PT-728 Differential Diagnosis Exam 1

Factors for Screening

Side effects of medications

Comorbidities

Visceral pain mechanisms

Reasons to Screen

Direct Access

Quicker and sicker patients

Signed prescription

Medical specialization

Disease progression

Patient disclosure

Inaccuracy of patient report to MD

Primary prevention

Stopping the process that lead to development of disease

Secondary prevention

Regular screening for early detection

Screening for Referral

Determining if individual has a condition that can be addressed in PT or if a referral is necessary

Red Flags: looking for patterns during examination

-Past Medical & Family History

-Risk Factors

-Clinical Presentation

-Pain Pattern

-Signs and Symptoms

•Medical Screening

method for detecting disease or dysfunction before medical care

Physical therapy diagnosis

the comparison of NMS symptoms to identify impairment classifications so that we can treat movement dysfunction

Patient/Client management

Examination

-Patient Interview

-Medical Screening

-Systems Review

-Physical Examination

Evaluation

Diagnosis

Prognosis

Intervention

Examination

Tailored process of:

-Obtaining the history

-Completing a medical screening

-Conducting a systems review

-Performing tests and measures

Purpose of Thorough Examination

Limit doubt

Practice according to the diagnostic evidence

Allow provider to proceed:

-With confidence

-With reasonable doubt

-With concurrent referral

Referral in lieu of treatment

PQRST of patient interview

-Palliating and Provoking/ Previous Symptoms

-Quality

-Region

-Severity

-Timing

Pain referral chart

Presence of serious pathology is suggested by

1) Pain that is worse during rest vs activity

2) Pain that is worsened at night or not relieved by any position

3) Poor response to conservative care including a lack of pain relief with prescribed bed rest

4) Poor success with comparable treatments

Red Flags - Category 1

Blood in sputum

Loss of consciousness or altered mental status

Neurological deficits not explained by monoradiculopathy

Numbness or paresthesia in perianal region

Pathological changes in bowel or bladder

Pattern of symptoms not compatible with mechanical pain

Progressive neurological deficit

Pulsatile abdominal masses

Red Flags - Category 2

Age > 50

Clonus

Fever

Elevated sedimentation rate

Gait deficits

History of disorder with predisposition for infection or hemorrhage

History of metabolic bone cancer

History of cancer

Impairment of precipitated by recent trauma

Long term corticosteroid use

Long term workers compensation

Nonhealing wounds or sores

Recent history of unexplained weight loss

Writhing pain

Red Flags - Category 3

Abnormal reflexes

Bilateral or unilateral radiculopathy or paresthesia

Unexplained referred pain

Unexplained significant upper or lower limb weakness

Referral flow chart

Constitutional Symptoms

Nausea/Vomiting

Change in bowel habits

Night Sweats/Day Sweats

Fatigue

Sleep pattern

Fever

Weight Loss

Syncope/Dizziness

Shortness of breath

Cholesterol levels

HDL

Women: >50

Men: > 40

LDL < 100

Total: < 200

Cardiovascular System: Upper Quarter

Difficulty breathing/SOB

Nausea

Syncope/Dizziness

Fatigue

Angina

Palpitations

Symptoms related to activity

Medications

(Nitroglycerin and oxygen)

Cardiovascular System: Lower Quarter

Arterial claudication

Deep Venous Thrombosis

Swelling

Varicose veins

Dry, shiny skin

Loss of hair growth

Poor Nail Condition

Rubor on Dependency

Esophagus pain referral

Large intestine pain referral

Small intestine pain referral

Stomach pain referral

Pancreas pain referral

Endocrine system

Fatigue

Weight Loss

Increased urinary frequency

Anxiety

Changes in hair growth/non-healing wounds

Diabetic changes in vascularization

Fasting blood sugar prior to therapy sessions to determine appropriateness

Hepatic/Biliary system

Nausea

Jaundice

GI Bleeding/Symptoms

Ascites

Fatigue

Chills

Vomiting

Weight loss

Pain

5th Vital Sign

-HR, BP, RR, Temp.

Understand how and when a diseased organs can refer pain to the neuromusculoskeletal system helps us identify suspicious pain patterns

-Chest, back, shoulder, scapula, pelvis hip, groin, and SI joint are the most common sites of referred pain from a systemic disease process

Mechanisms of Referred Visceral Pain

Visceral pain (pain from internal organs) is not well understood

Viscerosenseory fibers ascend the anterolateral system to the thalamus, with fibers projecting to several regions of the brain

The regions encode the site of origin of the viscera pain, but unfortunately they do it poorly

Embryologic Development

Pain is referred to a site where the organ is located in fetal development.

