Diagnosis, Orders and Management Decisions

A case management station is where the examiner finds out whether you can think like a primary contact doctor: take a set of findings, name what is wrong, decide what else could be wrong, order only the tests that change the plan, and choose between treating, co-managing and referring. Candidates who perform the history and examination well still lose the station when the impression is vague, the orders are a shotgun list, or a red flag is noticed but never acted on. This chapter turns those decisions into a repeatable routine you can run under time pressure.

Section 1Forming the diagnosis in a station

What the examiner is listening for

Case management stations on practical exams generally share a structure: a door card outside the room gives the patient's name, age, sex, chief complaint, sometimes vital signs, and the task. Inside, a standardized patient (SP) gives consistent answers and may reproduce findings such as pain on a provocative test. An examiner or the SP records performance on a checklist, and some stations add a written component. Check the current official candidate materials for the exact format, timing and scoring rules; this book does not reproduce them.

Whatever the scoring detail, checklists of this kind reward an impression that is specific ("lumbar disc herniation with left L5 radiculopathy," not "low back pain"), defensible (you can name the findings behind it) and safe (you have actively considered and excluded the dangerous causes, and you say so). Many stations also contain critical actions, items that weigh far more than ordinary points, such as recognizing a stroke sign and calling for emergency care. A polished candidate can still fail a station by missing the one critical action it was built around.

Working diagnosis versus differential diagnosis

The working diagnosis (also called the primary diagnosis or clinical impression) is the single condition that best explains the chief complaint and the findings. It drives the plan. The differential diagnosis is the short, ranked list of other conditions that could explain the same picture and that you have either ruled out, made less likely, or cannot yet exclude. A useful station differential has two to four items and always includes at least one "cannot miss" condition when the presentation allows it, even if your findings argue against it. Naming the dangerous alternative and explaining why you think it is unlikely shows the examiner that your safety screen was deliberate, not accidental.

Build the working diagnosis with four parts whenever the findings support them: tissue or structure (disc, facet joint, muscle, ligament, nerve root, peripheral nerve), region and level (C6, L4 to L5, right sacroiliac joint), side, and qualifiers such as acuity (acute, subacute, chronic), severity, neurologic involvement and mechanism. "Acute right C6 radiculopathy secondary to a probable C5 to C6 disc herniation, with intact strength" is a complete board impression. When you cannot be that specific, say what you can: "mechanical neck pain without neurologic deficit, most consistent with cervical facet syndrome at C5 to C6, right."

Linking findings to the impression

The habit that separates strong candidates is explicit linking: attach the two or three findings that carry the impression. "Your pain runs down the back of the leg to the outside of the foot, the straight leg raise reproduced it at 40 degrees, and your ankle reflex is reduced on the left. That pattern points to irritation of the S1 nerve root, most likely from a disc." This proves the exam was purposeful and teaches the patient.

Think in terms of pertinent positives (findings that support your impression) and pertinent negatives (absent findings that argue against an alternative). In a low back case, normal saddle sensation, normal bladder function and symmetric strength are pertinent negatives against cauda equina syndrome; their absence from your summary looks as if you never checked. In a neck case, the absence of dizziness, diplopia, dysarthria, dysphagia and drop attacks are pertinent negatives against vertebrobasilar ischemia. Say them.

A fast reasoning routine

While reading the door card, list three things: the most likely diagnosis for that age, sex and complaint; the cannot miss diagnoses; and the common mimics. A 68 year old man with new low back pain should trigger malignancy (prostate, myeloma), compression fracture and abdominal aortic aneurysm before you open the door; a 24 year old woman with right flank pain should trigger kidney stone, pyelonephritis and ectopic pregnancy. Use the history to rank the lists and the examination to test the top two or three.

1. Anatomic localization. Is the problem local (joint, muscle, ligament), radicular (dermatome, myotome, reflex), peripheral nerve (a single nerve territory), central (upper motor neuron signs, bilateral symptoms, gait) or referred from a viscus?
2. Mechanical versus non-mechanical. Mechanical pain changes with position, movement and load and eases with rest. Constant pain unchanged by position, night pain that wakes the patient, and pain with systemic features suggest inflammatory, infectious, neoplastic or visceral causes.
3. Acuity and trajectory. Improving, stable or worsening? A progressive neurologic deficit changes urgency immediately.
4. Red flags. Any flag changes the plan from "treat" to "investigate or refer" until it is cleared.
5. Yellow flags. Fear avoidance, catastrophizing, depression, work dissatisfaction and passive coping predict chronicity and shape the plan, not the diagnosis.

