Case History
11%of exam
Chief ComplaintOPQRSTRed FlagsHistory Taking
Physical Examination
9%of exam
Vital SignsInspectionPalpationAbdominal Exam
Neuromusculoskeletal Examination
11%of exam
Orthopedic TestsReflexesMyotomesDermatomes
Diagnostic Imaging
11%of exam
Imaging SelectionOttawa RulesDXI CategoriesX-ray Views
Clinical Lab & Special Studies
7%of exam
CBCESR/CRPHLA-B27Special Studies
Diagnosis or Clinical Impression
14%of exam
Red FlagsDifferential DxEmergency ReferralClinical Reasoning
Chiropractic Techniques
14%of exam
Technique SystemsContraindicationsListingsBiomechanics
Supportive Interventions
8%of exam
PhysiotherapyModalitiesExercise TherapyNutrition
Case Management
15%of exam
Treatment PlanReferralDocumentationEmergency Care
Quick Facts
- Exam
- NBCE Part III
- Body
- NBCE
- Items
- 130 (TMCQ+EMCQ+DXI)
- Time
- 4 hrs (2x120min)
- Pass
- 375 scaled
- Format
- CBT, Prometric
- Level
- Board licensure exam
- Blueprint
- Aug 2024 update
History Taking Mnemonic
OPQRST structures every pain history
Onset: sudden or gradualProvocation: what changes painQuality: sharp, dull, burningRadiation: where pain travelsSeverity: rate zero to tenTime: duration and pattern
Case History Essentials
- OPQRST
- Symptom characterization mnemonic
- Mechanism of injury
- Document first in trauma
- Bowel/bladder change
- Cauda equina screen
- Night pain unrelieved
- Serious pathology flag
- Unexplained weight loss
- Cancer screening flag
- Constitutional symptoms
- Fever, malaise, infection flag
Physical Exam Fundamentals
- Vital signs
- BP, pulse, respiration, temp
- Inspection
- Posture, gait, symmetry
- Palpation
- Tenderness, muscle tone, spasm
- Auscultation
- Heart, lungs, bowel sounds
- Murphy's sign
- Gallbladder inflammation indicator
- CVA tenderness
- Kidney, renal involvement
Adson's vs Wright's Test
Adson's test
- Head rotate, extend, inhale
- Scalene muscle compression
- Checks radial pulse
Wright's test
- Arm hyperabduction position
- Pectoralis minor compression
- Checks radial pulse
Different compression location tested
Spinal Orthopedic Tests
- SLR (Lasegue)
- Sciatic nerve tension test
- Kemp's test
- Facet, foraminal encroachment
- Valsalva maneuver
- Raises intrathecal pressure
- Milgram's test
- Intrathecal space pathology
- Braggard's test
- Confirms sciatic tension
- Spurling's test
- Cervical foraminal encroachment
Lachman vs Anterior Drawer
Lachman test
- 20-30 degrees flexion
- Most sensitive ACL test
- Preferred exam maneuver
Anterior drawer
- 90 degrees flexion
- Less sensitive test
- Hamstring can mask laxity
Lachman is more accurate
Extremity Orthopedic Tests
- Lachman test
- ACL tear, most sensitive
- McMurray's test
- Meniscus tear indicator
- Neer's test
- Shoulder impingement sign
- Phalen's test
- Carpal tunnel syndrome
- FABER (Patrick's)
- Hip, SI joint pathology
- Adson's test
- Thoracic outlet syndrome
Reflexes & Dermatome Levels
- Biceps reflex
- C5 nerve root level
- Triceps reflex
- C7 nerve root level
- Patellar reflex
- L4 nerve root level
- Achilles reflex
- S1 nerve root level
- Thumb dermatome
- C6 nerve root level
- Big toe dermatome
- L5 nerve root level
Ottawa Rules Memory Aid
Pain plus cannot bear weight means image
Ankle: malleolar zone tendernessKnee: age 55 or tender fibula
X-ray vs MRI Selection
X-ray
- Bone, alignment, fracture
- First-line, low cost
- Fast and widely available
MRI
- Disc, cord, soft tissue
- Shows nerve root compression
- No ionizing radiation
Bone versus soft tissue
Imaging Ordering Decision
- Suspected fracture→Order X-ray first(Confirms bone injury)
- Ankle pain, no weight-bear→Order X-ray(Ottawa ankle rule)
- Knee pain, age 55+→Order X-ray(Ottawa knee rule)
- Suspected disc herniation→Order MRI(Soft tissue detail)
- Suspected bone metastasis→Order bone scan(Whole-body screen)
- Complex fracture pattern→Order CT scan(Detailed bone anatomy)
- Suspected nerve entrapment→Order EMG/NCV(Confirms radiculopathy)
- No red flags, acute→Delay imaging(Trial conservative care)
Imaging Selection & Ottawa Rules
- X-ray
- First-line, bone alignment
- MRI
- Soft tissue, disc, cord
- CT scan
- Complex fracture detail
- Bone scan
- Metastases, infection screen
- Ottawa ankle rule
- Malleolar pain, no weight-bear
- Ottawa knee rule
- Age 55+, fibular tenderness
DXI Interpretation Categories
- Arthritic
- Degenerative, inflammatory joint disease
- Congenital variants
- Skeletal anomalies, normal variants
- Trauma
- Fracture, dislocation patterns
- Tumors
- Neoplastic bone processes
- Misc osteoarticular
- Metabolic, other bone disease
- Soft tissue
- Non-osseous imaging findings
Lab & Special Studies
- CBC
- Infection, anemia screen
- ESR/CRP
- Inflammation marker levels
- RF
- Rheumatoid arthritis marker
- HLA-B27
- Ankylosing spondylitis marker
- Uric acid
- Gout marker level
- Urinalysis
- Renal, systemic screen
Mechanical vs Inflammatory Back Pain
Mechanical
- Worsens with activity
- Improves with rest
- Older typical onset
Inflammatory
- Morning stiffness over 30min
