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| Question | Answer |
|---|---|
| Name four objectives of finding differential diagnosis'. | 1-R/O referable conditions 2-Determine further testing 3-Deteremine Tx 4-Avoid misdiagnosis |
| Name four factors to consider when approaching differential diagnosis' | 1-Common disorders occur commonly 2-Know the most common presentation 3-No disease seems rare to the person who has it 4-Pt can have more than 1 disorder |
| Name 3 Red Flags associated with headaches. | 1-Sudden Onset 2-Associated Neurological s/sx 3-New headache |
| 3 Signs of a subdural hematoma | 1-Senior=more common d/t head trauma 2-Symptoms=immediate--months to develop 3-Hemiparesis=contralateral with ipsilateral pupil dilation |
| Top 4 positive Likelihood ratios (+LR) for Temporal Arteritis (Giant Cell arteritis) s/sx. | 1-Jaw claudication 2-Diplopia 3-Beaded Temporal artery 4-Enlarged Temporal artery |
| Features of a cluster headache(least common headache) | Middle aged male Drinker/smoker Facial/orbital pain Lasts 30-45 minutes average. Lasts 2 hours maximum. |
| 90% of all HA fall into any of these three categories. | 1-Tension Type 2-Migraine 3-Cervicogenic |
| Main differences between migraine with aura(classic) and migraine without aura(common) | No aura(common) last days and is not debilitating With aura(classic) POUND-Pulsatile, 4-72 hOurs, Unilateral, Nausea, Debilitating |
| Top 4 history findings for patients with migraines. | 1-85% pulsatile 2-75% pain in neck 3-75% photo, phono, nausea 4-50% triggered by weather, stress, sleep/fatigue, diet |
| Of the children that report migraine headache, what percentage report a visual aura as well? | 20% of children report spots, dots, colors, or lights for less than 30 minutes. |
| What piece of patient history might indicate a 70% chance that a child may experience migraines at some point in their life? | Family History will reveal if mom and dad have migraines. |
| What is believed to be the cause of aura in migraines? | that a 'Spreading wave of Cortical Depression" is what causes auras. |
| Which cranial nerves is associated with blood vessels in the head and sensations of the face and how does it relate to Chiropractic? | Cranial nerve 5. This cranial nerve relates to C0-C4 cervical spinal nerve roots, which is where Chiropractic steps in with adjustments. |
| 5 step pathway of a migraine neurological signal | 1. Superior Salivatory Nucleus 2. Pterygopalantine ganglion 3. Cranial Dura vasculature 4. Trigeminal ganglion 5. Brain stem |
| What is believed to be the cause of migraines? | Irritation of the Trigeminal nerve releases vasodilators increasing localized serotonin. if serotonin is locally released=pain starter if serotonin is centrally released=pain blocker |
| What are five prodromic features of a Migraine with aura? | 1-hyperexcitable foci in visual cortex =30m to move P-A 2-Scintillating Scotoma, blind spot=common 3-Pt sees angular/ bubbling surfaces 4-may have auditory dysfunction and weakness 5-Idiopathic if not d/t diet/sleep/meds |
| What lifestyle changes may reduce the risk of migraines? | 1-avoid dietary triggers 2-drug use caution 3-stabilize routine 4-reduce stress |
| Abortive options for a migraine | 1-Ergotamine 2- NSAIDS 3-Triptans(serotonin agonist IE Sumatriptan) |
| Prophylactic options for migraine | 1. Anti-seizure 2. Anti-depressant 3. Anti-hypertensive 4. Sub-q injection of CGRP inhibitor(Aimovig)*newest |
| How is the surgical release decided to be used? | Botox or lidocaine to relieve tension, if it works, it may be repeated. If effective short term only, surgical decompression of Trigeminal nerve at fascial/occipital musculature. |
| is acupuncture useful for migraines headaches according to Linde et. al.? | 51% improved by 50% with acupuncture. 53% improved by 50% with SHAM acupuncture |
| What are some features and prevalence of Tension Type headaches?(opposite s/sx as migraine) | Most prevalent at 38% of HA in US are Tension-Type 1-Non-pulsatile 2-Non-debilitating 3-bilateral most commonly 4-Temporal/sub-occipital 5-Overlaps with TrP and cervicogenic HA |
