical symmetrical
movement
range
2
RHEUMATOLOGIC FINDING CAUSES/DIAGNOSES

PAINFUL, SWOLLEN HANDS •Gout
•Pseudogout
•RA
•Scleroderma (early)
•CRPS (complex regional pain syndrome,
formerly RSD or RSDS)
ACUTE MONOARTHRITIS (PAINFUL, SWOLLEN, •Septic arthritis
WARM JOINT) •Gout
•Pseudogout
•Intraarticular fracture
•Hemarthrosis
CAUSES OF HEMARTHROSIS •Trauma
•Intraarticular fracture
•Hemophilia
•Osteonecrosis
ARTHRITIS, HIGH FEVER, AND RASH •Rubella
•Fifth disease (parvovirus B-19)
•Gonococcemia or meningococcemia
•Secondary syphilis
•Lyme disease
ARTHRITIS AND A RASH •SLE
•Dermatomyositis
•Psoriatic arthritis
•Reactive arthritis (Reiterʼs)
•Vasculitis
ACUTE ONSET OF POLYARTHRITIS AND FEVER •Vasculitis
•JRA
•Endocarditis
•Rheumatic fever
CHRONIC MONOARTHRITIS •Mechanical derangement
•Neuropathic joint
•RA
CHRONIC DISTAL SYMMETRICAL •RA
POLYARTHRITIS •SLE
•Polymyositis
•Gout or pseudogout
ARTHRITIS AND SUBCUTANEOUS NODULES •RA
•Gout (tophi)
•Sarcoidosis
•Rheumatic fever
DIP JOINT ARTHRITIS •OA (Heberdenʼs nodes type)
•Nodal gout
OLIGOARTHRITIS •Psoriatic arthritis
•Lyme disease
•Reactive arthritis
•Gout
•Pseudogout
3
SPONDYLITIS •AS*
•Reactive arthritis*
•Enteropathic arthritis*
•Psoriatic arthritis*
•RA**
*Seronegative
**Seropositive
ENTHESOPATHY •Reactive arthritis
•AS
•DISH
ARTHRITIS AND WEIGHT LOSS •Severe RA or RA with vasculitis
•Cancer
•Enteropathic arthritis
•HIV
ARTHRITIS AND A HEART MURMUR •Endocarditis
•AS
•Rheumatic fever
•RA or SLE
JOINT PAIN AND MUSCLE WEAKNESS •RA
•AS
•Polymyositis/dermatomyositis
•SLE
•Progressive systemic sclerosis
PROXIMAL JOINT PAIN AND STIFFNESS •Polymyalgia rheumatica
•Osteomalacia
•Multiple myeloma
•Metastatic cancer
•Adhesive capsulitis
FACTORS OTHER THAN INFLAMMATION THAT INCREASE •Anemia
THE ESR •Female sex
•Pregnancy
•Hypercholesterolemia
FACTORS THAT DECREASE THE ESR •Polycythemia
•Sickle cell disease
•Spherocytosis
•Microcytosis (thallasemia, iron deficiency anemia)
COMMON MUSCULOSKELETAL •Polyarthritis
MANIFESTATIONS OF ACROMEGALY •Carpal tunnel syndrome
•Degenerative back pain
•Myopathy
•DJD
COMMON MUSCULOSKELETAL •Fibromyalgia
MANIFESTATIONS OF HYPERTHYROIDISM •Adhesive capsulitis
•Back pain (osteopenia)
•Myopathy (esp proximal)
COMMON MUSCULOSKELETAL •Fibromyalgia
MANIFESTATIONS OF HYPOTHYROIDISM •Polyarthralgia/polyarthritis
•Carpal tunnel syndrome
•Delayed relaxation phase of DTRs
4
COMMON MUSCULOSKELETAL •Weakness