Using test accuracy without doing statistics in the room

You need not calculate likelihood ratios in a station, but know which tests rule in and which rule out. A negative result on a highly sensitive test helps rule a condition out (SnNout); a positive result on a highly specific test helps rule it in (SpPin). Clusters perform better than single tests: the commonly taught cervical radiculopathy cluster combines a positive upper limb tension test, rotation toward the symptomatic side under 60 degrees, a positive distraction test and a positive Spurling's test.

Section 2Ordering imaging and laboratory tests

The rule: order what changes management

Every order must answer "what will I do differently depending on the result?" Most acute, uncomplicated spinal pain without red flags needs no imaging at the first visit; routine imaging there does not improve outcomes, adds cost and radiation, and finds incidental degeneration that frightens patients. Examiners reward withholding unnecessary imaging and explaining why as much as ordering the right study when it is indicated.

Justify each order aloud in one sentence that contains the suspected condition and the trigger: "Because you are 72, have had steroid treatment and your pain started suddenly after a minor bump, I want lumbar radiographs today to look for a compression fracture." That sentence is the station equivalent of a clinical indication on a requisition, and it is exactly what an examiner checklist item such as "orders appropriate imaging with rationale" is looking for.

Clinical decision rules

Decision rules are validated shortcuts that tell you when imaging is unlikely to show a significant injury. Learn them in the form you can recite.

Red flags that justify imaging in spinal pain

For low back and neck pain without trauma, the indications for early imaging come from red flags. Each flag points at a specific dangerous condition, and the condition determines the modality.

Choosing the modality

Gadolinium contrast for MRI is used with caution in severe renal impairment, and iodinated contrast for CT requires attention to kidney function and allergy history.

Laboratory tests a chiropractic station expects you to know

Chiropractic scope for ordering laboratory tests varies by jurisdiction, but every candidate is expected to know which test answers which question, and to say so whether you order it yourself or recommend it in a referral. Tests are adjuncts to a clinical suspicion; never order a panel and hope.

Section 3Management decisions

Treat, co-manage or refer

After the impression, the station asks the central management question: is this patient appropriate for chiropractic care alone, appropriate for chiropractic care alongside another provider, or in need of referral before (or instead of) chiropractic care? Saying the decision out loud, with its reason, is usually a checklist item in itself.

• Treat when the presentation is a neuromusculoskeletal condition within scope, the pain behaves mechanically, the findings support the diagnosis, there are no red flags (or they have been cleared), there is no contraindication to the planned procedures, and the condition is expected to respond to conservative care.
• Co-manage when chiropractic care is appropriate but another provider must manage part of the problem: a stable radiculopathy that may need medication or an injection, a patient with diabetes or on anticoagulants whose comorbidity affects technique choice and healing, osteoporosis needing medical therapy, inflammatory arthritis under rheumatology care, chronic pain with depression or anxiety needing behavioral health support, or pregnancy under obstetric care.
• Refer when the complaint is not a neuromusculoskeletal condition (visceral, systemic or psychiatric), when a red flag needs investigation outside your scope, when there is an absolute contraindication to the care you would provide, when the condition is worsening or a neurologic deficit is progressing, or when a properly conducted trial of care has failed.

Referral is not abandonment, and you can say so: "I want your doctor to see you today about the fever and back pain together. Once infection is ruled out, I am happy to help with the back pain."

The treatment plan

A treatment plan said aloud in a station should be short but complete. Use the same order every time so you never leave out an element:

Frequency is highest in the acute phase and tapers as function improves; a common pattern for an acute uncomplicated case is two to three visits per week for two weeks, then reassessment. Chronic cases use lower frequency and more active care. A trial of care (commonly about two weeks) must produce measurable change; if a second trial with a different approach also fails (roughly four weeks overall), change the plan, investigate further or refer.

Outcome measures and meaningful change

Measurable goals require baseline numbers. Use a validated measure suited to the region, record it at the first visit and repeat it at every re-examination.

Home care and active management

Guidelines for spinal pain favor reassurance, staying active and exercise, with manual therapy as part of a multimodal plan. Home care should include an activity modification (not bed rest), a diagnosis specific exercise (repeated extension for a directional preference disc presentation, deep neck flexor training for neck pain, eccentric loading for tendinopathy) and a self care measure. Teach and check: "Show me how you will do that exercise." When yellow flags appear, explain that hurt does not equal harm, set graded activity goals, and consider behavioral health co-management for high risk patients.

Address yellow flags when they appear: explain that hurt does not equal harm, set graded activity goals, and consider screening tools such as STarT Back. Patients at high risk of chronic disability benefit from more education and psychologically informed care, and sometimes from a referral to behavioral health; this is co-management, not dismissal of the physical problem.

Section 4Contraindications and urgent referral scenarios

Contraindications to manipulation

A contraindication is a condition that makes a procedure inadvisable. An absolute contraindication means do not perform that procedure in that region at all (other care may still be possible elsewhere or with different methods). A relative contraindication means the procedure can be modified (lower force, different technique, avoid the region, avoid end range, avoid rotation) with appropriate caution and consent. Stations test whether you notice the condition and whether you choose an appropriate modification or referral.

