Hello everyone. I know I'm looking forward to only a
three-day week this week and the food-coma that will be induced
Thursday. I always look forward to Thanksgiving. I'm fortunate to
have a huge family, who are local for the most part, equipped with
two grandmothers who are incredible cooks, and one uncle who's a
chef. Not to toot our own horns or anything, but we do turkey-day
Today I'd like to share with you, probably, one of my last case
presentations that walked into the clinic last Friday. This patient
presented with strange neck and upper shoulder pain that began 4-5
days prior. The patient could not pinpoint a certain action, or
mechanism of injury; he had not lifted anything heavy nor sustained
any trauma. As the patient was sitting and telling me his story I
could notice he was struggling with some nasal congestion. I then
began to ask the patient if he had been feeling sick as of late, to
which he answered that he had been fighting off some nasal
congestion and a sore throat for about a week. Ding, ding, ding! So
now we have a patient with some weird neck and upper shoulder pain:
that is worse with laying down for extended periods of time and
while on his drive to work; that feels better with massage during a
warm shower; who has been fighting off what sounds like an upper
respiratory infection. What's the next step? If you guessed a
physical exam to rule out any life-threatening conditions, you are
The patient was informed of the risks of a physical exam, he
consented, and off we went. Through the physical exam we ruled out
a disc issue and facet involvement. In fact, the only instigating
exam finding was pinpoint tenderness at a nodule at the right
suboccipital area (base of the skull), and the same in the area of
the left sternocliedomastoid muscle area (left side of the neck).
As soon as I palpated over these nodules, the patient would note
that was his pain generator. One should not jump to the conclusion
of muscle spasm just because palpating over a muscle is tender.
What caused that "knot" to form? This is where listening to the
patient is key, but not allowing the patient to give you a
diagnosis; that's why you are the doctor and they are the
Remember, that pesky sore throat? I did. I decided to take a
look down the patient's throat, and what did I find? His throat was
fiery red on the right side. Can you see where I'm heading from
here? Now here is where I only give myself an 80% (very generously,
if Dr. Maola has anything to say about it). I honed in on a throat
infection that was causing inflammation of lymph nodes beneath the
suboccipital and sternocliedomastoid muscles leading to neck and
upper shoulder pain. This made sense with the red throat, stuffy
nose, and alleviation of pain when the lymphatic chains were
manually drained by massage in a hot shower. Seems pretty sealed
up, right? Wrong.
Dr. Chad Maola, our dean of academic assessment and mentor of
mine, saw a very big flaw in my diagnosis. He asked me to take a
look inside the patient's ears. Sure as I'm writing this right now,
that poor patient's right ear was red as could be; an ear infection
was the root of all the pain! The ear infection was causing the
lymph nodes to swell, and the infection was draining down the
eustation tube (tube that connects the middle ear to the throat for
drainage) to the back of the patient's throat causing a sore
Image from Northwestern University
Now, I could have managed the patient for a throat infection and
manually drained the lymphatic chains and offered the patient some
relief, but what would have happened if I didn't notice the ear
infection. With an ear infection in adults, ear pain is an
end-stage symptom, right before tympanic membrane rupture. In real
life, if this patient came to me, paid me $80 or so for a
diagnosis, then had to turn around and head to an urgent care
clinic to spend another $80 for them to tell him that he in fact
had an ear infection rather than a primary throat infection, he
wouldn't be very happy.
I adjusted the patient's cervical spine which resulted in an
instant sensation of ear drainage and sent him on his way with some
instructions on dripping in some warm garlic olive oil into his
ear, continue to massage out his lymphatic chains in the shower,
and to seek a physician for antibiotic therapy to clear up the
infection. Sure enough, the patient felt ear pain that night, found
relief from the garlic olive oil, and after visiting his general
practitioner received an antibiotic prescription to resolve the
infection. The patient was happy, and I learned yet another
valuable lesson from Dr. Maola and my patient.
