Final Dx Clusters

Question 1

Diagnostic Cluster for Lumbar Stenosis:

Answer 1

► Relief during immediate sitting is strongly suggestive of spinal stenosis (Sensitivity 0.46; Specificity 0.93).
The most diagnostic combination included a cluster of:
1) bilateral symptoms;
2) leg pain more than back pain;
3) pain during walking/standing;
4) pain relief upon sitting;
5) age >48 years.
- Meeting any one of five positive findings demonstrated a high sensitivity of 0.96 (95% CI = 0.94-0.97) and a low negative likelihood ratio (LR-) of 0.19 (95% CI = 0.12-0.29).
Meeting four of five findings yielded a LR+ of 4.6 (95% CI = 2.4-8.9) and a post-test probability of 76%.

Question 2

Diagnostic Cluster for Cauda Equina Syndrome:

Answer 2

· Rapid symptoms within 24 hours 89% sensitivity
· History of back pain 94% sensitivity
· Urinary retention 90% sensitivity
· Loss of sphincter tone 80% sensitivity
· Sacral sensation loss 85% sensitivity
· Lower extremity weakness or gait loss 84%sensitivity

Question 3

Diagnostic Cluster for Lumbar Radiculopathy:

Answer 3

· Dermatomal pattern (OR = 4.1)
	· Pain on cough, sneezing, straining (OR = 3.2)
	· More pain Sitting (OR=1.9)
	· Subjective muscle weakness (OR = 2.2)
	· Subjective Sensory loss (OR = 2.1)
	· Paresis/Motor Loss (OR = 3.7)
	· +SLR (OR = 3.9)
	· Unilat Ankle reflex (OR = 3.9)

Question 4

Diagnostic Cluster for Lumbar Compression fracture:

Answer 4

· age >50 (sensitivity 0.84, specificity 0.61)
· age >70 (sensitivity 0.22, specificity 0.96)
· trauma (sensitivity 0.30, specificity 0.85)
· Adequate trauma, although in elderly trauma can be minor
· corticosteroid use (sensitivity 0.06, specificity 0.995)

Question 5

Diagnostic Cluster for Spine Cancer:

Answer 5

· Age > 50 (sensitivity 0.77, specificity 0.71)
· previous history of cancer (sensitivity 0.31, specificity 0.98)
· failure to improve in 1 mo. of therapy (sensitivity 0.31, specificity 0.90)
· no relief with bed rest (sensitivity >0.90, specificity 0.46)
· duration of pain > 1 mo (sensitivity 0.50, specificity 0.81)
· COMBO: age >50 or cancer hx or unexplained wt loss or failure of conservative tx (sensitivity 1.00, specificity 0.60)
· Insidious onset (no stats)
· constitutional symptoms (no stats)

Question 6

Ottawa Knee Rules - knee x-ray is only required for knee injury patients with any of these findings:

Answer 6

○ age 55 or over
○ isolated tenderness of the patella (no bone tenderness of the knee other than the patella)
○ tenderness at the head of the fibula
○ inability to flex to 90 degrees
○ inability to weight bear both immediately and in the emergency department (4 steps - unable to transfer weight twice onto each lower limb regardless of limping).

Question 7

Ottawa foot rules indicate whether a foot X-ray series is required. It states that it is indicated if there is any pain in the midfoot zone and any one of the following:

Answer 7

1. Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR
   
   2. Bone tenderness at the navicular bone (for foot injuries), OR
      An inability to bear weight for four steps.

Question 8

Well’s Clinical Prediction Rule for DVT:

Answer 8

· Major criteria
		○ Active cancer within the last 6 months
		○ Paralysis
		○ Recently bedridden
		○ Localized tenderness
		○ Thigh and calf swollen
		○ Family history of DVT
	· Minor criteria
		○ Hx of recent trauma
		○ Pitting edema
		○ Dilated superficial veins
		○ Hospitalized within the last 6 months
		○ Erythema 
(+) Positive is >3 major criteria AND >2 minor criteria

Question 9

Motor Testing: 0

Answer 9

no muscle contraction / flaccid (if can’t complete dt pain, then write that down otherwise just thinking paralysis)

Question 10

Motor Testing: 1/5

Answer 10

no joint motion; inability to complete ROM w gravity eliminated

Question 11

Motor Testing: 2/5

Answer 11

muscle completes ROM w gravity eliminated

Question 12

Motor Testing: 3/5

Answer 12

muscle completes ROM against gravity but wo resistance

Question 13

Motor Testing: 4/5

Answer 13

muscle completes ROM against gravity w some resistance

Question 14

Motor Testing: 5/5

Answer 14

almost completely normal… diff if one side is weaker than the other (with some resistance)

Question 15

OA of Hip

Answer 15

The American College of Rheumatology diagnosis of hip OA:
Test: If either cluster of signs/symptoms are positive, the working Dx of OA can be made; this does not necessarily confirm this is exactly why the patients has sxs.
Cluster 1:
Pain in the hip (not SIJ)
less than 115 deg of hip flexion
less than 12 deg of hip IR
Cluster 2:
pain in hip w IR
over 60 minutes of AM stiffness
> 50 years old

Question 16

Dx cluster for AS

Answer 16

• age at onset less than 40 yo
• pain not relieved by supine position
• morning back stiffness
• pain duration > 3 mo
• 4/5 of above (+) and improved by exercise (+LR = 1.27)