Today You Will Learn History & Exam

Hx & Exam Distance Learning Notes

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History & Exam(4 hours)

presented by

Steven C Eggleston, D.C., Esq.27 La Plaza Penthouse

Palm Springs, CA 92262(877) 4-CHIROLAW

Today You Will Learn1) Histories may be done by NON-

Licenced individuals

2) Consultations may ONLY be done by LICENSED DCs

3) The ONLY history question is “What are your symptoms?

4) Consultations begins with, “How MUCH does it hurt” b/c that requires expertise

Today You Will Learn

1) Use a GOOD symptoms form for the patient to fill out

2) Consult with the patient about everything they put on the Symptoms form

3) Examine every Symptom4) Diagnosis = Symptom

confirmed by Examination5) Treatment Plan = You need

one for EVERY Diagnosis

Sample FILLED OUT Forms

1) You will see an INITIAL EXAM that is FILLED OUT for a sample patient

2) You will see 3 Follow Up Exams and all the associated forms (aka RE-Exams)


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History = C.A. (aka NON-licensed person)

Your C.A. may help them fill in the form

He/She may NOT ask:

“How bad is…?”“How severe is…?”“How often does it happen?”“Is it sharp, dull, achy, etc?”

ONLY a licensed D.C. may ask questions


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What PARTSof the patient are:

100% healed?Still have ssx?Improved a little?Improved med.?Improved a lot?

NOT improving?Getting WORSE?

2nd Re-Exam

2 months of care

Some are 100%

Some are NOTImproving

Some neededother doctors

3rd Re-Exam

24+ Treatments

An HONESTassessment ofthe patient

Shows THOUGHTby the doctor

You need INFO..!!!

The Symptoms Form & Symptoms Update

1) Give you the road map (basics)

2) Help you see progress (or lack of)

3) Are EASY for the reader to understand

4) Make you look SMART on paper (withoutdoing a lot of the work)

The NEXT Steps

1) Dig deeper

2) Specific areas

3) Patient doesmost of thework

Patient FillsOut This Form

Signs It

All BEFOREyou see him/her

You Write in onlyPOSITIVE tests


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11 Useful Cervical Tests

1. Cervical Compression w/ 7 Variations2. Maximum Cervical Compression 3. Spurling’s4. Modified Spurling’s5. Cervical Distraction6. Shoulder Abduction (Bakody’s Sign)7. Valsalva8. Dejerne’s Triad9. Naffzigger (Juggular Compression) Test10.Shoulder Depression Test11.Lhermitte’s Sign Test

Cervical Compression Testaka Foraminal Compression Test

1. Patient is seated2. Doctor stands behind patient and places both hands on top of head3. Doctor applies gradually increasing pressure straight down to compress the cervical spine

Mechanism/Rationale

The downward pressure compresses the facets, vertebral bodies, disc, and narrow the IVF

Cervical Compression Testaka Foraminal Compression Test

EXAM FINDINGS/INTERPRETATION: Creation or exacerbation of local or diffuse cervical spine pain suggests

1.joint involvement (subluxation, DJD, or trauma).

2.Creation or exacerbation of pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests cervical radiculopathy (space occupying lesion, eg. Tumor, disc protrusion or stenosis)

Note: Ill defined, diffuse pain into the shoulder or arm may be present due to sclerogenic referral.

Cervical Compression Test

This is a GENERAL, NON-specific test. Therefore, after performing the Cervical Compression test, what follow up procedures can/should be performed to bring accuracy and specificity to your diagnosis?

The doctor can/should do:

1.variations of the compression test (7 of them)

2.perform the Cervical Distraction test

3.Valsalva

4.neurological exam of the sensory, motor, and reflex functions of the cervical spinal nerves

7 Cervical Compression Test Variations

1. Press straight down with both hands on top of head2. Press straight down while patient has head lateral flexed to the left (Jackson's Test)3. Press straight down while patient has head laterally flexed to the right (Jackson's Test)4. Press straight down while patient has head in forward flexion5. Press straight down while patient has head in extension6. Press straight down while patient has head in right rotation7. Press straight down while patient has head in left rotation

The 7 Cervical Compression Test Variations

In the Cervical Compression Test with lateral flexion, where will joint and disc compression be more localized?

To the side of lateral flexion (ipsilateral).


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In the LATERAL Cervical Compression Test,Which side will the IVF be narrowed?

(Ipsilateral side)


In the FLEXION Cervical Compression Test,what part of the vertebral motor unit will experience increased load?