| What are some features and prevalence of Cervicogenic type headaches? | 18% prevalence in US 1-pain in neck/suboccipute that may radiate 2-Provoked by specific head movements 3-Restricted ROM/contour/tenderness of neck 4-Possible evidence of change in cervical curve on X-ray |
| What is sclerotongenous pain referral? | Pain that is referred from facet structures |
| Which cervical facet structures will likely be involved with sclerotongenous pain referring to superior portion of the head? | C2-C3 |
| Which cervical facet structures will likely be involved with sclerotongenous pain referring to most lateral portion of the shoulder and upper 2/3 of scapula? | C5-C6 |
| Which cervical facet structures will likely be involved with sclerotongenous pain referring to the middle 2/3 of crevice-thoracic junction? | C3-C4 |
| Which cervical facet structures will likely be involved with sclerotongenous pain referring to the majority of lower trap/rhomboid region? | C6-C7 |
| What did researchers at DUKE University conclude regarding Tension-type and cervicogenic type headaches? | Their research supports Chiropractic manipulation, but does not suggest it is better than other soft tissue approaches for "episodic tension-type" headaches. |
| What does the Cochrane review have to say about CMT and headaches? | CMT=drugs for short term MIGRAINES CMT is better than drugs at lasting relief, yet drugs are better at immediate relief in CHRONIC Tension Type headaches. |
| What type of headache does CMT treat equally as effective as amitriptyline? | Migraines are equally resolved short term with CMT or drugs. |
| What type of headache does is CMT inferior at treating? | Chronic tension type headaches are best treated acutely with drugs. However, CMT is superior at lasting relief beyond treatment. |
| What are the best treatments for cervicogenic type headaches? | CMT and neck exercises demonstrate short and long term improvement |
| What is the neck toning program used prophylactically for cervicogenic head aches? | Exercise to improve neck stability, relieve tension, and improve circulation and involves resisted isometric anterior translation. aka, push against forehead. 5s hold 5rep 5xday |
| How many visits is considered ideal for treating headaches with CMT? | 18 visits. 1/2 of each group=30%reduction in 24 weeks. 1/2 of the higher dose group=30% reduction sooner than 24wk |
| From most to least, what is the reported distribution of dizziness causes according to a Dizziness and Balance Clinic, for patients over 65yo. | 32% d/t BPPV 22% d/t fear of falling or disuse equilibrium 13% d/t vestibular loss 5% d/t other causes |
| What 3 categorical slices make up a whole "pie" of dizziness as it relates to vascular supply? | 1-Vestibular 2-Cerebellar/proprioceptive 3-Vision |
| On the NRS, what are cluster headaches usually rated at? | 10/10...assoc with heavy drinking/smoking/middle aged male |
| On the NRS, what are Tension type headaches usually rated at? | 5/10...suboccipital or bilateral temporal, usually in afternoon |
| Red flag questions to rule out referable conditions. | 1-New headache 2-Trauma 3-Fever 4-If elderly, new temporal head ache |
| 3 Differential Considerations for elderly patients with headaches include | 1-vascular supply 2-Tumor 3-Temporal Arteritis/Giant Cell Art |
| What is noted with a continuous head ache? | a Continuous headache indicates intracranial process |
| what is noted as a risk with head trauma as it relates to headaches? | Possible sub-dural hematoma, s/sx include clumsiness, speech |
| what is a concern if patient presents with stiff neck and fever? | Meningitis is a concern |
| Some treatment considerations for headaches | 1-Rebound effect of headache 2-Anti-depresseants 3-St johns wart 4-Feverfew |
| Complaints of "dizziness" include which categories? | 1-Spinning 2-Fainting 3-Loss of balance 4-Light headed |