Urgency levels and what to say

The response to a red flag must match its urgency. Use four levels and decide which one applies before you speak. In the station, stop any further examination or treatment that could worsen the condition, stay with the patient when the problem is an emergency, explain what you are doing and why, and document.

Cauda equina syndrome

Cauda equina syndrome (CES) is compression of the lumbosacral roots below the conus, usually by a large central disc herniation at L4 to L5 or L5 to S1, less often by tumor, abscess, hematoma or severe stenosis. Key features: saddle anesthesia, urinary retention (the earliest and most consistent sphincter sign, later overflow incontinence), fecal incontinence or reduced anal sensation, sexual dysfunction, bilateral or alternating sciatica, and leg weakness with reduced ankle reflexes. Outcome depends on early decompression, so the response is same day emergency evaluation for MRI and surgical consultation: no outpatient MRI and waiting, no manipulation, no driving home. Call ahead and send a brief written summary.

What to say: "The numbness between your legs and the change in your bladder tell me the nerves at the bottom of your spine may be squeezed. That is an emergency, because the sooner the pressure is relieved, the better those nerves recover. I am not going to treat your back today. I am calling the emergency department now. Is someone here who can drive you, or should I call an ambulance?"

Fracture and infection

For suspected fracture, use the Section 2 decision rules. A suspected unstable cervical fracture (midline tenderness, dangerous mechanism, neurologic signs) means immobilize the neck, do not move the patient unnecessarily, and call emergency services; a suspected stable compression fracture needs radiographs before any manipulation of the region. Suspected spinal infection (fever, IV drug use, recent bacteremia or procedure, diabetes, unrelenting pain with focal spinous tenderness) needs same day medical evaluation, because an epidural abscess can progress to paralysis within hours to days.

Vascular emergencies: dissection and stroke

Cervical artery dissection (vertebral or internal carotid) often presents first with neck pain and headache, which is why patients with an early dissection may seek chiropractic care before any neurologic signs appear. Suspect it when neck or occipital pain is sudden, severe and unusual for the patient, especially after minor trauma or sudden neck movement, and when accompanied by any posterior circulation sign: the 5 Ds and 3 Ns (dizziness, diplopia, dysarthria, dysphagia, drop attacks; nausea, numbness, nystagmus) plus ataxia. Internal carotid dissection can produce a partial Horner syndrome (ptosis and miosis), pulsatile tinnitus, and pain around the eye or temple.

Stroke signs follow BE FAST: Balance loss, Eyes (vision loss or double vision), Face drooping, Arm weakness, Speech difficulty, Time to call 911. In the station, a patient with any of these signs (during history, examination or after a procedure) needs: immediate cessation of examination and treatment, a call to 911, notation of the time last known well, monitoring of airway, breathing and level of consciousness, keeping the patient lying down or seated safely (nothing by mouth), and staying with them until care arrives. Do not drive the patient yourself and do not send them home to call their physician.

Cardiac, aortic and other visceral emergencies

If a problem appears after treatment

If a patient becomes dizzy, nauseated, confused, weak or develops a new neurologic symptom during or after care: stop, keep the patient lying or seated safely, check consciousness, airway, breathing, circulation and vital signs, perform a rapid neurologic screen (BE FAST, pupils, nystagmus), call 911 for any focal sign or failure to resolve promptly, note the time and stay with the patient. Then document exactly what happened and what you did, and tell the patient honestly. A brief vasovagal response that resolves lying down is managed by positioning and observation, but call it benign only after the neurologic screen.

Section 5Common case management station patterns

One routine for every station

Case stations look different on the door card but share one skeleton. Practice a single routine until it is automatic so your attention is free for reasoning. The official instructions for each station always take priority, so read the task line twice.

Neck pain walk through

Low back pain walk through: neurogenic versus vascular claudication

Headache walk through

Every headache station is first a red flag screen. Use SNOOP: Systemic symptoms or illness (fever, weight loss, cancer, immunosuppression), Neurologic signs (focal deficit, confusion, papilledema), Onset sudden (thunderclap), Older age at onset (new headache over 50), and Pattern change (progressive, positional, triggered by Valsalva or exertion, a change from a prior pattern). Then classify the primary headache.

Extremity walk through

Visceral mimic walk through

Visceral pain is referred to the body wall through shared spinal segments. Stations hide a visceral cause behind a musculoskeletal complaint; the clues are pain unchanged by movement or position, constant or colicky pain, systemic symptoms, links to meals, urination, menstruation or exertion, and abnormal vital signs.

Words worth knowing