indroduction of differential diagnosis

1. Dr.Riaz Ahmed PT
Lecturer
DPT, MS Sport Physical Therapy
Differential Diagnosis
and Clinical Decision Making
9th semester

2. CDM & DD course Outline
 Intro to Medical Screening.
 Differential Diagnosis.
 Cardiovascular system DD
 Pulmonary system DD
 Neurological system DD
 Musculoskeletal system DD
 Renal system DD
 Gastrointestinal DD
 General Symptoms DD

3. Differential Diagnosis
 Process by which differentiate two or
more conditions or diseases which
have similar signs or symptoms.

4. Screening
 It is a method for detecting
disease or body dysfunction
before an individual would
normally seek medical care.

5. Screening for referral
 Therapist’s responsibility
 Cost effective
 Treat specifically
 Identify sign and symptoms of systemic
disease…shoulder and back pain. Peptic ulcers,
gallbladder disease, liver disease, and myocardial
ischemia are only a few examples of systemic diseases
that can cause shoulder or back pain.
 Cancer is major part of medical screening.
Cancer can present as primary neck, shoulder, chest,
upper back, hip, groin, pelvic, sacroiliac, or low back
pain/symptoms.

6. Reason for Medical Disease
Screening
 Direct access Therapist has primary responsibility or
first contact.
 Quicker & sicker
 Signed prescription
 Medical specialization
 Progression of time & disease
 Patient /client disclosure
 Presence of one or more yellow or red

7. Quicker
 "Quicker" refers to how health care
delivery has changed in the last 10 years
to combat the rising costs of health care.
Hospital inpatient/clients are discharged
much faster today than they were even
10 years ago. Outpatient/client surgery is
much more common, with same-day
discharge for procedures that would
have required a 7- to 10-day
hospitalization in the recent past.
Patient/clients on the medical surgical
wards of most hospitals today would
have been in the intensive care unit
(ICU) 20 years ago.

8. sicker
 "Sicker" refers to the fact that
patient/clients in acute care,
rehabilitation, or outpatient/client
setting with any orthopedic or
neurologic problems may have a past
medical history of cancer or a current
personal history of diabetes, liver
disease, thyroid condition, peptic
ulcer, and/or other conditions or
diseases.

9. Signed prescription
 Under direct access, the physical
therapist may have primary responsibility
or become the first contact for some
clients in the health care delivery system.
On the other hand, clients may obtain a
signed prescription for physical therapy
from their primary care physician or other
health care provider, based on similar
past complaints of musculoskeletal
symptoms, without actually seeing the
physician or being examined by the
physician .

10. Medical Specialization
 Additionally, with the increasing
specialization of medicine, clients may
be evaluated by a medical specialist
who does not immediately recognize
the underlying systemic disease, or
the specialist may assume that the
referring primary care physician has
ruled out other causes.

11. Progression of Time and
Disease
 In some cases, early signs and
symptoms of systemic disease may be
difficult or impossible to recognize until
the disease has progressed enough to
create distressing or noticeable
symptoms.

12. Patient/Client Disclosure
 Finally , sometime s patient/clients tell
the therapist things about their current
health and social history unknown or
unreported to the physician . The
content of these conversations can
hold important screening clues to point
out a systemic illness or viscerogenic
cause of musculoskeletal or neuro -
muscular impairment .

13. Yellow or Red Flags
 A yellow flag is a cautionary or
warning symptom that signals " slow
down" and think about the need for
screening.
 A red-flag symptom requires
immediate attention , either to pursue
further screening questions and/or
tests , or to make an appropriate
referral .

14. RED FLAGS
Factors that require immediate medical attention
 - Blood in sputum
 - LOC or altered mental status
 - Neurological deficit not explained by monoradiculopathy
 - Numbness or paresthesia in the perianal region (aka
saddle anesthesia)
 - Pathological changes in bowel and bladder
 - Patterns of symptoms not compatible with mechanical
pain (on physical exam)
 - Progressive neurological deficit
 - Pulsatile abdominal mass (AAA)

15. Yellow Flags
 Depression
 Anxiety
 Malingering/Non-Organic Pain

16. Past Medical History
 Personal or family history of cancer
 Recent (last 6 weeks) infection
 Recent history of trauma such as motor
vehicle accident or fall (fracture; any
age) or minor trauma in older adult with
osteopenia/osteoporosis
 History of immunosuppression (e.g.,
steroids, organ transplant, HIV)
 History of injection drug use (infection

17. Clinical Presentation
 No known cause/insidious onset
 Cyclical presentation:
Better/worse/better
 Weight loss/gain within 10-21days
 Unrelieved by rest/positional change
 Unrelieved by PT intervention
 Persist longer than expected
 Growing mass
 Unable to alter symptoms during
examination