| When a patient describes dizziness as either room or self spinning, what is the likely diagnosis? | Vertigo=vestibular cause |
| When a patient describes dizziness as fainting or near fainting, what is the likely diagnosis? | Presyncope=vascular cause |
| When a patient describes dizziness as loss of balance, what is the likely diagnosis? | Dysequilibrium=proprioceptive, cerebellar cause |
| When a patient describes dizziness as light headedness, what is the likely diagnosis? | Psychological=anxiety or hyperventilation type causes |
| Where are the Hair cells of the inner ear specifically located? | ampulla of each semi-circular canal and each otolith organ |
| What is the basic function of the hair cells of the inner ear? | convert head movement into neural firing d/t displacement of hairs. |
| What are some questions to ask that can accurately diagnose 60-75% of patients with dizziness? | 1-True vertigo(spinning) 2-Length of episode 3-Hearing loss 4-Positional trigger(BPPV) |
| What is indicated by length of dizziness episode? | 1-BPPV (seconds-minutes) 2-Meniere's (hours to a day) 3-Vestibular Neuritis (days-weeks) |
| What is indicated by hearing loss when associated with dizziness? | 1-Labrynthitis (last days) 2-Meniere's (last hours-days) 3-Acoustic neuroma(central lesion) (continuous/progressive) |
| Which 2 conditions that involve dizziness, do not typically present with hearing loss? | BPPV and Vestibular Neuritis |
| Which condition that involves hearing loss, and is continuous and progressive, does not present with sudden onset? | Acoustic Neuroma/central lesion |
| What is the most common disease affecting the ANS that can cause s/sx of dizziness? | Diabetes can cause presyncope. |
| Identify 4 general exams for dizziness. | 1-Raglands sign + =pre-syncope 2-Otoscopic exam with pneumatic section +=sound lateralizes to block 3-Ophtalmoscope exam for nystagmus + = Vertigo 4-Vertebrobasilar exam |
| Describe the basics of Ragland's sign. | presyncope test. BP taken lying then standing. BP +15-20mmHg upon standing is normal. If blunted for a few minutes, presyncope is Dx. |
| What is the most sensitive test for Myelopathy? | The inverted supinator sign |
| What are some pathological signs of myelopathy? | Hoffmans, Babinski, Clonus |
| what are some signs of myelopathy? | abnormal gait/ataxia, Hyperreflexia/DTR's, + inverted supinator sign. |
| Who is more likely to have BPPV, men or women? | women are twice as likely. Possible connection to migraines. |
| Identify maneuvers that distinguish between causes of dizziness. | 1-Rhomberg's +=balance lost when eyes are closed--proprioception 2-Hautant's += arms deviate contralateral to head rotation w/extension 3-Rotation in chair +=stabilize head, rotate body--proprioception 4-Halpike/Barany += Vertigo |
| What maneuver is most useful for ruling in BPPV? | Halpike/Barany maneuver |
| What indicates a Peripheral cause of dizziness when performing Halpike test? | Latent, severe, Rotational nystagmus, that adapts/fatigues.=BPPV |
| What indicates a Central cause of dizziness when performing Halpike test? | Not latent, mild, vertical nystagmus, and does not adapt or fatigue=Acoustic Neuroma |
| What does horizontal/rotational nystagmus indicate? | peripheral disorder that typically fatigues. |
| What does vertical nystagmus indicate? | central disorder that won't fatigue. |
| What is Semonts maneuver used for? | Cupulolithiasis=immediate onset of vertigo and persistent nystagmus |
| What is Epleys maneuver used for? | Canallithiasis=15-30s delayed onset of vertigo and fatiguing nystagmus. |
| Which canal is implicated in 78-96% of all cases of BPPV? | the Posterior Canal |
| what are some recommendations for 24-48 hours after Epleys? | Sleep with head elevated slightly. Dont lay on involved side Limit head motion |
| What drugs are most effective at suppressing vestibular symptoms. | Benzodiazapines (lorazepam/Ativan, Diazepam/valium) |
| What is the summarized treatment of BPPV? | habituation exercises, repositioning maneuvers. |