MANIFESTATIONS OF ADDISONʼS DISEASE •Fibromyalgia
•Arthralgias
•Joint effusions
•Muscle wasting
COMMON MUSCULOSKELETAL •Painful tibias syndrome
MANIFESTATIONS OF CUSHINGʼS SYNDROME •Joint effusions
•Osteonecrosis
COMMON MUSCULOSKELETAL •Pseudogout
MANIFESTATIONS OF HYPERPARATHYROIDISM •Polyarthralgia/polyarthritis
•Brown tumors
•Fracture
COMMON MUSCULOSKELETAL •Cheiroarthropathy
MANIFESTATIONS OF DIABETES MELLITUS •Dupuytrenʼs contracture
•Trigger finger
•DISH
•Neuropathic joints
Degenerative spondylolisthesis is more
common in DM
MOST COMMON CAUSES OF HYPERURICEMIA •Uric acid overproduction
Gout (10% of cases)
Overweight
Excessive alcohol use
Psoriasis
Multiple myeloma
•Uric acid underexcretion
Gout (90% of cases)
Renal insufficiency
Excessive alcohol use
Hypertension
Hypothyroidism
Hyperparathyroidism
CONDITIONS ASSOCIATED WITH CPPD •Aging
•OA
•DM
•Hyperparathyroidism
•Hypothyroidism
•Hemochromatosis
CAUSES OF MIGRATORY ARTHRITIS •Hepatitis B or C
•Rheumatic fever
•SLE
•Lyme disease
•Gonoccocal arthritis
•Endocarditis
5
WHEN SHOULD YOU SUSPECT THAT CERVICAL/ARM PAIN IS NON-

MECHANICAL and/or SERIOUS?
When the patient has…
1. Gradually increasing pain. Cervical disc lesions can do this, but only over a short
period of time.
2. Expanding pain area.
3. Bilateral arm pain.
4. Radicular arm pain in a patient younger than 35. Cervical disc lesions are uncommon
in this age group.
5. Arm pain lasting longer than 6 months.
6. Limitation in ALL cervical ranges of motion.
7. Involuntary muscle spasm in passive ROM.
8. Resisted movement of neck is painful AND weak.
9. Lateral flexion away from the painful side is the only painful movement. Worry about
costoscapuloclavicular lesions or apical lung tumor.
10.Scapular elevation is weak and limited. Worry about the brainstem.
11.Hornerʼs syndrome is present (ipsilateral miosis, ptosis, anhydrosis). Worry about
lesion of the cervical sympathetic ganglia from a tumor in the thorax of apical lung
tumor.
12.Hoarseness, especially if painless.
13.T1 palsy. Leads to atrophy and weakness of the intrinsic muscles of the hand. Often
is the first sign of ALS.
14.Paralysis.
15.Three nerve roots are involved. Disc lesions occasionally affect 2 nerve roots, but 3-
root involvement almost always is due to a more serious cause.
16.Muscle weakness in the absence of pain.
17.Dermatomal pain or paresthesia initially present only distally, but then moves
proximally.
18.Babinski sign.
6
WHEN SHOULD YOU SUSPECT THAT THORACIC SPINE PAIN IS NON-

1. Progressively increasing pain.

2. Expanding area of pain.
3. Continuous pain.
4. Pain not affected by movement, activity, or posture.
5. First symptoms in the thoracic area in a patient older than 50.
6. Central thoracic spine pain radiating bilaterally toward the front. Think of tumor,
extradural hematoma, or, sometimes, herpes zoster (more likely unilateral).
7. Gross limitation of bilateral lateral flexion and rotation. Worry about AS.
8. Gross limitation of extension. Think infection, tumor, AS, DISH.
9. Limitation of lateral flexion away from side of pain as the only restricted motion. Think
lung or abdominal neoplasm or thoracic neuroma.
10.Flexion with a rigid thoracic section. Think AS, fracture, tumor, osteomyelitis.
11.Altered neurological signs in the legs.
12.Signs of multiple root involvement.
13.Involuntary muscle spasm with passive movement.
14.Local paravertebral mass.
15.Gibbus deformity.
7
WHEN SHOULD YOU SUSPECT THAT LOW BACK/LEG PAIN IS NON-