18. Cont…
 Postmenopausal vaginal bleeding
 Bilateral symptoms:
◦ Edema
◦ Numbness/tingling
◦ Clubbing
◦ Skin rash
Change in muscle tone or ROM for
individuals with neurological symptoms (CP,
SCI, TBI, MS)

19. Pain pattern
 Back or shoulder pain
 Pain with full and painless ROM
 Night pain
 Constant and intense
 Poorly localized
 Vascular/ neurological/
musculoskeletal/ emotional

20. Associated Signs and
Symptoms
 Recent report of confusion (or
increased confusion
 Presence of constitutional
symptoms
 Proximal muscle weakness,
especially if accompanied by
change in DTRs
 Joint pain with skin rashes,
nodules

21. Physical Therapist Role in
Disease Prevention
 Primary Prevention:
Stopping the processes) that lead to the development of
diseases), illness(es), and other pathologic health
conditions through education, risk-factor reduction, and
general health promotion
 Secondary Prevention:
Early detection of disease(es), illnesses), and other
pathologic health conditions through regular screening; this
does not prevent the condition but may decrease duration
and/or severity of disease and thereby improve the
outcome, including improved quality of life
 Tertiary Prevention:
Providing ways to limit the degree of disability while
improving function in patients/clients with chronic and/or
irreversible diseases

22. DIAGNOSIS BY THE
PHYSICAL THERAPIST
 It is the policy of the (APTA) that PT shall
establish a diagnosis for each patient.
 PTs use diagnostic labels that i d e n tify
the impact of a condition on function at
the level of the system (especially the
movement system) and the level of the
whole person.
 The PT is qualified to make a diagnosis
regarding primary NMS conditions though
we must do so in accordance with the

23. SCREENING AND
SURVEILLANCE
 Therapists can have an active role in both
primary and secondary prevention through
screening an d education . Primary
Prevention involves stopping the process(es )
that lead to the formation of cancer in the first
place (Bo x 1-4). According to the Guide,1
physical therapist s are involved in primary
prevention b y "preventing a target condition
in a susceptible o r potentially susceptible
population through such specific measures
as general health promotion efforts . Risk -
factor assessment an d risk reduction fall
under this category.

24.  Secondary Prevention involves the
regular screening for early detection o f
disease or other health-threatening
conditions such as hypertension,
osteoporosis , incontinence , diabetes , o
r cancer . This does not prevent any of
these problems , but improves the
outcome . The Guide outlines the
physical therapist' s role in secondary
prevention as "decreasing duration o f
illness , severity of disease , and number
o f sequelae through earl y diagnosis an
d prompt intervention "

25.  Surveillance is the analysis o f health
information t o look for problems
occurring in the general population ,
in specific groups , o r in the
workplace that require targeted
prevention . Surveillance often uses
screening result s from groups o f
individuals t o look for abnormal trends
in health
Surveillance

26. How do you dignose your
patients?

27. Clinical Decision Making/ Clinical
Reasoning process
 It is a process by which a health
care provider take objective data
acquired from an actual patient
and integrate it with factual
knowledge from text books and
medical literature to either make a
diagnosis or develop a treatment
plan.

28. Clinical Reasoning process
 Critical evaluation of the arguments for
and against the diagnosis.
 Application of biostatistics
 Integration of different types of
knowledge into a complete decision
making process

29. Guide to physical therapy
practice

32. Difference b/w medical and
physical therapy diagnosis
 Medical diagnosis
Based on the pathologic or
pathophysiologic state at the cellular
level.
 Physical therapy diagnosis
Based on Model of disablement :
impairment ,functional limitation or
disability.

33. Differential diagnosis
 A process of identifying all of the possible
diagnoses that could be connected to the
signs, symptoms, and lab findings, and
then ruling out diagnoses until a final
determination can be made.
 List of diaganosis

34. Recognizing Flags
CASE EXAMPLE 2-6
 A 60-year-old man was referred to
physical therapy for weakness in the
lower extremities. The client also
reports dysesthesia (pain with touch).
 Social/work history: single, factory
worker, history of alcohol abuse, 60-
pack year* history of tobacco use.

35. Recognizing Red Flags
CASE EXAMPLE 2-6
• Age
• Smoking history
• Alcohol use
• Bilateral symptoms
• Progressive neurologic symptoms
 Consultation with the physician is
certainly advised given the number and
type of red flags present, especially the
progressive nature of the neurologic
symptoms in combination with other key
red flags.

36. THANKS