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![Objective. Presenting pain is reproduced by resisted hip or
trunk flexion with accompanying tenderness/tightness on
palpation of the right iliopsoas muscle (compared with the
left iliopsoas muscle). There are no implicating neurologic
signs or symptoms,
Assessment. A musculoskeletal screening examination is
consistent with your diagnosis of a possible iliopsoas or
abdominal oblique tear.
Jane appears to have a combination of musculoskeletal and
systemic symptoms, such as those outlined earlier. Of
particular concern are the symptoms of fatigue, night sweats,
abdominal distension, nausea, repeated episodes of
exacerbation and remission, and severe quality of pain and
location (right lower abdominal quadrant].
These symptoms appear to be of a systemic nature rather than
caused by a musculoskeletal lesion.](https://image.slidesharecdn.com/introtoscreening-250523002351-b917d847/85/introduction-to-screening-for-defferential-daignosis-pptx-43-320.jpg)
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introduction to screening for defferential daignosis.pptx
- 1. ) Differential Diagnosis and ClinicalDecision Making DPT-1st lecture
- 2. Introduction to screeningfor referral in Physical Therapy
- 3. Screening It is amethod for detecting disease or body dysfunction before an individual would normally seek medical care.
- 4. Screening for referralin Physical Therapy It is the Therapist’s responsibility is to have an appropriate patient for physical therapy In order to be Cost effective…we must determine NMS dysfunction…Treat specifically PT must be able to identify sign and symptoms of systemic disease that can mimic neuromuscular or musculoskeletal dysfunction…shoulder and back pain Cancer is major part of medical screening
- 5. Reason for MedicalDisease Screening Direct access Quicker & sicker Signed prescription Medical specialization Progression of time & disease Patient /client disclosure Presence of one or more yellow or red flags
- 6. DIRECT ACCESS Directaccess is the right of the public to obtain examination , evaluation, and intervention from a licensed physical therapist with out previous examination by, or referral from, a physician , or other practitioner.
- 7. Signed Prescription clientsmay 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.
- 8. F o ll o w - U p Questions Always ask a client who provides a signed prescription: • Did you actually see the physician (chiropractor,dentist, nurse practitioner, physician assistant)? Did the doctor (dentist) examine you?
- 9. Case 1-1 Apatient visited physiotherapy clinic with signed prescription of physician without detailed examination. Actually the patient had telephonic conversation with physician and described the same previous pain history and recovery with physiotherapy. The patient presented with hip and bilateral leg pain , during examination it is observed that there is swelling in both legs, chest pain and low blood pressure. There is also history of heart disease. What would be the next step of therapist? What treatment options? What is the most appropriate way to handle this situation?
- 10. Suggestions: Good ideais to call Best idea is to write a brief but complete report. Highlight significant findings: B/L edema, low BP that day… Open ended comment like “please advice” or what do u think Some physician ask for your opinion.
- 11. Medical Specialization Withincreasing specialization of medicine, client evaluated by Medical specialists who does not immediately recognize underlying systemic disease. or the specialist may assume that the referring primary care physician has ruled out other causes
- 12.
- 16. Progression of Timeand 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 Case 1-3
- 17. Quicker and Sicker "Quicker" refers to how health care delivery has changed in the last 10 years to combat the rising costs of health care. The therapist must be alert to red flags of systemic disease at all times but especially in those clients who have been given early release from the hospital or transition unit.
- 18. Cont… "Sicker" refersto 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. So, the need to view the whole patient and not just the body part in question.
- 19. Patient/Client Disclosure Finally,sometimes p a t i e n t / c l i e n t s tell the therapist things about their current health and social h i s t o r y u n k n o w n or u n r e p o r t e d to the physician.
- 20. Yellow or RedFlags 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 .
