NBCE Part IV Critical Information

Case Management & Chiropractic Set up

APPROACH

Starting in 2026, NBCE transitioned Part IV to a centralized testing center on its Greeley, Colorado campus, replacing the current decentralized, twice‑a‑year format. Part IV stations will now reflect complete patient encounters, including history, focused exam, clinical decision‑making, communication, and documentation in SOAP note format and a chiropractic technique testing station. NBCE believes that this change will allow them to better assess clinical reasoning, professionalism, and patient education skills, not just rote performance of isolated diagnostic procedures.

While NBCE hasn’t specifically labeled one station as the “patient education station,” the new format integrates patient education into the broader seven‑station case management sections. There will be Seven full patient encounter stations. Each station will have the following components: 2‑min chart review, 14‑min interaction, then 6‑min SOAP note post‑station in which you will be expected to document the full encounter and follow‑up plan, including patient education elements. You will be graded in five domains: 

  • Patient Evaluation: gathering a focused history.

  • Patient Examination: performing relevant tests.

  • Clinical Decision‑Making & Case Management: choosing diagnostics and care.

  • Interpersonal/Communication Skills and Clinical Professionalism: including educating the patient about diagnosis and care and to address their concerns.

  • Documentation: generating a clear SOAP note summarizing the encounter and plan.

Each of the case management stations will last 22 minutes in which you’re expected to communicate findings clearly and compassionately to the simulated patient, addressing their concerns and expectations. You'll explain the next steps—whether that's referral, imaging, exercises, manual therapy, or lifestyle recommendations. Your ability to teach a patient about their condition, contraindications, and follow‑up care is built into scoring criteria under communication and case management domains. Since there are no separate stations within each case management station, it is imperative to manage your timing efficiently.

The station will commence by reading the instructions provide to you at the computer station outside of the individual station rooms. You will be given a note book to make notes if you so desire. You have two minutes for this part. Read the instructions on the screen carefully. Use the note book provided to write down the patient’s name, age, and the chief complaint. You could start your notes in the SOAP format, i.e., Subjective: Chief complaint. HPI: OPQRSTA, PMH, F/SH and ROS. You will be notified when that 2-minute time is over and should proceed to the assigned examination room where you will find your patient seated.

Greet your patient. Explain who you are. Confirm their name and explain what is going to happen in the next 14 minutes. I would recommend that you spend no more than 5 minutes taking a focused history. The next 5 minutes in the station should be spent on the focused physical examination and any specific physical tests that might be helpful in establishing the diagnosis. In the remaining 4 minutes, use this time to formulate a diagnosis and plan. Explain to your patient your findings, diagnostic conclusion of you have come to one, your plan of action, or the need for further testing or referral, making sure that you address the patient’s concerns. Give the patient the opportunity to ask you any questions or share with you any additional pertinent information that they might not have told you previously. At the end of the 14 minutes, you will be allowed to leave the station. Thank your patient for their time and patience.

Proceed to the next phase which is to document your findings using the SOAP note format. The chiropractic technique evaluation session will assess your ability to verbalize while demonstrating your ability to perform 10 chiropractic adjustments in 14 minutes. There will be a 20-minute break between your 4th and 5th case management stations.

While the old format's segmented stations focused on narrow performance points, the new format demands higher-level reasoning, comprehension, and real-world clinician behaviors—including educational communication—which many students struggled with in the past. The integrated patient‑education skillset is essential to demonstrate—explain clearly the “why” behind management decisions. This is dependent on your ability to communicate not only with the patient but with the “examiner” your thought process. Your teachers have not been given the specific OSCE checklists that NBCE uses. This OSCE checklists was generated as a guide and will be modified in the future as needed.

The importance of a detailed history in making a diagnosis cannot be overemphasized. In a 1970s study1, researchers demonstrated the correct diagnosis can be made on a good history alone 80% of the time. In 10% of diagnoses, additional information obtained from the physical examination is necessary to the diagnosis. In 5% of diagnoses, lab testing or imaging is needed to make the diagnosis. Therefore, it is important that you know how to obtain a good history within the five minutes allocated for this activity. Because you only have 5 minutes, you need to be very selective in what to ask and what can be left out. Let us use the example of a 45-year-old female patient with abdominal pain to demonstrate these important areas.

First, a detailed History of the Presenting Illness or chief complain is necessary. You can follow the familiar OPQRST format:

Onset: when did this pain start?