| What is the summarized treatment of Meniere's? | Reduced Salt intake, use of diuretics, CMT. |
| What is the summarized treatment of Labrynthitis? | antibiotics |
| what is the summarized treatment of Acoustic Neuroma? | surgical excision. |
| What are the main types of vertigo? | BPPV, Menieres, Labrynthitis, Acoustic Neuroma. |
| Is Chiropractic care reported to have better OR, Odds Ratio, for treatment of Dizziness or Balance disorders, or worse than MD's? | Chiropactic>MD for treatment of dizziness or balance issues. d/t general, 65 or older, trauma, or neurological/msk. ALL better Odds of being helped by CMT. |
| What are some questions to ask that will help distinguish between Seizures and Syncope? | hypoxic event with fever only sudden start/stop drugs Fam/personal hx known triggers |
| If patient is not confused after seizure, it is a good way to rule out epilepsy, why? | With epileptic seizures, brain activity mimics REM sleep. This is known as POSTICTAL confusion. |
| how useful is postictal confusion at determining if it was a seizure? | It is the most sensitive test, where, if this is negative(no postictal confusion) the patient likely did not have a seizure) SensiNegOut |
| How useful is cut tongue at determining if it was a seizure? | it s the most specific test, where, if this is positive(pt has cut tongue) pt likely had a seizure. SpeciPosiIn |
| How many points is waking with a cut tongue worth? Postictal confusion? Based on the point scoring system to distinguish seizure from syncope. | Waking with cut tongue=2 Postictal confusion = 1 |
| How many points are required to make the diagnosis of seizure versus syncope according the point system? | Point score 1 or higher= most likely a seizure. If patient wakes with cut tongue and postictal confusion, thats 3 point, very likely a seizure. |
| What is the age relationship of seizures and their causes? | 0-4 known--development, infection, trauma, CVD 5-20 idiopathic 21-35 brain tumor, trauma, infection, CVD 36+ = CVD, brain tumor, trauma, degenerative disease |
| What are the two broad categories of seizures. | 1-Generalize (whole brain) 2-Focal (specific part of brain) |
| Within the generalized seizure category of seizures, what two are identified? | 1-Tonic-clonic/grand mal 2-Absence/petit mal |
| Within the Focal seizure category of seizures, what two are identified? | 1-Simple(consciousness preserved) 2-Complex(pt unconscious) |
| What does the Dix-Halpike maneuver screen for? | Screens for non-vestibular vertigo |
| When doing the Halpike maneuver, what two signs indicate a peripheral cause of vertigo? | 1-fatiguing nystagmus 2-latent s/sx |
| What are some key traits of a central cause of vertigo? | 1-poor speech discrimination if hearing loss is present 2-tone decay in hearing 3-vertical nystagmus |
| What some clusters of signs of cervicogenic vertigo? | 1-possible trauma related 2-imbalanced/pulling to one side 3-+ Hautants test 4-+Chair rotation test 5-Corrected with CMT |
| What are some clusters of signs of BPPV? | 1-trauma or elderly 2-head position prozac/palli 3-lasts seconds-minutes 4-No hearing loss 5-+Semonts(cupulolisthiasis=non-fatiguing nystagmus) 6-+Epley's(canalithiasis=fatiguing) |
| What are some clusters of signs of Meniere's disease? | 1-Sudden paroxysmal attacks 2-lasts hours--days 3-Low tone hearing loss 4-Fullness in ears 5-Tinnitus 6-+Halpike...non-fatiguing |
| What are some clusters of signs of Labrynthitis? | 1-Severe Dizziness that lasts weeks 2-Permanent hearing loss 3-Fever and ear pain (bacterial infection) 4-Treated with antibiotics |
| What are some clusters of signs of Vestibular Neuritis? | 1-Severe dizziness lasting weeks 2-No hearing loss 3-Viral cause |
| What are some clusters of signs of Acoustic Neuroma? | 1-Mild dizziness 2-hearing loss 3-Typically elderly 4-Compresses facial cranial nerves |
| How to differ between fatigue and true muscular weakness? | EMG/NCV studies |
| signs of a neurological weakness | MC =distal extremities first--LMNL more common in DC than UMNL--Neurological weakness is typically painless. |