(Anterior part)

Disc compression anteriorly may cause what POSTERIORLY?

Radicular symptoms (disc protrusion OR torn ligament)


In the EXTENSION Cervical Compression Test,what part of the vertebral motor unit will experience increased load?

(Posterior part)

Watch for:*Radicular symptoms (Possible IVF stenosis)*Reduction of radicular symptoms (disc movedforward, reducing the posterior protrusion)*Vague, non-localized pain (torn ligament(s))

Maximum Cervical Compression Maneuver

Doctor does NOT touch the patient

Patient Seated

Tell patient, turn your head to the right and thentilt your head back

Repeat on the left

Meaning: Local or diffuse pain = DJD, joint trauma, torn ligt.Radicular DERMATOMAL Pain = Disk or stenosis

Spurlings Test

Patient Seated

Tell patient, turn your head to the right/left and Then tilt your head back

Downward blow to top of patient’s head

MODIFIED Spurlings TestPatient Seated

Tell patient, turn your head to the right/left and then tilt your head back

Both hands clasped on atop patient’s head,apply gradually increasing downward pressureto compress the cervical spine

Meaning:Local joint pain = torn ligt, DJD, traumaDiffuse sclerognic referred pain = torn ligt.Radicular dermatomal ssx = disk, stenosis, spurs


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Cervical Distraction Test

Patient Seated, lift up patient’s head slowly

Meaning:

Decreased dermatomal radicular ssx = likelydisk herniation, DJD, IVF stenosis or tumor

Increased local pain = torn ligament such asALL, PLL or capsular ligament

Shoulder Abduction Test (Bakody’s Sign)

Purpose:To reduce the traction of the compressed spinal nerve that is causing dermatomal radicular symptoms (n/t, pain).

How to: Patient seated. Tell patient “Raise yourhand and place the palm of your hand on thetop of your head” (on symptomatic side)

Meaning: Reduction of pain/paresthesia in affected arm/hand = nerve root compressionis the problem causing radiation into arm.

Shoulder Abduction Test (Bakody’s Sign)

What if Shoulder Abduction Test CAUSES pain?

Pectoralis Minor (hyperabduction) syndrome

Valsalva Maneuver

Purpose: Differentiate between space occupyinglesion (i.e. disk, osteophytes, stenosis or tumor)

How to: Patient seated. Tell patient “Take a deep breath and bear down as if to movebowels.”

Meaning: Increased radicular symptoms into arm =space occupying lesion or Dejerine’s Triad.

Dejerine’s Triad

Purpose: For you to recognize the patient’s symptoms as being a space occupying lesion(i.e. disk herniation, stenosis, osteophytes, tumor)

How to: Pay attention if the patient states they have increased dermatomal pain, tingling, numb into arm FOLLOWING cough, sneeze or bearingdown to move bowels.

Double Check: Do Valsalva Maneuver to replicatethis in your office

Naffzigger (Jugular Compression) Test

Purpose: Another confirmation of space occupyinglesion (i.e. disk herniation, stenosis, osteophytesor tumor)

How to: Compress BOTH jugular veins for 30-45seconds to “back up” venous drainage and increase intrathecal pressure.

Meaning: Space occupying lesion or stenosis exists if it aggravates dermatomal radicular ssx.


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Naffzigger (Jugular Compression) Test

CONTRAINDICATED FOR:

Geriatric patientsAtherosclerosis patients

Can cause light headedness, dizziness

*DO NOT PRESS THE CAROTID ARTERIES

Shoulder Depression Test (aka nerve root compression)

Purpose: Test for nerve root dural sleeve adhesions

Note: It can also aggravate muscle spasmsor torn ligament pain

How to: Side flex neck while pressing downon shoulder

Meaning: Torn ligament or muscle spasmspresent if this aggravates local neck pain

Shoulder Depression Test (aka nerve root compression)

Variation: depress the patient’s clavicle duringthis test

Meaning: Costoclavicular Syndrome IF thiscauses upper extremity pain because you narrowed the costoclavicular space doing this.