Palliation and provocation: what makes your pain better? What makes your pain worse?

Quality: how would you describe your pain?

Radiation: does you pain move and go elsewhere?

Situation and severity: where exactly is this pain? On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain you have ever experienced, what number is your pain now?

Timing: is your pain worse at any specific time of the day?

Ask if there is any anything else going on even if it seems unrelated as this will help in developing an early hypothesis which will drive the rest of your history taking efforts. For instance, if the patient says that he has a fever, then think of infectious causes of abdominal pain. Taken together with the location of the pain, you can begin to speculate which organ is affected which would guide you when you are doing a Review of Systems.

Next ask whether this has ever happened in the past [Past Medical History]. The answer will give you a hint as to whether this is a recurrent problem or not. If the patient has had this problem before, ask when and what she did when she had this problem previously. If not, ask if any family member has had a similar problem as this might be something that runs in the family [Family History]. If there is a family history of this illness, what was the outcome?

Next, if time permits do the Review of Systems and focus on the system in which the complaint is located. So, as we are dealing with abdominal pain, you should focus on the gastrointestinal and then the genitourinary systems. The GI related questions must include asking about the appetite, bowel movement, diarrhea, vomiting and blood in the stool. The GU-related review should include asking about dysuria, frequency of urination, nocturia and hematuria. As this patient is female, do not forget the dictum that all females in their fertile years with abdominal pain, must be assumed to be pregnant until proven otherwise. It is imperative to ask when her last menstrual period was because the combination of lower abdominal pain and six to eight of amenorrhea means that her pain might be due to an ectopic pregnancy. As this is an examination in a chiropractic school, do not forget to ask about back pain or other musculoskeletal system questions as vertebral subluxation can present with visceral pain. If the gastrointestinal and genitourinary systems review does not yield any useful information, shift to reviewing the respiratory system as pneumonia can present with referred abdominal pain.

If there is still time, ask about their Social History: do you smoke, if so, how much? do you drink, if so, how much and how often? what about your sleeping habits? what about your diet? What did you have for breakfast, lunch and dinner yesterday? How often do you eat vegetables and fish? End by asking if there is anything they would like to tell you or discuss with you today

The following are some of the more common presentations in the chiropractic setting:

a. neck pain

b. shoulder pain

c. elbow pain

d. wrist and hand pain

e. low back pain

f. hip pain

g. knee pain

h. ankle and foot pain

i. muscle weakness

j. sensory loss

k. dizziness

l. chest pain

m. dyspnea

n. abdominal pain

o. edema

o. fatigue

A stepwise approach is recommended, and it should start with the pertinent questions to ask if this were one of the three history taking stations. This is followed by a list of diagnostic triads to be considered. After this, is a list of possible physical examinations you could be asked to consider based on the location of the complaint. A list of possible ortho-neuro tests follows with a detailed checklist for the performance of each test, and finally, a summary on the causes, presentation, and management of patients with each of the conditions mentioned in the diagnostic triads.

With each symptom, there will be the following components:

  1. take a focused history

  2. identify the most likely diagnosis at this stage based on the history

  3. perform a specific physical examination based on the system most likely affected

  4. perform a specific physical or ortho-neuro examination test

  5. identify the most likely diagnosis at this stage

  6. choose what additional tests might be helpful in establishing the diagnosis

  7. interpret a given a specific test result

  8. identify the final diagnosis given all the above information

Describe a management plan that is appropriate for the diagnosis or lack of diagnosis if that is the case. Here are some guidelines on managing patients. This is based on your diagnosis. The purpose of making a diagnosis in health care is to determine the level of intervention. Here are the various levels of intervention starting with the most serious:

  1. Call 911

  2. Refer urgently to the hospital

  3. Refer to an appropriate specialist

  4. Co-manage with a medical doctor

  5. Treat

  6. Wait and see

These are the ABCDEs that necessitate a 911 call:

  1. Airway obstruction

  2. Bleeding profusely

  3. Chest pain > 10 minutes

  4. Distant hospital > 15 minutes away

  5. Evidence of vital sign disruption

These are considered vital signs disruption that warrant a 911 call:

  1. Temperature greater than 104 or less than 95

  2. Pulse rate greater than 150 9r less than 40 beats per minute

  3. Respiratory rate greater than 30 and less than 8 breaths per minute

  4. Blood pressure greater tahn190/120 or less than 90/50 mm Hg

For example, if your diagnosis in this 45-year-old female patient with abdominal pain were acute cholecystitis, your plan should include the following: referral to the hospital or an appropriate specialist, an explanation as to why a referral, a request that after her condition has been properly treated if she would like someone in your office to find out how she is doing on a week or so. If you were unable to make a diagnosis, then you could order additional tests, like x-rays, ultrasound or blood tests such as a complete blood count, comprehensive metabolic panel or urinalysis. Please explain why you are doing this. If your diagnosis were a subluxation at T9 and you were planning on adjusting her, explain why a T9 subluxation could be the cause of her abdominal pain and how an adjustment would be helpful.

Review your notes and ensure you have addressed her fears and expectations before ending with the following questions, “Do you have any questions for me at this time?” Don’t forget to thank the “patient” for their patience and help. 

SOAP NOTE FORMAT

The SOAP note – an acronym for Subjective, Objective, Assessment, and Plan – is a widely adopted clinical documentation method designed to organize patient information logically and efficiently. Originally developed by Dr. Lawrence L. Weed in the late 1960s, the SOAP format was part of a broader initiative to improve medical record-keeping through the Problem-Oriented Medical Record (POMR) system. Dr. Weed sought to standardize how clinicians recorded clinical encounters, enhance diagnostic reasoning, and improve continuity of care by creating a structured yet flexible format that could be applied across medical disciplines (Weed, 1968).

Each SOAP note2 begins with the Subjective (S) section, which captures the patient’s narrative: their chief complaint, symptoms, history of present illness, and relevant background such as medications, allergies, and social or family history.

This is followed by the Objective (O) section, which includes measurable and observable clinical data such as vital signs, physical exam findings, laboratory results, and imaging interpretations. Together, these sections provide a comprehensive picture of both the patient’s reported experience and the clinician’s findings.

The Assessment (A) section is where clinical reasoning comes into play. Here, the provider synthesizes the subjective and objective data to generate a differential diagnosis, a most likely diagnosis, and the rationale supporting that conclusion.

The final section, Plan (P), outlines the recommended next steps: diagnostic testing, treatment strategies, referrals, patient education, and follow-up scheduling.

The SOAP format is not only a clinical tool but also a critical part of education and professional evaluation. It is widely used in medical, chiropractic, nursing, and allied health curricula to teach clinical reasoning, case synthesis, and communication. Licensing boards such as the National Board of Chiropractic Examiners3 (NBCE) includes SOAP-based assessments in practical exams like Part IV and OSCEs, requiring candidates to demonstrate both clinical decision-making and documentation proficiency.

In modern healthcare, the SOAP note retains its relevance. Electronic health records (EHRs) often incorporate SOAP-like structures to standardize data entry and support interprofessional communication. Furthermore, accurate SOAP documentation is essential for legal accountability, medical billing, and quality assurance processes. It ensures that a patient's condition and care plan are clearly communicated and traceable.

In summary, the SOAP note remains a foundational pillar of clinical documentation. Its structured yet adaptable design supports clear communication, enhances diagnostic accuracy, and reflects a clinician’s competence in evaluating and managing patient care.

References

  1. Weed, L.L. (1968). Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record as a Basic Tool. Cleveland, OH: Case Western Reserve University Press.

  2. Bickley, LS. Bates’ Guide to Physical Examination and History Taking, 13th edition, 2020, Wolter Kluwer.

  3. National Board of Chiropractic Examiners (NBCE). (2025). Clinical Competency and Case Management: Proposed Changes to Part IV.

CHEST PAIN

Take a focused history from this 26-year-old female patient whose main complaint is chest pain.