1. Pain is located in the thoracolumbar /upper lumbar region. Only 5% of mechanical

back pain occurs in the region.
2. Gradually increasing pain.
3. Expanding area of pain.
4. Continuous pain.
5. Sciatica that lasts too long. Radicular pain that has not improved in 9 months is
virtually always due to a serious cause.
6. Bilateral sciatica.
7. Increasing back pain after surgery.
8. Acute low back pain in a geriatric patient.
9. Gross and bilateral limitation of lateral flexion of the lumbar spine. Think of AS,
neoplasm, Pagetʼs, osteomyelitis, or fracture.
10.The only gross restriction in ROM is lateral flexion away from side of pain. Be highly
suspicious of abdominal neoplasm, especially colon or kidney, or a lumbar neuroma.
11.Flexion with a rigid lumbar spine. Think of the seronegative spondyloarthropathies.
12.The degree of weakness is greater than the degree of pain.
13.Involvement of multiple roots.
14.Weakness of the L1 and L2 roots.
15.Saddle paresthesia/anesthesia and incontinence.
16.Presence of the sign of the buttock. While this could be due to a severe disc lesion, it
can also signify sacral, iliac, or femoral malignancy, septic arthritis of the SI joint, or a
rectal abscess.
8
DDX: SI joint sclerosis
ANKYLOSING SPONDYLITIS:
! Male predominance
! Typically bilateral
! Blurring of SI joint
! Loss of subchondral cortex
! Joint irregularly widened
! Sclerosis on either side of joint but more on the ilium side
! Ankylosis of joint
PSORIATIC ARTHRITIS:
! Possibly unilateral
! Erosion of joint margins
! Sclerosis
! Possible ankylosis
! Patient with psoriasis
REACTIVE ARTHRITIS:
! Asymmetrical involvement of SI joints
! Male predominance
! May have ankylosis of joint
! Irregularity of joint margin
! Loss of cortical outline
! Joint sclerosis
OSTEITIS CONDENSANS ILII:

! Occurs in females of childbearing age
! Dense sclerosis along SI joint on ilium side
! Usually following pregnancy
! Bilaterally symmetrical
! Joint space normal
PAGETʼS (OSTEITIS DEFORMANS)

! Male predominance
! Increased trabecular pattern in ilium and sacrum (mosaic)
! Sclerotic bone with osteopenia
! Increase in bone size
! Irregular joint margins
9
CLINICAL DDX OF NEUROMOTOR SYNDROMES
FINDING LMN LESION UMN LESION EXTRA- CEREBELLAR

PYRAMIDAL
ATROPHY Yes Minimal No No
TONE Decreased Increased Increased Possibly

(spasticity) (rigidity) decreased
WEAKNESS Yes (individual Yes (groups of No No

muscles) muscles)
FASCICULATE Yes No No No
GAIT Foot drop and Spastic Festinant, Broad based,

steppage, (circumduction, shuffling ataxic
waddling, scirrors)
quadriceps,
trendelenburg
10
FAST-TRACK NEURO DDX
PROBLEM: ABNORMAL BLADDER CONTROL
Question 1: Are there also bowel control problems?
If NO: Neuro exam is normal = urologic problem (do UA, BUN, creatinine, PSA)
! Neuro exam is abnormal, skip to question 3.
If YES:
Question 2: Are there mental SXs?
If YES = dementia if no motor signs; = brain tumor, stroke, if motor signs.
If NO mental SX:
Question 3a-3c:
! a. Bowel and bladder Sx ONLY? = diabetic autonomic neuropathy
! b. Also perineal paresthesia/numbness? = cauda equina syndrome
! c. Also UMN signs? = spinal cord lesion or brain lesion
PROBLEM: DISTAL SYMMETRICAL WEAKNESS
Question 1: Are the deep tendon reflexes present?
If YES:
! Question 1a. Myotonia is present? = myotonic dystrophy
! Question 1b. Fasciculations are present? = LMN disorder
If NO:
Question 2: Is sensory impairment present?
If YES: Diabetic, alcoholic, B12, or heavy metal neuropathy

If NO: Guillian-Barre (ascending weakness), SLE, tick paralysis
PROBLEM: PROXIMAL SYMMETRICAL WEAKNESS
Question 1: Is swallowing affected?
If YES: Polymyositis (normal reflexes, elevated CPK)
If NO:
Question 2: Are deep tendon reflexes normal?
11
If YES: Limb girdle dystrophy

If NO: Myasthenia gravis, or congenital myopathies, or glycogen storage diseases
PROBLEM: DISTAL AND PROXIMAL SYMMETRICAL WEAKNESS
Question 1: is there a dermatomal sensory abnormality?
If NO: Guillian-Barre syndrome (advanced stage)
If YES:
Question 2: is there involvement of sphincters?
If NO: Radiculopathy
If YES: Paraplegia (legs only) or quadriplegia (arms and legs)
PROBLEM: ASYMMETRICAL WEAKNESS
Question 1: What is the timing of the onset?
INSIDIOUS: CNS mass or degenerative disease (spastic tone and hyperreflexia)
SUDDEN:
Question 2: What is the extent of involvement?
-A group of muscles:
! Innervated by 1 nerve = mononeuropathy; compressive or vascular
! Innervated by a few nerves = plexopathy or polyneuropathy
-One extremity: CNS or multiple root lesions
-Hemiplegia (arm and leg on same side): CNS vascular lesion
PROBLEM: HEARING LOSS
Question 1: Is the hearing loss unilateral or bilateral?