| Signs of a muscular weakness | MC= starts proximally--Gross movement weakness + no pain |
| What are two myoneural diseases that cause weakness? | 1-Myasthenia Gravis (tune down) 2-Muscular Dystrophy (dysfunctional dystrophin) |
| What are 5 general causes of weakness as seen in a DC's office? | 1-Discogenic origin (recurrent meningeal nerve) 2-Plexus= diffuse s/sx 3-Nerve root =derma/myotome, DTR 4-Peripheral n.= muscle group, patch of skin, DTR 5-Referred= no objective neurological findings |
| What are two s/sx of weakness often misinterpreted by patients? | 1-decreased ROM 2-Joint laxity |
| What innervates the facets and is implicated in signaling facet pain? | Middle branch of the posterior primary rami |
| True or False: the MC cause of cervical radiculopathy is disc herniation. | False: approximately 80% of radicular presentations are due to foraminal encroachment. |
| Why are cervical radiculopathies more likely to be due to facet encroachment than disc herniation? | Protection from the PLL, combined with location of nerve roots in the IVF, and loss of nucleus pulpous by 45 yo. |
| y/n does a compressed nerve root typically signal pain along the dermatomal path? | No, excluding C4 and S1, approximately 70%/64% cases of radiculopathy did NOT trace dermatomal pain. |
| y/n Do patients typically COMPLAIN of weakness when nerve roots are involved? | No. Only 15-30% of radiculopathic patients COMPLAIN of weakness. |
| y/n Do patients who do not complain of weakness, typically demonstrate weakness on exam? | Yes. 64-75% of radiculopathic patients will demonstrate weakness upon examination, regardless of having not complained of weakness when asked. |
| y/n Does numbness always extend throughout the pain radiation? | No, often the numbness is proximal while the pain is distal. |
| t/f If a nerve root is found compromised, it will only effect one muscle. | Untrue, there are several redundant and overlapping nerves to muscles. |
| t/f trauma is usually reported when cervical radiculopathy symptoms begin. | untrue. Trauma is reported in only 15% of cervical radiculopathy cases. |
| What level nerve root does a lumbar disc herniation impact? | L4/L5 disc herniation will likely impact L5 nerve root. |
| y/n a + SLR at 30-70 degrees ensures nerve root involvement. | A + at 30-70 is testable on SLR test. However, NOT always. SLR + 0-30@42% SLR + 30-60@26% |
| If a disc ruptures, there will always be radiation into the extremity. y/n | no. there will not always be radiation into the extremities with a disc rupture. |
| What three S1 signs offer 86% likelihood of L5-S1 disc rupture? | 1-pain in S1 area 2-Achilles DTR 3-Sensory decline in S1 |
| What three L5 signs offer 87% likelihood of L4-L5 disc rupture? | 1-Big toe weakness(extensor) 2-Pain in L5 region 3-Sensory decline in L5 |
| What two tests are 100% reliable for L4-L5 disc herniation? | 1-Extensor hallicus weakness 2-Sensory defect in L5 area |
| You _____know when someone has radiculopathy, but you ______ ______ always know when they do not have radiculopathy. | CAN. CAN NOT----testing confirms radiculopathy when +. However, a - does not rule out radiculopathy. |
| What is the most SENSITIVE test for ruling-out Cervical Radiculopathy? | ULTT a is the most sensitive. when - rules out (SNOUT) |
| What is the most specific test for ruling in Cervical Radiculopathy? | Spurlings A is the most specific. When + rules in (SPIN) |
| Nerve roots that flex and extend the hip. | L2/3 flex, L4/5 extend |
| Nerve roots that extend and flex the knee. | L3/4 extend, L5/S1 flex |
| Nerve roots that flex the ankle. | L4/5 dorsiflexion, S1/2 plantar flexion |
| What are the two main categories of fatigue | 1-Metabolic (50%) 2-Psychogenic (50%) |
| What are some general causes of fatigue. | 1-Stress 2-Metabo/hormonal 3-Depression 4-Infection 5-Chronic Fatigue Syndrome 6-Sleep disorders |
| What are some features of macrocytic anemia. | 1-Increased MCV 2-Increased presence of macrocyitic cells |