I hope today's entry helps someone down the line. Assess every
option and always allow the patient to tell you what their signs
and symptoms are, and then you diagnose them. I hope everyone has a
quick short week and a terrific Thanksgiving!
It's an exciting day down here at the Florida campus; today the
NUHS Whole Health Center - Pinellas Park outpatient clinic is
open and ready for business. The other interns and I walked up this
morning to a fresh, state-of-the-art facility, which even has that
new clinic smell. It's an incredible facility, equipped with 10
treatment rooms, a physical therapy room, separate lab room, an
interactive classroom, and super-cool conference room. I am typing
this now from our very own intern lounge--pretty fancy.
Yes, we are very excited about all the brand-spanking-new
equipment, but we are also enthusiastic to have an outpatient
facility. Up until now, the Florida campus has had to get by with a
4-room clinic that only caters to the faculty, staff and dependents
of those affiliated with St. Pete College and the University
Partnership (which includes NUHS, Barry University, Florida State
University, University of Florida and others).
The new facility will now allow us to treat anyone and everyone.
The services we provide will still be free to the population we
would see at our student clinic, but will be at a very minimal cost
to anyone else who would like treatment. We are hoping that this
will open up a whole new population of patients, and bring some
more real-world cases through the door. The more practice we can
take on while in school will just help us feel that much more
confident once we graduate and are on our own.
Speaking of being on our own, I've started the process of
outfitting my clinic once I'm out of the NUHS nest. As many of my
colleagues and professors around here know, I've signed on to be an
associate with a great doctor, have signed a lease for my future
practice (opening in South Tampa, April 1, 2013...shameless plug),
and last week even bought almost all the physiotherapy equipment
I'll need. These things were a learning experience in and of
themselves. Finding the right location that you believe you can
succeed in is very important. I staked out the building I wanted
for nearly 2 years before it finally opened up about 2 months ago.
Then I was very fortunate to make a relationship with a local MRI
rep who clued me in on a practice that was downsizing and needed to
get rid of a lot of equipment for a very discounted price. From the
experiences I've had, I would recommend starting to make
relationships as soon as you can, and maintain them, even its just
a text or a phone call once a month to touch base. It goes a long
I hope everyone has a productive week, and best of luck to
everyone taking Part 4 boards this coming weekend. Please everyone
wish us luck. I know we are all prepared, but a little luck never
hurts either. If anyone needs any help or advice about the new
clinic, or starting his or her own, please shoot me an email, its
fresh in my head, so hopefully I can help.
Good Luck this weekend,
Hello, everyone. The weather down here in Florida is finally
cooling off, and it feels incredible. Don't get me wrong, I love
hanging around the beach and cooling off in the pool, but not much
beats sitting at an outside bar on a Sunday watching some football
and not sweating through your clothes.
Speaking of watching some good football, how about those FSU
Seminoles? Granted we played Duke this past weekend, but 48-7 was a
blowout, and I got to see it live and in person. My younger brother
and I made the trip up to Tallahassee for the weekend to catch the
game and party a little bit. We had a great time, and I realized
how much I miss college.
All College Day
We had a really cool, world-learning adventure last week at St.
Pete College's All College Day. Dr. Jennifer Illes recruited us
10th trimester interns to perform blood pressure
screenings at this SPC faculty event. We set up our NUHS table,
outfitted it with brochures and cards, and started with the
I was happy to see so many of the SPC faculty and staff take so
much interest in our school and clinics. This wasn't just an
opportunity to practice taking blood pressures on people, it was
killer practice on how to market and communicate with people who
weren't all that familiar with our clinics, or profession for that
matter. Now, more than ever, I am realizing how important of a
trade it is to be able to communicate with the public in such a way
that shows that you are knowledgeable, but at the same time able to
show that you are likeable and easy to understand. This skill is
invaluable, and only comes from practice.