Question 2: What was the timing of the onset?
UNILATERAL:
! ACUTE: infarct or bacterial infection
! CHRONIC PROGRESSIVE: suspect tumor (CT or MRI)
12
BILATERAL:
! ACUTE: viral infection (vestibular neuronitis, labyrinthitis)
! SUBACUTE, INTERMITTENT: Meniereʼs disease (with vertigo and tinnitus)
! CHRONIC PROGRESSIVE: refer for hearing aids
PROBLEM: DIZZINESS
Question 1: What does patient mean by dizziness?
LIGHTHEADEDNESS: Orthostatic hypotension

! ! ! Multiple sensory defects
! ! ! Cervical spine disease
DYSEQUILIBRIUM:!Cerebellar disease
! ! ! Spinal cord disease
! ! ! Basal ganglion disorders
VERTIGO:!
! Question 2: Is vertigo affected by head motion?
If YES:
! Benign positional vertigo (vertigo ONLY with head motion)
! Meniereʼs disease (with hearing loss and tinnitus)
! CVA, TIA, MS (with other brain stem signs)
IF NO:
! Drugs, alcohol, toxins
! Vestibulopathy
! Psychogenic
PROBLEM: AREFLEXIA
Question 1: Is it symmetrical?
If SYMMETRICAL:
Question 2: Is it generalized or segmental?
! Generalized = Normal finding

! ! ! Hypothyroidism (other signs)
! ! ! Adieʼs syndrome (tonic pupils)
! Segmental:
! ! Fasciculations?
13
! ! ! If YES = Anterior horn cell disorder

! ! ! ! LMN disease
! ! ! ! Syringomyelia
! ! ! If NO = myelopathy (will have dermatomal sensory deficit)
If ASYMMETRICAL:
Question 3: What is the distribution?
! One segment = Mononeuropathy
! ! ! Radiculopathy
! Several segments = Plexopathy
! One or two (ipsilateral) extremities = CNS lesion
PROBLEM: SYNCOPE
Question 1: Triggered by specific situation?
If YES:
! Question 2: History of heart disease?
! ! If NO: vasovagal syncope (will have bradycardia during event)
! ! If YES: MI (chest pain, abnormal EKG)
! ! ! Arrhythmia (no chest pain, abnormal EKG)
If NO:
! Other neurologic symptoms? = TIA or other CNS lesion
! Occurs when standing up?
! ! Associated with hypotension = orthostatic hypotension
! ! Not associated with hypotension = aortic stenosis; anemia
! History of heart disease?
! ! MI (chest pain, abnormal EKG)
! ! Pulmonary embolus (chest pain, normal EKG)
! ! Arrhythmia (no chest pain, abnormal EKG)
! ! Using hypertensive medication? = Hypotension (overmedicated)
14
INTERPRETATION OF ABNORMAL RESISTED SHOULDER ROM (most commons)
RROM PAIN PAIN & WEAK WEAKNESS
ABDUCTION Supraspinatus Partial rupture Complete rupture

tendinopathy; deltoid supraspinatus supraspinatus; C5,
lesion subscapular, or axillary
nerve lesion
ADDUCTION Pectoralis major, teres M C7 nerve root lesion

and m, latissimus dorsi
lesion; biceps lesion; AC
joint lesion
INT. ROT. Subscapularis Partial rupture C6 nerve root lesion

tendinopathy subscapularis
EXT. ROT. Infraspinatus tendinopathy Partial rupture Complete rupture

infraspinatus infraspinatus; C5,
suprascapular nerve
lesion
FLEXION Biceps, anterior deltoid Biceps rupture; C5, C6

lesion nerve root lesion
EXTENSION Triceps lesion C7 nerve root lesion
15
Leukemias:
ALL = acute lymphocytic leukemia