-Think of heart and kidney

-Ear & kidney come from same embryonic tissue

Multi-Segmental Innervation

Viscera have multisegmental innervations

Visceral-organ cross-sensitization

-Referred visceral pain to somatic tissues based on overlapping or same segmental projections of spinal afferent neurons to the spinal dorsal horn

Think of Cardiac Pain

-C5 goes to heart = have C5 (shoulder) pain during MI

-Can occur in any structure innervated by C3-T4 including jaw, neck, upper trap, shoulder, and arm

Direct Pressure and Shared Pathways

Ganglions from each neural system gathering and sharing information through the cord to the plexuses where the response is decided

Anything that impinges the central diaphragm can refer pain to the shoulder

Anything that impinges the peripheral diaphragm can refer pain to the ipsilateral costal margins and/or lumbar region

Head of pancreas impinges on central diaphragm

Tail of pancreas impinges on peripheral diaphragm

Assessment of Pain and Symptoms

Interview techniques and specific questions for pain assessment

-Need more than just a number on pain scale

Include detailed health history, physical examination, medication history, assessment of functional status, consideration of psycholosocial-spiritual factors

Elderly

-An accepted part of the aging process

-OTC analgesic meds for more than 6 months

-Loss of Independence?

-Early Stages of Dementia

Young

-Never underestimate that a young client is unable to answer questions about pain.

-Various scales

-Lack of cooperation, withdrawal, acting out, distractibility or seeing comfort, altered sleep patterns vocalizations and eating patterns.

Characteristics of Pain

Location

Description of Sensation

Intensity

Duration

Frequency

-constant vs. intermittent

-want symptoms to change w/ provocation

Pattern/Source

-MSK vs. emotional vs. visceral

Cutaneous

Somatic

visceral

neuropathic

referred

Cutaneous pain

Related to the skin: superficial somatic structures located in the skin and subcutaneous tissue

Able to point to pain

organs can refer pain to skin

Somatic pain types

Deep somatic:

-poorly localized and may be associated with an autonomic phenomenon

Superficial somatic

-involve the skin, superficial fascia, tendon sheaths and periosteum

Somato-visceral

-myalgia causes functional disturbance of the underlying viscera

Somato-emotional (psychosomatic)

-sources of pain occur when emotional or psychologic distress produces physical symptoms

Viscero-somatic

-visceral structures affect the somatic musculature

Visceral pain

Sources include the internal organs and the heart muscle

Not well localized

Visceral fibers synapse at the level of the spinal cord close to fibers supplying specific somatic structures

-When they converge, the nervous system has trouble interpreting the input which can lead to unclear impulses

Viscero-Viscero Reflex

-occurs when pain or dysfunction in one organ causes symptoms in another organ

Characteristics of Viscerogenic Pain

Gradual, progressive and cyclical pain patterns

Constant pain

-red flag

Physical Therapy Intervention "Fails"

Bone pain and aspirin

Pain does not fit expected pattern

-

How Do We Differentiate Between Somatic and Visceral Pain??

Superficial Somatic:

sharp and more localized

Deep Somatic:

dull, deep ache

responds to rest or non weight bearing

Visceral:

dull and ache but not feel better after rest

It is less likely that the client with back, hip, SI or shoulder pain that has been present for the last 5-10 years is demonstrating a viscerogenic cause of symptomsNeuropathic

Neuropathic pain

Damage or pathophysiologic changes of peripheral or central nervous system

Malfunction of nervous system

Usually described as sharp, shooting, burning, tingling, or electric shock sensation

Not alleviated by opiates or narcotics

-gabapentin

-lyrica

Referred pain

Felt in an area far from site of the lesion but supplied by the same or adjacent neural segments

Occurs by way of shared central pathways for afferent neurons and can originate from any somatic or visceral source

Questions to ask...

-Are you having any pain anywhere else in your body?

-Are you having symptoms of any other kind that may or may not be related to your main problem or concern

Tension pain

difficult to find a comfortable position

inflammatory pain

constitutional signs and symptoms

visceral peritoneum is less localized than parietal

Ischemic

sudden, intense, constant and progressive

Myofascial pain

occurs when prolonged muscular contraction or cocontraction results in

-local ischemia

-increased cellular metabolites

-subsequent pain

Faulty ergonomic, prolonged work position, or repetitive motion

increased release of substance p

Joint Pain

morning pain

-systemic

no morning pain

-MSK

Muscle Spasm

sudden involuntary contraction of muscle or group of muscles:

Somatic-somatic response: -painful musculoskeletal problem may also have a varying degree of reflex muscle spasms to protect joint

viscero-somatic: painful visceral disease can have muscle spasm of the overlying musculature

Muscle Trauma

acute trauma, burns, crush, or unaccustomed intensity or duration of muscle contraction

Broken fibers leak potassium into interstitial fluid setting off cascade of chemical reaction within the muscle