DIAGNOSTIC APPROACH

HPI Onset one month ago

Palliative resting quietly

Provocative sometimes after activity and sometimes with specific thoracic movements

Quality sticking

Radiation does not radiate

Severity 6 out of 10

Situation retrosternal

Timing on and off for the past month

Additional symptoms: none

Think of the following diagnostic triads:

Sweating

    • Myocardial infarction squeezing retrosternal pain

    • Pulmonary embolism pleuritic pain, shortness of breath and hemoptysis

    • Dissecting thoracic aorta tearing chest pain and feeling of impending doom

Fever

    • Pneumonia bronchial breathing, basal crackles, rust-colored sputum

    • Tuberculosis bronchial breathing apical crackles, hemoptysis

    • Pericarditis pain worse lying down, better on sitting and leaning forward

Painful Chest Wall

    • Herpes zoster unilateral band of vesicles and pustules along a dermatome

    • Rib fracture history of injury, pain worse in sternal compression

    • Tietze syndrome tender swollen 2nd or 3rd costochondral junction

Atypical Chest Pain

    • GERD heartburn worse on lying down after heavy meals

    • Mitral Valve Prolapse midsystolic click in mitral area

    • T4 syndrome springing of T4 reproduces the symptoms

Other causes

  • Angina pectoris squeezing chest pain worse with exertion and relieved by rest

  • Panic attack dyspnea, chocking sensation, circumoral numbness

  • Midthoracic subluxation segmental taut and tender fibers with hypomobility

Physical Examination

Given the history of burning retrosternal pain in a 26-year-old female, the presumptive diagnosis is gastroesophageal reflux disease. Perform the test that is more likely to support your presumptive diagnosis or to exclude some of the differential diagnoses like pneumonia, pericarditis, mitral valve prolapse or pleurisy:

a. inspect the anterior chest

b. palpate the anterior chest

c auscultate the precordium

d. auscultate the posterior chest

e. perform Schepelmann test

f. percuss for spinal tenderness

g. examine for a midthoracic subluxation

With each of the above, verbalize what is normal and what you would consider abnormal and the significance.

Inspect the anterior chest


1

Explain to the patient what you would like to do and obtain permission to expose the chest


2

Look for bruises, swellings, pulsations or dermatomal rashes


3

Explain that the presence of a bruise might indicate an underlying rib fracture


4

Explain that pulsations in the precordium might indicate underling cardiac problems


5

Explain that a vesiculopustular rash in a dermatome is suggestive of herpes zoster


 

Palpate the anterior chest


1

Explain to the patient what you would like to do and obtain permission to expose the chest


2

Expose the anterior chest adequately


3

Explain that if at any time the exam is uncomfortable, you would modify your technique


4

Warm your hands


5

Palpate with the palm of the hand for swellings, tenderness, pulsations or thrills


6

Explain that a tender swollen costochondral joint might suggest Tietze syndrome


7

Explain that a tender area along a dermatome might be the prodrome of herpes zoster


8

Explain that tenderness under a bruised area might indicate an underlying rib fracture


9

Explain that pulsations in the precordium might indicate underlying cardiac problems


10

State that a thrill [palpable murmur] is indicative of an underlying heart valve pathology


 

Auscultate the precordium


1

Explain to the patient what you would like to do and obtain permission to expose the chest


2

Warm the diaphragm before use


3

Ensure the earpieces of the stethoscope are facing forward in the ears


4

Ensure that the diaphragm is in use


5

Auscultate the aortic area [2nd right intercostal space parasternally]


6

Auscultate the pulmonary area [2nd left intercostal space parasternally]


7

Auscultate the tricuspid area [[4th left intercostal space parasternally]


8

Auscultate the mitral area [5th left intercostal space midclavicular line]


9

Comment on the heart sounds S1 and S2 and whether normal or not


10

Comment on whether any additional hearts sounds [S3 or S4] were heard


11

Comment on whether there were any murmurs, midsystolic clicks or friction rubs


12

State the presence of a midsystolic apical click is indicative of mitral valve prolapse


13

State the presence of a precordial friction rub is indicative of pericarditis




Auscultate the posterior chest


1

Explain to the patient what you would like to do and obtain permission


2

Ensure the earpieces of the stethoscope are facing forward in the ears


3

Ensure that the diaphragm is in use and is warm


4

Auscultate just medial to medial border of scapula [1st intercostal space] bilaterally


5

Auscultate just medial to the medial border of the scapula [3rd] bilaterally


6

Auscultate just medial to the medial border of the scapula [5th] bilaterally


7

Auscultate just medial to the medial border of the scapula [7th] bilaterally


8

Auscultate over the 9th intercostal space bilaterally


9

Auscultate below the inferior border of the scapula [10th] bilaterally


10

Comment on the breath sounds: normal, absent, decreased or increased


11

Comment on the presence of any adventitious sounds: crackles, wheezes or rubs


12

Explain that the presence of crackles may mean heart failure or pneumonia


13

Explain that wheezes might occur in asthma


14

Explain that a pleural rib is found in pleuritis




Perform the Schepelmann test


1

Explain to the patient what you would like to do and obtain permission


2

Instruct the patient to stand facing you


3

Ask the patient to raise both arms overhead with the elbows extended


4

Instruct the patient to bend towards the side with the pain


5

If this is painful, indicative of intercostal nerve irritation as in herpes zoster or rib fracture