- 21. RED flags Factorsthat 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)
- 22. Yellow Flags Depression oScreened for within general health questionnaire and followed-up with physical therapist if considered positive “ During the past month, have you often been bothered by feeling down, depressed, or hopeless?” “ During the past month, have you often been bothered by little interest or pleasure in doing things?” - Anxiety - Malingering/Non-Organic Pain
- 23. 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
- 24. Risk Factors Substanceabuse Tobacco use Sedentary lifestyle Age Obesity Gender Domestic violence
- 25. Clinical Presentation Noknown 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
- 26. Cont… Postmenopausal vaginalbleeding Bilateral symptoms: Edema Numbness/tingling Clubbing Skin rash Change in muscle tone or ROM for individuals with neurological symptoms (CP, SCI, TBI, MS)
- 27. Pain pattern Backor shoulder pain Pain with full and painless ROM Night pain Constant and intense Poorly localized Vascular/ neurological/ musculoskeletal/ emotional
- 28. 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
- 29. Constitutional Symptoms Fever Diaphoresis Night sweats Nausea Vomiting Diarrhea Pallor Dizziness/syncope (fainting) Fatigue Weight loss
- 30. Important Question toend Are there any symptom anywhere else in your body that may not seem related to your current problem??
- 31. Physical Therapist Rolein 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
- 32. DIAGNOSIS BY THE PHYSICALTHERAPIST 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 state practice act.
- 33. How do youdignose your patients?
- 34. Guide to physicaltherapy practice
- 36. Definition of Physical TherapyDiagnosis 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.
- 37. Diagnosis ??? Alabel encompassing a cluster of sign & symptoms commonly associated with a disorder or syndrome or category of impairment ,functional limitation or disability.
- 38. Differential diagnosis Aprocess 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 diagnosis
- 39. Purpose of theDiagnosis Treat as specifically as possible by determining the most appropriate intervention strategy for each patient / client Recognize the need for a medical referral
- 40. Case referral Referral. A32-year-old female university student was referred for physical therapy through the student health service 2 weeks ago. The physician's referral reads: "Possible right oblique abdominis tear/possible right iliopsoas tear. " A faculty member screened this woman initially, and the diagnosis was confirmed as being a right oblique abdominal strain. History. Two months ago, while the client was running her third mile, she felt "severe pain" in the right side of her stomach. She felt immediate nausea and had abdominal distension. She cannot relieve the pain by changing the position of her leg. Currently, she still cannot run without pain.
- 41. Presenting Symptoms. Painincreases during sit-ups, walking fast, reaching, turning, and bending. Pain is eased by heat and is reduced by activity. Pain in the morning versus evening depends on body position. Once the pain starts, it is intermittent and aches. The client describes the pain as being severe, depending on her body position. She is currently taking aspirin when necessary.
- 42. SAMPLE LETTER John Smith,M.D. University of Montana Heolth Service Eddy Street Missoula, MT59812 Re: Jone Doe Dear Dr. Smith, Your client, Jane Doe, was evaluated in our clinic on 5 / 2 / 0 6 with the following pertinent findings: Subjective. She has severe pain in the right lower abdominal quadrant associated with nausea and abdominal distension Although the onset of symptoms started while the client was running, she denies any precipitating trauma. She describes the course of symptoms as having begun 2 months ago with temporary resolution and now with exacerbation of earlier symptoms. Additionally, she reports chronic fatigue and frequent night sweats.
- 43. Objective. Presenting painis reproduced by resisted hip or trunk flexion with accompanying tenderness/tightness on palpation of the right iliopsoas muscle (compared with the left iliopsoas muscle). There are no implicating neurologic signs or symptoms, Assessment. A musculoskeletal screening examination is consistent with your diagnosis of a possible iliopsoas or abdominal oblique tear. Jane appears to have a combination of musculoskeletal and systemic symptoms, such as those outlined earlier. Of particular concern are the symptoms of fatigue, night sweats, abdominal distension, nausea, repeated episodes of exacerbation and remission, and severe quality of pain and location (right lower abdominal quadrant]. These symptoms appear to be of a systemic nature rather than caused by a musculoskeletal lesion.
- 44. Recommendations. I suggestthat the client return to you for further medical follow-up to rule out any systemic involvement before the initiation of physical therapy services. I am concerned that my proposed intervention of ultrasound, soft tissue mobilization, and stretching may aggravate an underlying disease process. I will contact you directly by telephone by the end of the week to discuss these findings and to answer any questions that you may have. Thank you for this interesting referral. Sincerely, Catherine C. Goodman, M.B.A., P.T. R e s u l t . This client returned to the physician, who then ordered laboratory tests. After an acute recurrence of the symptoms described earlier, she had exploratory surgery. A diagnosis of a ruptured appendix and peritonitis was determined at surgery. In retrospect, the proposed ultrasound and soft tissue mobilization would have been contraindicated in this situation.