Rhabdomyolysis symptoms

-Red/brown urine

-Decreased urine output

-Fever

-Chills

-Tachycardia

-Nause/vomiting

-Confusion

Muscle Deficiency

weakness and stiffness

connective tissue changes may occur as small amounts of fibrinogen leak from vasculature into intracellular spaces, adhering to cellular structure causing muscular stiffness

Trigger Points

Hyperirritable spots within a taut band of skeletal muscle or in fascia

tender to palpation, local tenderness:

history of immobility, prolonged or vigorous activity:

reproduced w/ palpation or resisted motion:

Referred pain from a trigger point is characteristic and specific to every muscle

Active trigger point

pain when pushed

may refer pain to other site

pain at rest

Latent trigger point

pain when pushed

may refer pain to other site

NOT have pain at rest

Screening For Emotional and Psychologic Overlay

Anxiety: amplifies physical symptoms

Depression: identified factor that delays recovery for clients

Panic Disorder: sudden, unprovoked feelings of terror or impending doom with associated physical symptoms

-mimic MI

-muscle soreness afterwards

Illness Behavior Syndrome

Illness behavior is what people say and do to show they are ill and perceive themselves as sick or in pain:

-expresses and communicates the severity of pain and physical impairment

Most identified in people with chronic pain: expression depends on what and how the client thinks of their symptoms/illness

Conscious symptoms magnification is malingering

Unconscious symptoms magnification is illness behavior

Malingering

is a self-destructive, socially reinforced behavioral response pattern consisting of reports or displays of symptoms that function to control the life of the sufferer

-acts as if the future cannot be controlled because of the presence of the symptoms: "my back pain won't let me..."

-exaggerate limitations beyond those that seem reasonable in relation to the injury, apply minimal effort on maximal performance test, and overreact to physical loading during objective examination

Waddell's Nonorganic Signs

Five nonorganic signs and seven nonanatomic/ behavior descriptions of symptoms to differentiate between physical and behavior causes of back pain

3 or more positive signs: nonmovement dysfunction

A positive findings does not suggest an absence of pain but rather a behavior response:

does not confirm malingering or symptom magnification nor does it imply the nonexistence of physical pathology

Waddell's Nonorganic Signs defined

1) Superficial & Nonorganic Tenderness

-overreaction

2) Axial Loading & Acetablular Rotation

-axial loading thru head = reaction

-arms locked next to hips = reaction

3) Distraction

-PSLR test = reaction

-Quad test = no pain

4) Regional Sensory distribution & weakness

-weakness doesn't make sense

5) Overreastion

-Exaggerated response

3 or more positives on Waddell's Sign

Potential non-movement dysfunction

Nonmovement dysfunction

clinical pattern of nonmechanical, pain-focused behavior:

predictive of poor outcome and associated with delayed return to work or not working

Classification of Blood Pressure table

Orientation

Client's ability to answer questions about the person place, time and situation

Fruity (Sweet) Breath

could be sign of diabetic ketoacidosis

Bad Breath

could be a sign of

dental decay, lung abscess, throat or sinus infection GI disturbance, Bowel obstruction

Vitals

Vitals

Pulse

Blood Pressure

Temperature

Oxygen Saturation

Pain

(now called the 5th vital sign)

Walking speed

(the 6th vital sign)

Blood pressure and temperature are two most valuable vitals signs for screening for systemic diseases

Vital signs are the single easiest, most economic, and fastest ways to screen for many systemic illnesses

Pulse Rate

Normal resting pulse rate 60-100 beats per minute

Carotid and radial are preferred sites, but also can assess brachial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial

Pulse rate vs Heart rate

Pulse strength (amplitude)

gives an indication of the circulation blood volume and strength of left ventricle ejection

0 Absent, not palpable

1+ Pulse diminished, barely palpable

2+ Easily palpable, normal

3+ Full pulse, increased strength

4+ Bounding, too strong

Pulse Abnormalities

Weak pulse beats alternating with strong beats

Weak, thready pulse

Bounding pulse

(throbbing pulse followed by suddent collapse or decrease in force of pulse)

Two quick beats followed by a pause

Irregular rhythm

Pulse amplitude decreases with inspiration/increase with expiration

Pulse too fast

(Tachycardia)

Pulse too slow (Bradycardia)

Pulse should increase w/ inspiration and decrease w/ expiration

Respirations

Try to assess without drawing attention

Normal rate is 12-20 breaths per minute

Observe for use of accessory muscles, silent or nosiy breathing, puffed cheeks, pursed lips, nasal flaring

Pulse Oximetry

Oxygen Saturation on Hemoglobin (SaO2)

Normal range at rest and during exercise is 95% to 100%

Referral for medical evaluation advised when resting levels fall below 90%

Blood Pressure

Measurement of pressure in artery at the peak of systole (left ventricular contraction) and during diastole