| What are some features of microcytic anemia. | 1-Thalassemia minor 2-Iron definciency 3-Increased presence of microcytic cells |
| How many points is the mini-cog exam worth and how is it scored? | 1 point for each correct word + 2 point for a normal clock. Total points possible is 5. |
| What oral bacteria is currently being studied and implicated in alzheimers? | Gingipains are proteinate enzymes that are released by P. Gingivalis |
| history findings that guide diagnosis of anemic cause. | 1-Pregnancy=B12, Folate, Iron 2-Alcohol= B12, Folate, Iron 3-Ethnic= Thalassemia, sickle cell 4-Hemorrhagic= Iron 5-Chronic disease= RA, diabetes, cancer 6-Drugs= Chemo, corticosteroids |
| What is the most sensitive initial test for thyroid dysfunction? | Supra/Ultra sensitive TSH test. |
| What will show up on labs with hyperthyroidism. | Increased FT3/4 with decreased TSH |
| What will show up on labs with hypothyroidism. | Decreased FT3/4 with increased TSH |
| What is the most common cause of hyperthyroidism? | Graves disease |
| What two forms of hypothyroidism are mentioned? | 1-Hashimoto's (goiter present) 2-Atrophic Thyroiditis (no goiter) |
| Within the same age range, how fatal is diabetes? | risk of death is doubled in people with diabetes. 75% from microvascular involvement. 66% from HTN. |
| What is the leading cause of blindness in US? | Diabetes, between ages 20-74. |
| What is the leading cause of end stage renal disease? | Diabetes. 25-30% of renal patients have diabetes. |
| What is the most common cause of neuropathy? | Diabetes. 70-80% of patients with Type 2 diabetes develop neuropathy. |
| What is the greatest risk factor for diabetes? | obesity. Relative Risk with BMI >35= 95/fem 42/male |
| Some s/sx of diabetes | 1-Fatigue 2-Numbness/tingling in distal extremities 3-On/off blurry vision 4-Ortho-hypo 5-sudden weight loss 6-Frequent infections 7-impotence |
| Two tests used to diagnose Peripheral Neuropathy. | 1-Timed vibration= Sensitive. - rules out (.33 -LR) 2-On/off vibration= Specific. + rules in (26.6 +LR) |
| What are the HbA1c guidelines? | HbA1c <5.7%=norm HbA1c 5.7-6.4% =pre-diabetic HbA1c >6.5% =diabetic |
| Which cells does hyperglycemia impact the most? | the cells that do not require insulin. |
| What are some cells that do not require insulin? | 1-RBC 2-Hepatocytes(liver) 3-Nervous system 4-Intenstina mucosa 5-Renal tubes 6-Cornea |
| In order, what are the most common chronic conditions seen in clinic. | 1-HTN 2-Depression |
| What is a unipolar episode? | Major depressive episode. Unipolar only has one extreme, MC depression. NO identifiable exogenous trigger. Believed to be chemical imbalance. |
| What is a bipolar episode? | Major depressive episode followed by major manic episode. |
| What is the general belief and goal of medication for depression? | Increase serotonin receptors, decrease serotonin uptake, |
| Explain the receptor sensitivity hypothesis around depression. | Hypersensitivity= increased receptor responsiveness, up-regulated receptor sites. Mechanism of desensitization= increased NT availability leads to uncoupled receptors, and down regulated sites. |
| Define Somatization. | An unconscious psychological process that expresses psychological distress as physical symptoms. (IE anxiety makes palms sweaty. sleep dysfunction, weight loss/gain) memory dysfunction |
| Define anhedonia | loss of joy in life |
| What TWO history questions are very sensitive but mildly specific at ruling out depression? | 1-over the last two weeks have you ever felt depressed. 2-over the last two weeks...anhedonia (if negative, rules out depression 96% of the time. If positive, rules in depression 57% of the time) |
| What is more effective at treating depression according to Blumenthal et al. | Exercise = psychotherapy= pharmaceuticals |
| According to Cochrane, how does exercise compare to drugs for depression. | Exercise alone is better long term than drugs alone. Exercise + drugs was more effective than either were alone. |
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