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Exam 1- Diagnostic statement Flashcards

1
Q

Diagnosis that should be listed in a chart note, in correct order

A

Primary Dx (Name the pain. Worst thing. Basic Dx, as specific as possible)

Associated diagnosis

Complicating Diagnosis

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2
Q

6 components of a Dx statement

A

Time modifier

Mode of onset modifier

Primary Dx term

Associated modifier term

Complicating modifier terms

Aggravating modifier

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3
Q

Time modifier terms:

A

Acute

Subacute

Chronic

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4
Q

Which time modifier?

1st 72 hours of an inflammatory process, or a non-inflammatory severe pain event— 3 days

A

Acute

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5
Q

Which time modifier?

After 72 hours and up to 18 months depending on the amount of tissue damage for an inflammatory condition. For non-inflammatory, looking at a moderate pain even to full recovery.

3 days-1 1/2 year

A

Subacute

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6
Q

Which time modifier term?

Condition that resolves to a max medical improvement (less than full recovery) not getting any better.

A

Chronic

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7
Q

Which stage of inflammation?

1st 72 hours initiated by cellular and vascular destruction

A

1st stage (inflammation)

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8
Q

Signs of inflammation

A

Pain (dolor)

Heal (calor)

Redness (rumor)

Swelling (edema)

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9
Q

Causes of inflammation

A

Trauma

Infection

Chemical

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10
Q

Which stage of inflammation?

Swelling terminated
Pain decreased
No redness/heat

Tissue going through the inflammatory process is drying out and beginning to harden.

A

2nd stage (consolidation)

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11
Q

What is a result of the hardening process in the consolidation stage?

A

Stiffness

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12
Q

Which stage of inflammation?

Damage tissues begin to repair

A

3rd stage (repair)

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13
Q

What happens in the repair stage of inflammation?

A

Cellular activity begins to repair w/ scar tissue

Tissue can lay down in any direction (cross matrix pattern)

Results in adhesion

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14
Q

What is the result of proper repair- passive, active and resistive rehab exercise

A

Works on healthy scar tissue promotion

Results in scar tissue laying down in a linear fashion… allows the pt to have more flexibility.

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15
Q

Stage of inflammation:

Pts condition has resolved

A

4th stage (resolution)

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16
Q

What are the 2 states in which the pts condition can resolve

A

Full recovery - NO residual problems

Max medical (chiropractic) improvement (MMI, or MCI)

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17
Q

What happens with MMI/MCI?

A

Pt does not reach full recover- they are left with residuals.

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18
Q

Mode of onset modifier terms

A

Traumatic

Insidious

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19
Q

What does the traumatic mode of onset modifier term state?

A

Tissue is taken beyond it’s normal limits

Vascular and cellular tissue damaged

Ligament tears

Muscle and/or tendon tears

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20
Q

Which mode of onset modifier term is the slow onset of symptoms which are progressive over time?

A

Insidious

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21
Q

Histological grade I strain/sprain

A

0-50% tearing of tissue

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22
Q

Histological grade II strain/sprain

A

> 50-<100% tearing of tissue

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23
Q

Histological grade III strain/sprain

A

> 100% tearing of tissue

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24
Q

Functional def of Grade I strain/strain

A

Mild-moderate symptoms with no dysfunction. Recovers in 2-4 weeks with no intervention