(heart rest after closure of aortic valve)

Do not apply cuff above an intravenous line where fluids are infusing

It is recommended that patients who have undergone axillary node dissection avoid BP measurements on affected side

If a repeat measure is needed, wait 1 minute between measurements to avoid damaged blood vessel and inflammatory response

Yellow flags for BP

SBP greater than 120 and or DBP greater than 80 in the presence of risk factors (age, medications, personal or family history)

Decrease in DBP below 70 in adults age 75 or older

Persistent rise or drop in BP over time

Steady fall in BP over several years in and adult over 70

Lower standing SBP (less than 140) in adults over 65 with history of falls

Difference in pulse pressure greater than 40 mmHg

(60-80 is yellow flag)

More than 10mmHg difference in SBP or DBP from side to side in UEs

More than 40mmHg difference in SBP or DBP from side to side in LEs

BP in LEs is lower than in the UEs

DBP increases more than 10mmHg during activity or exercise

SBP does not rise as workload increases

SBP exceeds 200 during exercise, DBP exceeds 100 during exercise

BP changes in presence of other signs such as first-time onset angina, dizziness, nausea, pallor, or extreme diaphoresis

Sudden fall in BP

(more than 20 mmHg SBP or 10 mmHg DBP)

with

concomitant rise (10-20% rise) in pulse

Pulse Pressure

Difference between systolic and diastolic BP readings

Normally around 40mmHg

60-80mmHg difference is a yellow flag

Increase in pulse pressure is linked to higher risk of stroke and heart failure

Decrease in pulse pressure could indicate possible congestive heart failure or a blood loss

Pulse pressure does increase normally during exercises as we expect SBP to increase and DBP to remain about the same

•Systolic Blood Pressure increases with increased activity in a linear fashion

In a normal healthy adult:

Minimal to Moderate Exercise:

Expect increase in SBP 20mmHg or more

Intense Exercise:

Expect increase in SBP 40-50mmHg or more

ACSM suggests response to exercise is a progressive rise 10mmHg + 2 mmHg for each metabolic equivalent (MET)

Diastolic blood pressure should remain stable, may even see a small decrease

ACSM recommends reducing or stopping exercise if:

-SBP exceeds 200mmHg

-DBP exceeds 100mmHg

Lower standing SBP (less than 140) is and independent predictor of loss of balance and falls in adults over 65

In older adults decrease in BP may be an early warning sign of Alzheimer's disease

Body Temperature

Oral body temperature ranges from 96.8 to 99.5 (average 98.6)

Fever is likely indicator of infection

Call doctor if temperature rises above 101

Walking Speed: The 6th Vital Sign

General indication of function

Reliable, valid, sensitive measure of functional ability with predictive values in assessing future health, functional decline, hospitalization, or mortality

Timed 10 meter walk test

Low gait speed (at risk for falls/admissions/adverse events):

Pressure Ulcers table

Arterial vs. Venous Insufficiency table

Systolic Blood Pressure with doppler

Check SBP using dorsalis pedis and posterior tib

Divide the higher of each lower extremity by the highest brachial pressure

0.9 or less indicative of PVD and requires possible referral

1.0-1.3 is considered normal

Well's Criteria for DVT

Nail Bed Assessment

Systemic changes affect fingernails and toenails, but signs are typically more prominent in the faster growing fingernails.

Normal individual you can press or blanch the nail bed of a finger or toe and have a whitening effect.

Refill time should occur within 3 seconds

If the capillary refill time exceeds 3 seconds, the lack of circulation could be due to arterial insufficiency

Lymph Node Palpation

Look for obvious areas of swelling or redness

"Normal" lymph nodes usually are not visible or eaily palpable

Enlarged, visible, or palpable lymph nodes could indicate cancer, infection, virus, bacteria, allergies, thyroid conditions, or even food intolerances.

Neurological Screen Examination

Six major areas to assess

-Mental and Emotional Status

-Cranial Nerves

-Motor Function

-Sensory Function

-Reflexes

-Neural Tension

Cranial Nerve table

Cranial Nerve table

Motor Assessment - UQ

Motor Assessment - LQ

Reflex scale

0 No response, absent

+1 Low normal, decreased, slight contraction

+2 Normal, visible muscle twitch

+3 More brisk than normal, increased or exaggerated

+4 Hyperactive, very brisk, clonus

Deep tendon relfexes

Biceps (C5)

Brachioradialis (C6)

Triceps (C7)

Patellar (L3-4)

Achilles (S1-2)

Neural Tension

-Inability of nerve to glide in its protective sheath

-Clinical result can be numbness, tingling, pain

-Could be cause by disc protrusion, scar tissue, space occupying lesion (cyst, bone spur, tumor, cancer, disc)

-Does not tell etiology, but that peripheral nerve is involved