6

If bending to this side is not painful, ask the patient to bend to the other side



Percuss the spine for tenderness


1

Demonstrate what you plan to do by tapping the back of their hand with patellar hammer


2

Tell the patient that this may cause some pain and obtain permission


3

Instruct the patient to sit in the neutral permission and lean slightly forward


4

Lightly tap the spinous processes of the thoracic vertebrae starting from T1


5

If this is painful, this is indicative of vertebral pathology like a compression fracture


 

Perform the examination to determine the presence of a subluxation


1

Explain to the patient that you would like to examine them for a misalignment of their spine


2

Warn the patient what you are about to do might cause pain and obtain permission


3

Instruct the patient to line face down on the examination table


4

Push down on the spinous processes starting at T4 and work down to T6


5

If there pain when pressing one spinous process, palpate nearby muscles for increased tone


6

Attempt to move the spinous process from side to side


7

The presence of taut fibers, pain and/or hypomobility are indicative of a subluxation


 

Post-Station Documentation

In the documentation part of the case management section, document your findings using the SOAP note format. For example, you were given a 26-year-old female patient whose chief complaint was chest pain. The information provided on the form given to you indicated that she weighs 210 lbs., her blood pressure is 120/80, her pulse was 88 beats per minute and her temperature was 98.40 F. You found out in the station that her pain was located under her left breast. She described the pain as sticking at times with no radiation. The pain is not associated with any fever, cough or shortness of breath. She rated her pain today as 6 out of 10. She has had this pain on and off for the past three months. There was no change in her bowel habits. She denies any diarrhea or constipation and the color of her stool is normal. She did admit to passing a lot of water during both the day and night and found that she was drinking a lot of water because she was thirsty. Her Last Menstrual period was three weeks ago, and it lasted the normal 3 days with moderate flow. There is no dysmenorrhea or abnormal vaginal discharge. During the physical examination, a midsystolic click murmur was heard in the 5th left intercostal space in the midclavicular line when auscultating the precordium. Fill out the SOAP notes on the computer.

Patient: 25-year-old male

Vitals: BP 120/80 Pulse 88 bpm Temp 98.4°F Respiratory Rate 16 bpm Height: 5’10” Weight: 140 lbs.

Subjective
Chief Complaint: “Pain under my left chest.”

History of Present Illness:

  • Onset: Three months ago

  • Location: Left anterior chest below the nipple

  • Quality: Sticking

  • Radiation: None

  • Aggravating Factors: None

  • Relieving Factors: None

  • Severity: 6/10 today

  • Additional symptoms: Frequent urination and increased thirst

  • No past medical history of similar complaint

  • Review of the musculoskeletal system: no joint pain, no muscle pain or no weakness

Objective
General: Not in any distress

CVS Exam:

  • Midsystolic click in the mitral area

Assessment
Probable Mitral Valve Prolapse

  • Based on location and nature of pain and the midsystolic click murmur in the mitral area

  • Differential Diagnoses: Tietze syndrome or pleurisy

Plan

  • Refer to a cardiologist for further examination regarding the cardiac murmur

  • Order a Comprehensive Metabolism Panel looking at the Fasting Blood Sugar because of her increased urination and thirst and her weight

  • Follow up in two weeks

Disease Summary 

Angina pectoris

  • condition caused by reversible damage to the myocardium, due to narrowing of a coronary artery

  • presents with severe squeezing retrosternal or pre-cordial pain that is precipitated by exertion and relieved by rest

  • Levine’s sign may be present [right hand in a grip over the left lower chest]

  • co-manage with a cardiologist with chiropractic adjustments, weight reduction, stress management and dietary modification aimed at reducing saturated fats

Compression Thoracic Fracture

  • compression fracture of the thoracic vertebra

  • associated with osteoporosis; white females are more affected than males

  • presents with sudden onset of sticking chest pain after a coughing fit or trivial trauma