AML = acute myelocytic leukemia
CLL = chronic lymphocytic leukemia
CML = chronic myelocytic leukemia
FEATURE ALL AML CLL CML
Peak age of onset Childhood Any age Middle to old age Young adulthood
WBC count H 50%, L-N 50% H 60%, L-N 40% H in 98%, L-N 2% High in 100%
WBC differential Lymphoblasts Myeloblasts Many small Entire myeloid

elevated elevated lymphocytes series high
Anemia In > 90%; severe In > 90%; severe In 50%; mild In 80%; mild
Platelets Low in > 80% Low in > 90% Low in 25% H 60%, L 10%
Lymphadenopathy Yes Occasionally Yes Rare
Splenomegaly 60% 50% Yes, moderate Yes, severe
Other CNS involvement Auer rods seen in Possible WBC alkaline

common myeloblasts hemolytic anemia phosphate low;
and hypogamma- Philadelphia
globulinemia chromosome + in
> 90%
Signs/symptoms Infection, easy Infection, easy Fatigue, anorexia, Fatigue, anorexia,

bruising, bleeding, bruising, bleeding, weight loss, weight loss,
pallor, fatigue, pallor, fatigue, dyspnea on dyspnea on
fever, malaise, fever, malaise, exertion, exertion,
weight loss, weight loss, abdominal abdominal
tachycardia, tachycardia, fullness, pallor, fullness, pallor,
meningitis meningitis rash, pneumonia rash
Prognosis Cure is a realistic Cure is a realistic 3-20 yr survival 3-20 yr survival

goal goal time, depending time, depending
on severity on severity
16
Lymphomas:
HODGKIN NON-HODGKIN
Localized to specific group of lymph Usually disseminated among more than

nodes one nodal group
Tends to spread in an orderly, Spreads noncontiguously

contiguous fashion
Does not usually affect Waldeyerʼs ring* Commonly affects the mesenteric nodes
and the mesenteric nodes and may affect Waldeyerʼs ring*
Infrequently involves extranodal sites Frequently involves extranodal sites
Usually diagnosed at an early stage Usually diagnosed at an advanced stage
In children, usually displays a favorable In children, usually is high grade

histologic classification
Painless cervical adenopathy; pain with Asymptomatic peripheral adenopathy;

alcohol consumption; intense pruritis weakness, fever, night sweats, weight loss,
may occur; Pel-Ebstein** fever, night hepatosplenomegaly, edema; anemia;
sweats, weight loss; splenomegaly;
possbile ivory vertebra, jaundice, and
edema
Cure in 75% of cases Prognosis dependent on numerous

variables; 5-yr survival ranges from 25-75%
*The ring consists of (from superior to inferior):
■ Pharyngeal tonsil (also known as 'adenoids')
■ Tubal tonsils
■ Palatine tonsils (commonly called "the tonsils" in the vernacular, less commonly termed "faucial
tonsils")
■ Lingal tonsils
**a few days of high fever alternating with a few days or weeks of normal or low temperature
17
NEURO-MOST COMMONS
MOST COMMON… [any numbered lists are in decreasing order of frequency]

