Differential Diagnosis Flashcards
About ____% of LBP related to non-MSK issue
2
Why do we care/need to differentiate between systemic and MSK related LBP as PTs?
- direct access providers
- limited exam is completed by PCP
- pt had multiple complaints at PC visit and not enough time to address them
- pt reports new symptoms during PT visit
- symptoms may have progressed since PCP visit
T or F: MSK pain has gradual onset and gets worse over time
F, systemic does
T or F: MSK pain has identifiable agg and easing factors
T, systemic does not
T or F: MSK pain wakes pt up at night and they can’t do anything to fix it
F, systemic does
stabbing, throbbing, deep, and aching are all used to describe what type of pain?
non-msk
Red flag
serious pathology, refer out
yellow flag
beliefs and pain behavior
orange flag
- psychiatric
- depression, anxiety
*be careful what you ask/document
blue flags
work related, boss, tasks
black flags
system issues like insurance, legislation for workers comp, overly helpful or unhelpful family
What are some examples of red flags
- age and onset (over 50&traumatic)
- history of cancer
- fever, chills, night sweats
- unexplained weightloss (10lbs in 3 months)
- recent infection or immunosuppression
- resting pain, non-positional night pain
- saddle anesthesia
- bowel/bladder dysfunction
how should you document red flag screening
red flags aren’t helpful in isolation but be sure to document negative results so you can have defensible documentation
If pts say yes to constitutional symptoms what should you do? what if they say no?
send them to PCP if yes;
if no then document the negative
remember you have to address the symptoms you document
why is it important to ask about constitutional symmptoms?
they can indicate systemic disease
what are some examples of constitutional symptoms
- fever, diaphoresis, night sweats
- nausea, vomiting, diarrhea
- pallor, dizziness, syncope
- fatigue, weight loss
what is a Kehr’s sign
- classic symptom of a ruptured spleen
- referred pain from the phrenic nerve (which was irritated from a splenic injury)
what are the nerve roots for the diaphragm
C3-5, “keeps you alive”
How do you test for a Kehr’s sign
patient in supine, left upper quadrant palpation. if this creates left shoulder pain then it’s a positive Kehr’s sign (spleen injury)
right shoulder pain could be referred from what?
gall bladder or liver
T or F: most abdominal aortic aneurysms are asymptomatic
T
majority in 65 years or older and relatively frequent COD in elderly
what is the number one risk factor for an abdominal aortic aneurysm
smoking
AAA is 4 times more common in _____-
men
Mid back pain radiating to shoulder combined with nausea, vomiting, and diaphoresis could indicate what?
MI
what are some symptoms of AAA
- early satiety, nausea, weight loss
- throbbing or pulse-like pain
- abdominal palpation for pulsatile mass
______ % of AAA are found on accident. why?
- 75%
radiologic workup for cause of symptoms like back, groin, and buttock pain
how do you calculate pack years?
PPD x years of smoking
what does 50 - 20 - 15 mean?
- 50 years old or older
- 20 pack years or greater
- smoked within last 15 years (this part has been removed in recent guidelines)
What should you be concerned for if a pt develops a claw hand with no MOI and weakness in EDM, EDC, and EDI
weakness in ulnar nerve and PIN muscles:
- not a nerve specific issue or root level? Then Brachial plexopathy, or TOS, or Pancoast tumor!
What can a pancoast tumor be indicative of?
superior lobe lung cancer
What is McBurney’s point?
- if TTP in right LQ 1/3 between ASIS to umbilicus you may have acute appendicitis
what are some GI symptoms
- back pain and abdominal pain at the same level
- pain associated with meals
- pain associated with heartburn
- dysphagia, unintended weight loss
- sacral pain with valsalva maneuver
Pulmonary symptoms
- persistent fever, cough, chills
- pain aggravated by deep inspiration
- back pain relieved by breath holding
- auto splinting - relief laying on painful side
- no change with spinal movements
- tachycardia with drop in BP
what are some CVD symptoms?
- throbbing back pain
- pain without movement preference
- pain aggravated by exertion
- pain with pulsatile abdominal mass
- vascular claudication
What relieves pain for vascular claudication
rest, doesn’t change with position (neurogenic changes with position)
Temperature changes in leg can indicated CDV issue. What does it mean if one leg is warmer? cooler?
warmer - possible DVT
cooler - possible arterial occlusion
do we want to do heavy weight training with a pt with a known AAA or CVD
nah
what are some renal/urologic symptoms
- T9-L1 dermatomal pain
- back pain at level of kidney
- blood in urine, fever, chills
- increased urinary frequency
- difficulty starting or maintaining stream of urine or fully emptying bladder
- testicular pain
- history of traumatic fall, blow, or lift
T or F: axial spondyloarthritis is a chronic inflammatory rheumatic disease that can result in spine fusion and disability
T
what is the primary symptom for axial spondyloarthritis
chronic low back pain
low back pain in axial spondyloarthritis is most commonly misdiagnosed as what?
typical MSK caused LBP, esp if nothing is found on imaging, average delay in diagnosis is 10 years
when do you know to refer to a rheumatologist if you suspect axial spondyloarthritis
- age of onset is <45 and one of the following:
- idiopathic back pain, (+) HLA-B27, sacroiliitis on MRI, EAMs
- good response to NSAIDs
What are some symptoms of inflammatory back pain
- insidious onset of pain
- duration >3 months
- relieved by exercise
- no relief with rest
- morning stiffness >30 minutes
- alternating buttock pain
- good response to NSAIDs
- positional night pain
Can PT’s treat axial spondyloarthritis?
sure, early treatment can prevent progression.
PTs can treat symptoms
Rheumatology referral still needed
who is axial spondyloarthritis more common in
- men, smokers
- positive lab findings for HLA-B27, ESR, CRP
Can PTs manage suspected non-MSK cases of pain?
yes, but also need to see appropriate provider in addition. always err on the side of caution, defensible documentation, if pt makes no progress -> report back to PCP