Lhermitte’s Sign

How to:Don’t touch patientTell patient to flex head toward chest

Meaning: SHARP pain down spine AND intothe upper or lower extremities =

1) Myelopathy caused by spondylosisor spinal canal stenosis

2) Disk herniation with protrusion3) Tumor (space occupying4) Multiple Sclerosis

11 Useful Cervical Tests

1. Cervical Compression w/ 7 Variations2. Maximum Cervical Compression 3. Spurling’s4. Modified Spurling’s5. Cervical Distraction6. Shoulder Abduction (Bakody’s Sign)7. Valsalva8. Dejerne’s Triad9. Naffzigger (Juggular Compression) Test10.Shoulder Depression Test11.Lhermitte’s Sign Test


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Thoracic & Lumbar Tests

Spinal PercussionRib CompressionLhermitte’s SignLinder’s SignLindner’s SignValsalvaDejerine’s TriadBechterew’s TestKemp’s TestMinor’s Sign

Lasegue’s TestBraggard’s Test

Kernig’s TestMilgram’s Test

Bilateral Leg LoweringNeri’s (bowing) Test

ReflexesSensory (dermatomes)

Light touchTemperature


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Spinal Percussion & Rib Compression

Both test for FRACTURES

Tap (percuss) the Spinous Processes

Compress the rib cage A to P or Laterally

You can tell it is fractured when the patientscreams

Lhermitte’s Sign

In C-spine, patient is seated and flexes neck

For T-spine and L-spine, patient is seated withlegs extended, flexes both C and T spine.

Meaning: Shooting pain = disk lesion, corddisease or damage (myelopathy) or meningitis

Local Pain = S/S (signs & symptoms)

Linder’s Sign vs. Lindner’s Sign

Linder’sPassively flexpatient’s neck

Effect: Stretchdura and nerveroots

Radiating pain = disk lesionLocal pain = S/S

Lindner’s SignThis is the exact

same test witha slightly different

name.

Valsalva & Dejerine’s Triad

Ask patient to hold big breath and bear down.

This increases intrathecal pressure so pain or radiating pain may indicate space occupying lesion such as disk herniation, tumor, osteophytes.

Dejerine’s Triad – When patient has pain and/orradicular symptoms after cough, strain, sneeze

Bechterew’s Test

Patient is sitting: extend alternating legs, then extend both.

This stretches the sciatic nerve and lumbar nerve roots

Leaning back with pain may indicate disk injury,sciatic nerve injury or nerve root injury

Kemp’s Test

Patient is sitting. Doctor twists thoracolumbarspine and leans patient backwards, THENpress into the small of their back to pushthe patient forward.

This compresses the thoracolumbar spineobliquely backwards.

Local pain = facet injury, torn facet capsuleRadiating pain = Disk herniation pressing nerve


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Minor’s Sign

Watch a seated patient who complains of severe LBP or Sciatica stand up from a chair.

Minor’s Sign is the patient using their hands tosupport themselves. Commonly, one hand is on their back and the other holding up the “off” leg to keep the involved leg side in flexion.

Lasegue’s Test w/ Braggard’s Follow Up

Patient supine: Doctor passively raises one legat a time.

Meaning:Local pain at 0-35 degrees = Piriformis spasm or Sacroiliac symptomsLocal pain at 70-90 degrees = Lumbar symptomsRadiating pain at 35-70 = Sciatica or L5-S1-S2nerve root irritation OR Disk lesion

(This is the Lasegue’s portion)

Lasegue’s Test w/ Braggard’s Follow Up

Patient supine: Doctor passively raises one legat a time.

Meaning:If you have Sciatic Nerve pain at 35-70 degrees,LOWER the leg a little and dorsiflex the foot.

Replication of Sciatic Nerve Pain is caused by stretching the Sciatic Nerve and indicates EITHER Disk lesion or Sciatica (Braggard part)

Milgram’s Test

Patient supine: Doctor passively raises BOTHlegs 6” off table and asks patient to hold feetin that position for 30 seconds.

Meaning:Radiating pain during the 30 seconds is a space occupying lesion in the lumbar spine(i.e. Disk herniation, tumor, stenosis)

Neri’s (bowing) Test

Patient standing flexes forward to touch toes.

Meaning:If the knee on the sciatica side flexes to avoidstretching the sciatic nerve, this indicates theirpain is sciatic nerve related.

The BEST Test for Cervical & Lumbar

Palpation is the single best test you can use in trauma patients to identify the structure that is injured. Use it to identify whether the patient’s pain is coming from:

1) Torn Ligament (if you can reach it)2) Torn tendon (if you can reach it)3) Disk tear or herniation/protrusion (use some

motion to move it)


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Once you have a SYMPTOM that has beenCONFIRMED by an examination, you need a

DIAGNOSIS

Better yet, a SERIES ofDiagnoses that describe all the relevant

injuries in the patient’s body.