  • a gibbus might be present; spinal percussion will cause pain

  • lateral chest x-ray will show the collapsed wedge-shaped vertebra

  • refer to the hospital

Dissecting thoracic aorta

  • tear in the tunica intima, associated with Marfan’s, hypertension or chest trauma

  • presents with sudden, severe, tearing chest pain with diminished upper limb pulses and hypotension

  • call 911

  • chest x-ray will show the widening of the superior mediastinum

Gastroesophageal reflux disease [GERD]

  • condition caused by relaxation of the lower esophageal sphincter which allows for regurgitation of acid stomach contents into the esophagus

  • presents with burning retrosternal pain worse after lying down after a heavy meal

  • may be associated with a cough worse at night or nocturnal wheezing in an adult

  • endoscopy will show erosion and inflammation of the lower end of the esophagus

  • refer to a gastroenterologist if advice to raise the head of the bed by 6 inches, eat smaller meals more frequently, avoid lying down after eating and irritant foods including chocolate and peppermint sweets, along with melatonin and chiropractic adjustments are not helpful

Herpes zoster

  • infection caused by HHV type 3 [varicella zoster virus] which lies dormant in the dorsal root ganglia

  • presents with prodrome of unilateral chest pain and a band of hyperesthesia followed by the typical band of vesicles and pustules along a dermatome

  • Schepelmann test will be positive on the concave side

  • no diagnostic tests are needed

  • chiropractic adjustments may be helpful

  • low level laser and nutritional supplements may also be helpful

Mitral valve prolapse

  • valvular heart disease of unknown origin; more common in women

  • may be associated with Marfan’s syndrome

  • presents with atypical chest pain and a mid-systolic click heard best in the 5th left intercostal space in the midclavicular line

  • echography will confirm the diagnosis and the severity of the prolapse

  • refer to a cardiologist for an echocardiogram and further treatment

Myocardial infarction

  • condition caused by irreversible damage to the myocardium due to occlusion of a coronary artery

  • presents with severe squeezing retrosternal pain, sweating and a feeling of impending doom

  • Levine’s sign may be present: right hand in a grip over the left lower chest

  • call 911

  • ECG [ST elevation, T wave inversion and pathological Q waves] and cardiac enzymes [elevated Troponin I and raised CK-MB] will confirm the diagnosis in the hospital

Panic attack/disorder

  • psychological condition characterized by intense fear of unknown origin

  • presents with chest pain, choking sensation, feeling of dying or losing control, palpitations, sweating, shortness of breath; no diagnostic tests are necessary

  • co-manage with a cognitive behavioral therapist

Pericarditis

  • inflammation of the pericardial sac; may be viral, bacterial or chemical

  • presents with retrosternal chest pain, worse lying down and is relieved by sitting up and forward

  • ECG may show ST elevation but no pathological Q waves

  • refer to the hospital

Pneumonia

  • inflammation of the lung parenchyma due to viral, bacterial or fungal infection or to inhaled chemicals

  • presents with chills, fever, dyspnea, pleuritic pain, productive cough, increased tactile fremitus and crackles

  • chest x-ray will show local or patchy consolidation of a lobe in one lung or both lungs

  • refer to the hospital using the CURB 65 criteria: Confusion, Urea elevated, Respiratory rate >30, Blood pressure <90/60 or 65 years and older

Pneumothorax

  • air in the pleural cavity; may be spontaneous or traumatic

  • presents with chest pain, sudden onset of dyspnea, hyper-resonant percussion notes and absent breast sounds over the affected side

  • chest x-ray will show the collapse lung with absent lung markings on the affected side

  • refer to the hospital

Prinzmetal angina

  • condition caused by reversible damage to the myocardium due to spasm of a coronary artery

  • may be triggered by amphetamine use

  • presents with severe squeezing retrosternal or pre-cordial chest pain at rest

  • Levine’s sign may be present

  • provocative ECG stress tests will be positive

  • co-manage with a cardiologist with chiropractic adjustments, weight reduction, anger management and dietary modification aimed at reducing saturated fats

Pulmonary embolism

  • breakaway clot from a deep vein thrombus causing obstruction to the pulmonary artery or a branch

  • presents with sudden onset of dyspnea, pleuritic pain, and hemoptysis

  • d-dimer test is positive [sensitivity 95% - if the test is negative, then pulmonary embolism is excluded]