I would recommend jumping at any opportunity you could that
requires you to talk to the public. Being able to communicate with
patients in the treatment room is extremely beneficial, but you
first have to get them in the door. I will be performing screenings
for my own office in the months to come, and the practice we had
last week really opened my eyes to how the public really views our
profession, and how I'll have to work to sway people my way.
My uncle forwarded me an article last week that I thought was
awesome and would like to share with all you Negative Nancys out
there. The article by Hope Gillette titled "Negativity and Complaining is Bad for the Brain,
Experts Say," alludes to the fact that the brain reacts
differently in response to disturbing or negative information.
Listening to as little as 30 minutes of complaining can damage
neurons within the hippocampus, the part of the brain that deals
with problem solving. The article gives some simple tips to avoid
the inevitable day-to-day complaining that will be hurled your way,
and even how to flip the problem on chronic complainers. It's an
easy read that I thought was pretty cool, plus it gave me an excuse
to tell the complainers in our office to keep it to themselves.
Congratulations to everyone who passed their board exams; all
the interns down here in the Florida clinic did extremely well.
Hard work always pays off; so don't stop now!
I'd also like to congratulate our very own Dr. Rudy Heiser on
his second consecutive WAG (Wild Ass Guess) award win this past
weekend at the ACCR (American College of Chiropractic Radiology)
convention. The WAG is the pride of the DACBR community and Dr.
Heiser has brought it home to NUHS Florida for the second year in a
row. Florida campus representing!!
I hope everyone has a great week.
Catch you guys later,
Hello, and welcome back to another installment of Dex's blog
adventures. I'd first like to thank everyone for the positive
response to last week's case report. I'll do my best to put
together a few more cases to share in the weeks to come.
Cases really are the best way to train your mind to think
critically and to pick up on subtle clues to reach a diagnosis. If
you like radiology and case reports, as I do, try the American
College of Radiology website's Case In Point. Each day the ACR posts a new
case with images to subsequent. These cases are pretty challenging
at times, as the ACR targets their cases towards radiologists, but
they are at the very least a decent learning tool.
Perfecting the Diagnosis
So today I'd like to share with everyone yet another
semi-pitfall I had with a patient here in clinic. I've been
treating this individual twice a week for four weeks for lower
neck/upper shoulder pain. The history and exam led me to a
diagnosis of cervical sign facet syndrome with some upper trapezius
muscle, levator scapulae muscle and pec minor muscles
hypertonicity. I treated the patient as I would any patient with
these diagnoses, which you will see a lot, with adjustment of the
cervical and thoracic spine, myofascial work, and postural
correction. Not to toot my own horn, but I've seen a lot of success
with these treatments for these issues, but not with this
The patient would find some mild relief from the treatment I was
giving him, but no lasting gains. Therefore, I took a step back and
did some research on something else that could be causing these
signs and symptoms and found a paper on Levator Scapula Syndrome.
The paper describes the origin of some forms of shoulder pain to
the Levator Scapula muscle and how to treat the issue. According to
the paper, I had been treating the condition pretty right on, but
it alluded to the fact that an over-facilitated infraspinatus
muscle on the ipsilateral (same) side could contribute to a
dysfunctional levator scapula. Duh, right? The very next patient
visit, I stressed the infraspinatus by resisting external shoulder
rotation, and boom, the symptoms were perfectly recreated. I
reformed my treatment plan to include some myofascial release of
the infraspinatus muscle and within two weeks, the patient was
right as rain.
As physicians we won't always get the perfect diagnosis on the
first go round. Even more important than getting the correct
diagnosis the first time, is recognizing you hadn't and rectifying
that. It's all about putting the patient first.
Perfecting the Weekend
This weekend I took a break from putting patients first and
enjoyed myself a bit. Friday, my pals and I were first in the VIP
line (no big deal) for the Brews By the Bay craft beer and food
tasting at the Florida Aquarium. Needless to say we had a great
time. There were over 200 beer vendors and over 100 handing out
food, all with the back drop of live music, shark tanks, sea
turtles, and any other creature of the sea you could think of.