- Improves with activity
- Onset under age 40
Activity response is key
Red Flag Referral Decision
- Saddle anesthesia, bowel/bladder loss→Emergency referral now(Cauda equina syndrome)
- Pulsatile abdominal mass→Emergency referral now(Possible aortic aneurysm)
- 5 Ds, 3 Ns present→Stop, refer immediately(Vertebrobasilar insufficiency signs)
- Fever, IV drug use→Refer for workup(Possible discitis, infection)
- Progressive weakness, UMN signs→Urgent referral needed(Possible myelopathy)
- Age 50+, unexplained weight loss→Refer, order imaging(Rule out cancer)
- No red flags present→Continue chiropractic care(Conservative management appropriate)
Emergency Red Flags
- Cauda equina syndrome
- Saddle anesthesia, surgical emergency
- Abdominal aortic aneurysm
- Pulsatile mass, elderly patient
- Vertebrobasilar insufficiency
- Dizziness, dysarthria, drop attacks
- Myelopathy
- Upper motor neuron signs
- Discitis/osteomyelitis
- Fever, IV drug use
- Inflammatory spondyloarthropathy
- Stiffness improves with activity
Radicular vs Referred Pain
Radicular
- Dermatomal pattern present
- Travels below the knee
- Nerve tension test positive
Referred
- Sclerotomal, vague pattern
- Stays above the knee
- No nerve tension sign
Pattern reveals true source
VBI Warning Signs Mnemonic
5 Ds and 3 Ns signal VBI
Dizziness, Diplopia, DysarthriaDysphagia, Drop attacksNausea, Nystagmus, Numbness
Gonstead vs Diversified Technique
Gonstead
- Specific listing system used
- X-ray line of drive
- High segmental specificity
Diversified
- General HVLA approach
- Broadly taught technique
- Most common in practice
Specific vs general approach
Adjustment Contraindication Check
- Fracture at segment→Do not adjust(Absolute contraindication)
- Tumor or malignancy present→Do not adjust(Absolute contraindication)
- Active infection at site→Do not adjust(Absolute contraindication)
- VBI signs present→Stop, refer immediately(Vertebral artery risk)
- Anticoagulant therapy→Use caution, modify(Relative contraindication)
- Severe osteoporosis present→Modify force applied(Low-force technique preferred)
- No contraindications found→Proceed with HVLA(Standard adjustment technique)
Chiropractic Technique Systems
- Diversified
- HVLA, most common technique
- Gonstead
- Specific line-of-drive, listings
- Activator Methods
- Instrument-assisted, low force
- Thompson technique
- Drop-table segmental adjustment
- Flexion-distraction (Cox)
- Disc, stenosis technique
- SOT
- Pelvic block categories
Absolute vs Relative Contraindication
Absolute
- Fracture at the site
- Malignancy at the site
- Active infection present
Relative
- Anticoagulant therapy use
- Osteoporosis, modify force
- Disc herniation, use caution
Never adjust vs caution
Adjustment Contraindications
- Fracture at site
- Absolute contraindication
- Malignancy at site
- Absolute contraindication
- Active infection
- Absolute contraindication
- Atlantoaxial instability
- Down syndrome, RA caution
- Anticoagulant therapy
- Relative, bleeding risk
- VBI signs present
- Stop adjustment, refer
Supportive Care Modalities
- Ultrasound
- Deep heat, tissue healing
- IFC/e-stim
- Pain modulation, muscle stimulation
- Cryotherapy
- Acute inflammation control
- Thermotherapy
- Chronic stiffness relief
- Mechanical traction
- Disc decompression technique
- Therapeutic exercise
- Strength, stabilization training
Stroke Recognition Mnemonic
FAST identifies stroke, prompts emergency call
Face: drooping or asymmetryArm: weakness or driftSpeech: slurred or difficultTime: call emergency now
Case Management & Emergency Care
- Treatment plan
- Frequency, duration, goals
- Re-evaluation
- Reassess at defined interval
- Referral criteria
- Red flags, non-response
- SOAP documentation
- Subjective, objective, assessment, plan
- CPR ratio
- 30 compressions to 2 breaths
- FAST
- Stroke recognition mnemonic
Common Traps
Radicular pain ≠ referred pain
Radicular follows dermatome pattern ≠ Referred pain is sclerotomal, vague
Lachman ≠ anterior drawer
Lachman is more sensitive ≠ Drawer can be masked
Absolute ≠ relative contraindication
Absolute means never adjust ≠ Relative means proceed cautiously
Case history ≠ physical exam
History is subjective report ≠ Exam is objective finding
TMCQ ≠ EMCQ format
TMCQ is single best answer ≠ EMCQ is multi-question case
Ottawa rules ≠ diagnosis
Rules screen for imaging need ≠ Not a diagnostic conclusion
Gonstead ≠ Diversified
Gonstead uses specific listings ≠ Diversified is general HVLA
Last Minute
- 1.Passing score is 375 scaled
- 2.130 items: TMCQ, EMCQ, DXI
- 3.Case Management carries highest domain weight
- 4.Cauda equina is surgical emergency
- 5.Never adjust fracture or malignancy
- 6.VBI signs mean stop, refer
- 7.Ottawa rules reduce unnecessary X-rays
- 8.MRI shows disc, nerve compression
- 9.SLR tests sciatic nerve tension
- 10.FAST screens for stroke signs
- 11.Two 120-minute sessions, one break
- 12.DXI equals 20 percent weight
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