  • call 911

  • lung perfusion scan or spiral CT scan of the chest is diagnostic

Rib fracture

  • break in the rib commonly at the angle due to blunt force trauma

  • presents with chest pain, which is worse on breathing deeply, coughing, or sneezing

  • sternal compression will aggravate the pain

  • chest x-ray will confirm the fracture and rule out any co-existing pneumothorax

  • conservative care is advised; avoid the use of a “rib belt” as this promotes a lung infection

Sarcoidosis
  • chronic systemic, non-caseous granulomatous disease of unknown etiology
  • more common in African American females
  • presents with chest pain, cough, shortness of breath, splenomegaly, or erythema nodosum
  • CBC might show leukopenia
  • CMP may show hypercalcemia
  • Co-manage with a pulmonologist
T4 syndrome
  • syndrome associated with midthoracic subluxations, mainly at T4
  • unknown cause
  • more in females
  • presents with unilateral or bilateral chest pain, vague upper extremity pain, paresthesia in the hands, difficulty in breathing or weak grip; pushing suddenly on T4 may reproduce the pain
  • chiropractic adjustments along with physical modalities, postural advice and exercise may be helpful
Thoracic Subluxation
  • trauma, toxins or thots
  • presents with unilateral chest pain which may be aggravated by movement of the trunk or breathing; segmental hypomobility, taut and tender fibers and/or pain on pushing on the spinous process
  • not associated with paresthesia in the hands, fever, productive sputum or cardiac murmurs
  • chiropractic adjustment is very helpful
Tietze syndrome

  • inflammation of the 2nd, 3rd, 4th or 5th costochondral joint

  • seen more commonly with repetitive microtrauma

  • presents with localized chest pain with a swollen tender costochondral joint

  • if the joint is just tender but not swollen, then the diagnosis is costochondritis

  • refer to a rheumatologist if chiropractic care is unsuccessful

Tuberculosis

  • chronic infection caused by Mycobacterium tuberculosis

  • characterized by Ghon focus and complex with caseous necrosis and granulomas

  • presents with cough, night sweats, fever, hemoptysis, and weight loss

  • chest x-ray may show apical consolidation and cavitation

  • refer to an Infection Disease specialist or the Department of Health for further investigation

  • sputum examination with the Ziehl Neelsen stain will reveal acid, alcohol-fast bacilli

  • Lowenstein Jensen medium is used to culture this organism

CHIROPRACTIC SETUPS

INSTRUCTIONS TO THE CANDIDATE

 Technique A: Seated lateral distal index – spinous contact

Subluxation: C5 PLS (Posterior Left Superior)

Motion: Right rotation restriction

DO NOT ATTEMPT TO MOVE THE SEGMENT OR TO ADJUST THE PATIENT

1. The listing of C5 spinous posterior left superior (PLS) means:

  • The spinous process of C5 has shifted posteriorly in the sagittal plane relative to C6.

  • The spinous process is rotated to the left in the transverse plane, meaning the vertebral body has rotated to the right.

  • The superior component implies that the segment is misaligned superiorly, typically reflecting an extension malposition, which may be visualized as increased spacing between the spinous processes of C5 and C6.

2. Position of the Patient and Doctor

  • The patient is positioned seated as this technique says “seated”.

  • I will stand behind and slightly to the right of the patient to properly contact the right side of the C5 segment.

3. Contact Hand

  • Let me locate the spinous process of C5 first by first palpating the spinous process of C7 and then move 1 and then 2 spinous processes above this starting point.

  • I will use the distal part of my left index finger to contact the segmental contact point on the patient.

4. Segmental Contact Point

  • The segmental contact point is on the left base of the spinous process of C5.

  • I will palpate the misalignment, set my contact, and lock in the segment.

5. Stabilizing Hand

  • My right hand will stabilize the patient's head and support the right occiput and right jaw.

  • This hand helps control segmental tension and allows for a smooth pre-adjustive setup.

6. Procedure

  • I would do a posterior to anterior tissue pull, and rotate the patient’s head away from the left and bend the patient’s neck towards the left. The thumb of my stabilization hand les just in front of the patient’s ear.

7. Line of Drive

  • The line of drive for this listing is posterior to anterior with slight clockwise (rotatory) torque through the plane line of the disc.

  • I will use a short, quick amplitude with slight inferior to superior thrust to correct the misalignment and restore right rotation.

C5 seated lateral distal index-spinous contact