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25
Functional def of grade II strain/sprain
Moderate to severe symptoms with physical and lifestyle impairments, Recovery 6weeks to 18 months w/ health care interventions
26
Functional definition of grade III strain/sprain
Severe symptoms w/ complete loss of function
27
Achilles’ tendon rupture, cruciate ligament rupture, and surgical interventions are an example of what type of sprain/strain?
Grade III
28
What is the term used to describe the pt’s tissue causing their main complain?
Primary diagnosis term
29
What are the diagnostic terms that are conditions (symptoms) which accompany the primary Dx, but are not the actual symptoms of the pts CC?
Associated modifier terms
30
What are diagnostic terms that complicate the pt’s condition?
Complicating modifier terms
31
What do complicating modifier terms indicate?
That the pt will be harder to treat and take longer to treat.
32
Degenerative pathologies Systemic disease Congenital abnormalities Structural abnormalities These are examples of:
Complicating modifier terms
33
Which modifier term indicates pt lifestyles that causes the pt’s symptoms to worsen when the perform those duties?
Aggravating modifier
34
Work duties Home chores Emotional stresses These are examples of which modifier term?
Aggravating modifier term
35
Painful tissue in the dura mater indicates:
Recurrent meningeal nerve Innervated sinuvertebral nerve Nerve of von Luska
36
Which tissue is affected? Local symptom lateral to the spine and when severe enough can radiate along the course of the peripheral nerve
Nerve root
37
Which tissue is affected? Irritation compresses blood vessels causing numbness and pain Compression causes pain and nerve dysfunction can radiate
Peripheral nerve
38
What innervates the IVD? Where are symptoms for this when aggravated?
Recurrent meningeal nerve and the gray ramus communicans Local to the spine
39
Facet and diarthrodial joint symptoms are from what?
Ligaments Cartilage (joint surface) Synovium
40
What can elevate the pressure of the IVD?
Compression forces And increased intra thoracic and abdominal pressure (ex- coughing, sneezing, bearing down) These can result in increased symptoms
41
What causes joint surface symptoms to increase?
Compression forces
42
Joint capsule ligament symptoms are increased with what?
Stretching forces
43
Spinal exams reveal what?
Mostly extensor muscle involvement
44
Spinal stresses are from what?
Stretching forces Resistive forces
45
What type of symptoms does bone pathology produce
Local deep symptoms
46
What type of symptoms do fractures cause
Local symptoms, deformity and dysfunction
47
What are diagnostic terms for the tissue causing the CC?
Root words
48
Prefixes May describe what?
Conditions.. or may be multiple root words
49
Suffixes usually describe what?
The pathological condition of the root word.
50
Suffix for pain
-Algia
51
Suffix for inflammation
-itis
52
Suffix for condition. Generally means pathology
Opathy
53
Suffix for condition of root word..... generally describes degenerative changes ... when something is injured but not inflamed
Osis
54
Suffix for separation, break, tear
Lysis
55
Root words w/in the NS
Myelo Meninges Myelopathy Meningitis
56
Root word for spinal cord fibrils
Myelo
57
Meninges- root word meaning
Covering of the cord
58
Myelopathy root word meaning
SC fibrils pathology
59
Inflammation of the covering of the SC, caused by infectious and chemical processes
Meningitis
60
Root word describing the nerve root found in the spinal canal and IVF
Radical/Radicular
61
Nerve root pain, not radiating, no neurological findings
Radicualgia | Normal MRS tests! Still pain
62
Nerve root inflammation, AKA irritation (hyperexcitable) , can have paresthesia. May radiate along peripheral nerve, may have exaggerated neurological signs
Radiculitis Increased MRS- potential for UML
63
Nerve root pathology which is depressed nerve function (decreased MRS), may have radiating symptoms
Radiculopathy
64
Peripheral nerve pain, no neurological signs
Neuralgia
65
Inflammation of peripheral nerve. May have increased neurological signs, paresthesia and pain
Neuritis
66
Neuritis has (INCREASED/DECREASED) MRS
Increased
67
Peripheral nerve pathology which has decreased function and may have depressed neurological signs
Neuropathy
68
Neuropathy shows (INCREASED/DECREASED) MRS
decreased
69
Condition of the spine referring to disc degeneration or evidence of it.
Spondylosis
70
Evidence of spondylosis
End plate thickening (sclerosis, spurring, etc). | Also a complicating factor to the Dx
71
Separation of the pars interarticularis. There is no forward slippage of the vertebral body, is traumatic or developmental. Also a complicating factor to the Dx
Spondylolysis
72
Anterolistesis that may be due to a lysis (anterior slippage of the body).
Spondylolisthesis
73
Causes of spondylolisthesis
Traumatic Degenerative Developmental
74
Slippage/translation of the top vertebrae
Listhesis
75
Joint surface pain
Arthralgia
76
Joint surface inflammation
Arthritis
77
Condition of the joint. Describes joint pathology, generally degeneration.
Arthrosis
78
X-ray signs for arthrosis
Irregular surfaces Sclerosis Hypertrophy of joint surface
79
Joint pathology, usually referring to organic pathology
Arthropathy
80
Inflammation of the synovium.
Synovitis
81
Indications of synovitis
No X-ray indications. There may be physical exam indications. Fluid will be over Produced.
82
Capsular pain
Capsalgia
83
Capsule inflammation-swelling, possible heat, redness and painful
Capsulitis
84
What irritates the capsule?
Stretch
85
Disorder of peripheral ligamentous or muscular attachments of spine
Spinal enthesopathy (inflammation @ site of ligaments or tendinous insertion)
86
Myalgia
Muscle pain
87
Muscle inflammation
Myositis
88
Muscle facial inflammation
Myofascitis
89
Spasm of muscle implies what?
Acute and painful nature
90
Inflamed tendon
Tendonitis
91
Chronic tendon pain and adhesion
Tendonosis
92
Tendon synovial inflammation
Tenosynovitis
93
Increased joint movement
Hyperkinesia
94
Decreased joint movement, can be used as the diagnostic term for joint fixation, restriction
Hypokenesia
95
Painful musculoskeletal tissue w/ gross joint movement (active)
Kinesalgia
96
Injury or tear to muscle and tendons (overuse).
Strain
97
Injury or tear to ligaments.
Sprain
98
Which takes more force to damage- muscle or ligament?
Ligaments
99
Blunt trauma, generally to soft tissue. Shown as warm, bruised, swelling
Contusions
100
Skin scraping (road rash)
Abrasions
101
Cuts with sharp objects
Lacerations
102
Bone damage from trauma
Fractures
103
Right convexity curve of the spine
Dextro- scoliosis
104
Left convexity curve of the spine
Levo-scoliosis
105
When vertebra turns toward concavity
Idiopathic
106
End plate hypertrophy and facet joint degeneration, both present
Spondyloarthrosis Spondylosis + arthrosis
107
Pain symptoms, neurological findings normal
Radiculoneuralgia Nerve root + Peripheral nerve problem
108
Pain, paresthesia, increased MRS.
Radioculoneuritis Nerve root + peripheral nerve inflammation
109
Nerve with pain, paresthesia and decrease MRS
Radiculoneuropathy Pathology of nerve root + peripheral

NMS Diagnosis (3 decks)

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