 S/S of increased intracranial pressure: 1. MORNING HEADACHE, 2. papilledema, 3. projectile
vomiting, 4. bradycardia, 5. hypertension.
 S/S of neurofibromatosis: 1. café-au-lait spots, 2. axillary freckling, 3. pigmented neurofibromas,
4. brain tumors (meningiomas, acoustic neuromas, optic gliomas), 5. pheochromocytoma.
 S/S of syringomyelia: Hornerʼs syndrome, loss of crossed lateral spinothalamic tracts in a cape-
like distribution, atrophied intrinsic muscles of hand
 S/S of meningitis: 1. FEVER, 2. headache, 3. nuchal rigidity (most specific but not most
common), 4. altered sensorium.
 cause of viral meningitis: coxsackievirus.
 cause of bacterial meningitis: S. pneumococcus.
 complications of meningitis: 1. TEMPORARY PARALYSIS, 2. permanent deafness, 3. mental
retardation, 4. hydrocephalus, 5. epilepsy.
 cause of epidural hematoma: fracture of temporoparietal bone causing tearing of middle
meningeal artery.
 S/S of epidural hematoma: immediate loss of consciousness followed by a lucid interval, followed
by death in 5-6 hours.
 cause of subdural hematoma: blunt trauma to skull causing tearing of bridging veins between
dura and arachnoid.
 S/S of subdural hematoma: fluctuating loss of consciousness.
 S/S of an atherosclerotic MCA stroke: 1. usually preceded by TIAs in the same distribution as
stroke, 2. expressive aphasia (dominant hemisphere), 3. contralateral hemiparesis, 4. sensory
changes in upper extremity.
 S/S of atherosclerotic VB stroke: 1. vertigo, 2. ataxia, 3. ipsilateral sensory changes on the face,
4. contralateral motor and sensory changes in the trunk and limbs.
 cause of an intracerebral bleed: hypertension (lenticulostriate arteries).
 sites of intracerebral bleeds: 1. PUTAMEN, 2. thalamus, 3. pons, 4. cerebellum.
 S/S of subarachnoid hemorrhage: 1. SUDDEN ONSET OF VERY SEVERE OCCIPITAL
HEADACHE, 2. loss of consciousness, 3. neurologic deficits.
 risk factors for subarachnoid hemorrhage: 1. hypertension, 2. polycystic kidney disease, 3.
coarctation of the aorta.
 causes of lacunar infarcts: 1. HYPERTENSION, 2. diabetes mellitus.
 S/S of lacunar strokes: pure motor or pure sensory strokes.
 demyelinating disease in CNS: MS.
 S/S of MS: 1. paresthesias, 2. scanning speech, 3. intention tremor, 4. nystagmus, 5. optic
neuritis, 6. ataxia, 7. internuclear opthalmoplegia.
 causes of dementia: 1. Alzheimerʼs, 2. multi-infarct dementia, 3. B12 deficiency, 4. acute
intermittent porphyria, 5. primary hypothyroidism.
 S/S of Parkinsonʼs: 1. COGWHEEL RIGIDITY, 2. BRADYKINESIA (of voluntary activity), 3.
resting tremor, 4. stooped posture, 5. festinating gait, 6. expressionless face.
 S/S of Huntingtonʼs disease: 1. late onset of chorea, 2. extrapyramidal signs, 3. dementia.
 tumor associated with tinnitus and deafness: acoustic neuroma.
 causes of distal sensorimotor peripheral neuropathy: 1. DM, 2. alcohol, 3. lead toxicity, 4.
vincristine, 5. isoniazid, 6. B1 or B12 deficiency.
 cause of acute peripheral neuropathy: Guillian-Barre syndrome.
 cause of Bellʼs palsy: 1. HSV-1, 2. Lyme disease.
 causes of sudden monocular blindness: 1. OPTIC NEURITIS, 2. central retinal artery occlusion,
3. amaurosis fugax, 4. retinal detachment.
 cause of sensorineural hearing loss: presbycusis.
18
NEOPLASIA MOST COMMONS
Most common…
-B9 soft tissue tumor = lipoma
-CA derived from bone marrow = leukemia
-CA derived from lymph nodes = malignant non-Hodgkins lymphoma
-location in bone for met = vertebral bodies
-organ metastasized to = lymph nodes
-malignancy to met to lymph nodes = breast CA
-malignancy to met to lungs = breast CA
-malignancy to met to brain = lung CA
-malignancy to met to bone = breast CA
-primary site for osteoblastic met = prostate CA
-enzyme elevated in osteoblastic met = alk phos
-malignancies that produce purely osteolytic met = lung, kidney
-CA associated with fever not due to infection = Hodgkin’s disease
-CAs associated with secretion of hCG = choriocarcinoma, testicular CA
-tumors associated with release of serotonin = carcinoid tumors in terminal ileum with met to
liver
-cancers associated with secretion of AFP = 1. hepatocellular CA, 2. ovarian CA, 3. testicular
CA
-tumor markers ordered to R/O testicular CA = AFP, hCG
-tumor markers ordered to R/O surface-derived ovarian CA = CA 125
-tumor markers ordered to R/O small-cell CA of lung = CEA
-tumor markers ordered to R/O prostate CA = PSA
-tumor markers ordered to R/O multiple myeloma = Bence-Jones proteins in urine
(however, only 40% or Pts have this; serum protein electrophoresis is better)
-tumor markers to R/O breast CA = CEA & CA 15-3
-tumor markers to R/O colon CA = CEA
-tumor markers to R/O pancreatic CA = CA 19-9 & CEA
-cancers (in decreasing order of incidence) in men = prostate, lung, colorectal
-cancers (in decreasing order of incidence) in women = breast, lung, colorectal
-cancer mortalities (in decreasing order of incidence) in men = lung, prostate, colorectal
-cancer mortalities (in decreasing order of incidence) in women = lung, breast, colorectal
-inherited syndrome associated with acoustic neuromas = neurofibromatosis
-most common sources of brain metastasis: 1. breast, 2. lung, 3. melanoma
19