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Once you have a SYMPTOM that isconfirmed by an EXAM finding and a seriesof DIAGNOSES to describe it accurately,

California chiropractors are required to havea WRITTEN TREATMENT PLAN.

S = SymptomO = Objective findingA = Assessment aka DiagnosisP = Plan of Treating it.


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What About The Extremities?

There are 7 FREE Extremity History & Exam forms at

www.HBTInstitute.com

User Name = greatPW = doctor

Extremity Diagnosis Basics

First: Palpate

Second: Identify painful area asligament, tendon, muscle

Once you identify the TYPE of structure that is painful, you’re 99% there already

Knee Dislocation (too easy)Knee Anatomy

Knee Anatomy


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HIP Orthopedic Tests

•Ely’s Test•Gaenslen’s Test•Hibb’s Test•Nachlas Test•Ober’s Test•Ortolani Click•Patrick’s Test (FABER Test)•Pelvic Rock Test•Telescoping Sign•Thomas’ Test•Trendelenburg Test / Trendelenburg Sign•Yeoman’s Test


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Elbow Orthopedic Tests

•Cozen’s Test (Lateral Epicondylitis)•Golfer’s Elbow Test (Medial Epicondylitis)•Mill’s Test•Passive Tennis Elbow Test•Pinch Grip Test•Tinel’s Sign•Valgus Stress Test•Varus Stress Test


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What About Concussion Patients?

Chiropractic patients get concussions from:

1) Car accidents2) Donorcycle accidents3) Jet ski accidents4) Snowmobile accidents5) Snow and water skiing accidents6) Skateboard and bicycle accidents7) Falling off the roof or a ladder8) Falling on slippery ice or sidewalk


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History & Exam INCLUDES Documenting:

1) How injuries affect the patient’s life2) Changes in Activities of Daily Living3) Changes in Exercise Patterns4) Changes in ability to WORK5) Changes in TRAVEL plans6) Changes in SCHOOL Activities


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X-rays Are a Type of Exam

The BEST method is USE A DACBR

The 2nd Best method is USE A DACBR

The 3rd Best method is USE A DACBR

The method of LAST RESORT is to at LEAST Write out your X-ray findings.

BEWARE (aka BE AWARE)of SCLEROGENIC Pain Patterns

Torn Ligament Referred Pain Patterns

• Torn ligaments cause sclerogenicreferred pain in the pattern shown here

Ligament Referred Pain Patterns

• The P.I. patient often presents with aching trapezius pain and the chiropractor treats the traps as if it were the actual injury


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• A good chiropractor will recognize that when the traps still hurt 2 months after the accident it is NOT a strained trapezius…!!!


• Most common to look for:

• Capsular ligaments at the C4-5, C5-6 or C6-7 joint(s)


• Referred pain does not progressivelyimprove. It comes and goes FOREVER


• Ask your Whiplash patients how many hours of relief they are getting after your treatments


• If your patient has an actual trapezius injury

• You apply the proper treatments

• Patient experiences PROGRESIVE improvement

• Ask about FREQUENCY of pain (and)

• Ask about SEVERITY of pain

DJDCausedFUSIONat C3-427 yearsafter acar accidentin 1985


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Torn SpineLigamentsCauseDJD

Code isM24.28


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Arthritis: Natural Progression of Torn Ligament Injuries

It took 26 years for the C3-4 vertebrae to fuse

Arthritis: Natural Progression of Torn Ligament Injuries

Question #12: Which 2 vertebra fusednaturally after a tornAnterior LongitudinalLigament from a caraccident?

Constant vs. Occasional Numb

• Constant Numbness & Tingling is most likely a DISK HERNIATION

• Intermittent Numbness & Tingling is most likely TORN SPINE LIGAMENTS

• “Is your numbness or tingling there ALL the time or does it come and go?”


• Orthopedic test for INTERMITTENT N/T

– Cervical COMPRESSION followed by Cervical DISTRACTION

• Pathognomonic Sign: LOCAL (facet) neck pain on BOTH tests.

– Order STRESS X-rays and/or FLUOROSCOPY

– Prolotherapy, PRP, Stem Cell or FUSION surgery


• Orthopedic test for INTERMITTENT N/T

– Cervical COMPRESSION & DISTRACTION

• Pathognomonic Sign: LOCAL (facet) neck pain on BOTH tests.

– Order STRESS X-rays and/or FLUOROSCOPY

– Prolotherapy, PRP, Stem Cell or FUSION surgery

George’s Line in Flex/Ext shows Stair-Step which is a sign of torn ALL and/or PLL

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Today You Will Learn History & Exam