Then just for good measure I hit the Bucs game on Sunday. I
helped my uncle out by taking his tickets off his hands in the
5th row on the 50-yard line while he was out of
town. On top of that, my Florida State Seminoles and Tampa Bay
Buccaneers put wins up on the board. Pretty darn good weekend.
Catch you guys on the flip side,
Hello, all. Hope everyone is doing well. I had a pretty exciting
day last week that I'd like to share with everyone. I'm going to
set this up kind of like a case report, so try to read the case
without looking at the last part of the blog, and try to formulate
your own differential diagnosis and next appropriate steps in
management. Mind you, this is a real case that presented to the
clinic last week, so this does happen!
A 24-year-old male who has been under your care for 3 weeks
for insidious onset of back pain, presents to your office 3 days
after his last appointment with a new chief complaint of difficulty
urinating. Hopefully some bells are starting to go off already. The
patient relates that after his treatment 3 days prior, which
included IFC, ice therapy and a Thompson drop counter-nutation
sacral adjustment, he has had difficulty urinating but his low back
has been feeling much better. Upon questioning, the patient states
he has been drinking about 120-170 ounces of water per day since
the onset of urinary difficulty in hopes of having a complete void
of his bladder, but has only experienced "dribbling" urinary flow,
and feels as if he has to go every 10-15 minutes. The patient had
not tried to forcefully urinate in fear of "hurting himself" and
has not experienced any loss of control with coughing, sneezing or
laughing. Patient denied any bowel issues, any burning with
urination, loss of muscular function in the lower extremities, or
any abnormalities in lower extremity sensation. It was suggested
that if the patient had to urinate at any time during the
appointment for him to try to forcefully push out the urine; he did
go to the bathroom, but was unable to forcefully urinate. Before a
physical exam could be performed the patient began to experience a
deep cramping low back pain that referred somewhat to his flanks
and down the lateral portion of both legs to about the knees. At
this point the patient was told to make his way directly to the
So what are you thinking? By this time you should have at least
3 differential diagnoses rolling around in your noggin. The first,
and most severe thought should be Cauda Equina Syndrome (CES). My
other two differentials included nephro- or uretero-lithiasis
(kidney or ureter stone), and possibly a urinary tract infection.
The reason the patient was immediately asked to make an emergency
room trip was to rule out CES and if surgery or decompression was
necessary, he was at the hospital already.
Cauda Equina Syndrome is a serious neurological condition that
occurs when nerves of the spinal cord beyond the conus medullaris
(the cauda equina) are impacted and the functions they control are
disturbed. A disc herniation, a tumor, or any other space-occupying
lesion could cause the neural compression. With the patient's
history of aching low back pain, with progressive loss of the
ability to use his detrussor muscles (the muscles which push urine
flow), it was our concern that he may be on the verge of bladder
rupture, and/or ascension of urine back into the kidneys which
could cause a whole slew of other problems including hydronephrosis
and maybe even death.
The patient was very fortunate that an MRI study of his lumbar
spine revealed no compression of the cauda equina. I hope no one
thinks that this was a waste of time sending the patient out for
advanced imaging. As a physician you must always put the patient's
well being above all else. There would be no way I would be able to
sleep at night if I discounted a patient's signs and symptoms and
down-played a condition which ended up hurting the patient
indefinably. The patient was extremely relieved that he was
CES-free, but he isn't out of the woods yet. He still is having
urination issues, and therefore we referred him to an urologist for
consultation. You have to know when something is out of your scope
of practice, and not be too proud to refer someone to a physician
who could help them.
Well, I hope someone took something away from this patient
encounter of ours down here in the Florida clinic. Remember to
always put your patient first, and an expensive procedure to rule
out a life threatening condition will always be worth the money. If
anyone has any questions on Cauda Equina Syndrome or appropriate
management, shoot me an email and I'll do my best to find out any
answers you may have.
Have a great week,
• The Florida Campus
• Shadowing a Chiropractor
• President's Visit & Lecture
• What to Do in Florida
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