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CHIEF COMPLAINT: Right arm gets cold and hurts.

MECHANISM OF INJURY: Began insidiously 1 year ago

QUALITY OF PAIN: tingling, achy

SEVERITY OF PAIN: moderate

AGGRAVATING FACTORS: driving car; right lateral flexion of neck

ASSOCIATED SYMPTOMS: none

RELIEVING FACTORS: lying supine; left lateral flexion of neck

PAST MEDICAL HISTORY: non-contributory

FAMILY HISTORY: Mother had Hodgkin’s lymphoma

Part III Handouts v.1.0 Page 3 of 142

01 . Which orthopedic/neurologic tests do you expect to be positive? (CHOOSE 3)

A. Bracelet test E. Phalen

B. Adson test F. Costoclavicular test

C. Cervical distraction G. Hoffman sign

D. Wright test H. Babinski sign

02 . Which physical exam findings might you see? (CHOOSE 3)

A. Diminished pulses on right arm E. Hemoptysis

B. Edema of right arm F. Claw hand

C. Raynaud’s phenomenon G. Cough

D. Axillary lymphadenopathy H. Dyspnea

03 . Initial case management for this condition includes: (CHOOSE 3)

A. Referral to oncologist E. Run lab for CEA levels

B. Referral to cardiovascular specialist F. Cervical ROM exercises

C. Stretching of shortened muscles G. CMT

D. Cryotherapy H. Brugger’s postural exercise

Part III Handouts v.1.0 Page 4 of 142

01 . Which orthopedic/neurologic tests do you expect to be positive? (CHOOSE 3)

A. Bracelet test E. Phalen

B. Adson test F. Costoclavicular test

C. Cervical distraction G. Hoffman sign

D. Wright test H. Babinski sign

02 . Which physical exam findings might you see? (CHOOSE 3)

A. Diminished pulses on right arm E. Hemoptysis

B. Edema of right arm F. Claw hand

C. Raynaud’s phenomenon G. Cough

D. Axillary lymphadenopathy H. Dyspnea

03 . Initial case management for this condition includes: (CHOOSE 3)

A. Referral to oncologist E. Run lab for CEA levels

B. Referral to cardiovascular specialist F. Cervical ROM exercises

C. Stretching of shortened muscles G. CMT

D. Cryotherapy H. Brugger’s postural exercise

Part III Handouts v.1.0 Page 5 of 142

CHIEF COMPLAINT: Left shoulder pain and stiffness

MECHANISM OF INJURY: Insidious

QUALITY OF PAIN: Achy; sharp with movement

SEVERITY OF PAIN: 6/10

AGGRAVATING FACTORS: Movement; lying on either side

ASSOCIATED SYMPTOMS: Upper left arm pain

RELIEVING FACTORS: Moist heat

PAST MEDICAL HISTORY: fractured radius, age 7

FAMILY HISTORY: Diabetes; mother

Part III Handouts v.1.0 Page 6 of 142

A. Type 2 diabetes mellitus E. Rotator cuff syndrome

B. Disuse muscle atrophy F. Adhesive capsulitis

C. Iron deficiency anemia G. Shoulder dislocation

D. Clavicle fracture H. HADD

A. Cryotherapy E. Cold laser

B. Grade 5 mobilization of GH joint F. Iron supplements

C. Codman’s exercises G. Cardiovascular training

D. Wall-walking exercises H. Biceps curls

C. Cervical myofascial pain syndrome G. Diabetes mellitus

D. Migraine headache H. Immobilization

Part III Handouts v.1.0 Page 7 of 142

A. Type 2 diabetes mellitus E. Rotator cuff syndrome