UE differential diagnosis Flashcards
shoulder/UE screening clues
- simultaneous/alternating pain in other joints, esp easy fatigue, malaise, fever
- urologic S/S
- presence of hepatic S/S, esp when accompanied by risk factors for jaundice
- lack of improvement after tx, including trigger point therapy
- shoulder pain in a woman of childbearing age of unknown cause associated with missed menses (rupture of ectopic pregnancy)
- left shoulder pain w/in 24 hours of abdominal surgery, injury, trauma (Kehr’s sign, ruptured spleen)
general systemic questions- cancer
Does your pain wake you at night? -cancer
Can you find any way to relieve the pain and get back to sleep? -cancer
If yes, how? (cancer: pain is usually intense and constant; nothing relieves it or if relief is obtained in any way, over time pain gets progressively worse)
general systemic questions- +Kehr sign
Have you sustained any injuries in the last week during a sports activity, car accident, etc? -ruptured spleen associated with pain in the L shoulder, +Kehr’s sign
general systemic questions: rheumatic disease
Since the beginning of your shoulder problem, have you had any unusual perspiration for no apparent reason, sweats or fever?
Have you had any unusual fatigue (more than usual with no change in lifestyle), joint pain in other joints, or general malaise?
general exam questions: for the PT
has the client had a laparoscopy in the last 24-48 hours?
-L shoulder pain: + Kehr’s sign
systemic causes of shoulder pain
cancer cardiovascular/vascular pulmonary renal/urologic gastrointestinal/hepatic gynecologic/other
cancer & shoulder pain
NECK: metastases (leukemia, Hodgkin’s disease); cervical cord tumors; bone tumors
CHEST: metastases to nodes, lungs; bone metastasis to Tspine; breast cancer
ABDOMEN: pancreatic cancer; spinal metastases
cardiovascular/vascular & shoulder pain
NECK: TOS
CHEST: angina/MI; pacemaker; pericarditis; aortic aneurysm
ABDOMEN: abdominal aortic aneurysm
pulmonary & shoulder pain
NECK: pulmonary tuberculsis
CHEST: pulmonary embolism; pulmonary TB; pneumonia
renal/urologic & shoulder pain
ABDOMEN: kidney stones; obstruction, inflammation or infection of upper urinary tract
GI/hepatic & shoulder pain
CHEST: hiatal hernia
ABDOMEN: peptic/duodenal ulcer; ruptured spleen; liver disease; gallbladder disease; pancreatic disease
gynecologic/other & shoulder pain
CHEST: mastodynia; infection; diabetes; sickle cell anemia; hemophilia
ABDOMEN: ectopic pregnancy (rupture); subphrenic abscess; diaphragmatic hernia; anterior spinal surgery (post op hemorrhage)
PMH screening clues
- hx of rheumatic disease
- hx of DM (adhesive capsulitis)
- “frozen” shoulder of unknown cause in anyone with coronary artery disease, recent hx of hospitalization in coronary care or intensive care unit, status post CABG
- recent hx (1-3 months) of MI
- hx of cancer, esp breast or lung (metastasis)
- recent hx of pneumonia, recurrent upper respiratory infection, influenza
subjective exam: pulmonary questions
-Have you been treated recently for a lung problem (or think that you have any lung or resp problems)?
Do you currently have a cough?
- smoker’s cough?
- how long?
- productive cough (can you bring up sputum) and is the sputum yellow, green black or tinged with blood?
Do you ever have SOB, trouble catching your breath or feel breathless?
Does your shoulder pain increase when you cough, laugh or take a deep breath?
Do you have chest pain?
What effect does lying down or resting have on your shoulder pain?
- in the supine or recumbent position, a pulmonary problem may be made worse, whereas a MS problem may be relieved
- pulmonary pain may be relieved when the client lies on the affected side, which diminishes the movement of that side of the chest
pulmonary causes
pleural irritation results in sharp, localized pain aggravated by resp movement
“autosplinting”-lying on the affected side to decrease movement: also decreases pain
-if pain is MS, it would increase in this position
Yellow flag- shoulder pain worsening with recumbence bc of increased venous return
pneumonia: shoulder pain when affected lung presses on diaphragm-usually accompanied by confusion
should look for:
- persistent/productive cough
- chest pain
- tachypnea
- dyspnea
- wheezing
- hyperventilation
should do chest auscultation
subjective exam: cardiac questions
Have you recently (ever) had a heart attack?- referred pain via viscerosomatic zones
Do you ever notice sweating, nausea, or chest pain when the pain in your shoulder occurs?
Have you noticed your shoulder pain increasing w/ exertion that does not necessarily cause you to use your shoulder (climbing stairs, bicycle)?
does your mouth, jaw or teeth ever hurt when your shoulder is bothering you? -angina
for the client with known angina: does your shoulder pain go away when you take nitroglycerin? ask about effect of taking antacids/acid-relieving drugs for women
cardiac causes
felt in shoulder bc heart and diaphragm supplied by C5 and C6
pain with increased activity not directly involving arm/shoulder
ask about:
- nausea
- unexplained sweating
- jaw pain/toothache
- back pain
- chest discomfort/pressure
if known to have heart disease ask about:
- effect of nitroglycerin (men) on shoulder symptoms
- antacids/ acid-relieved drugs (women) on shoulder symptoms
take vital signs
do chest auscultations
angina/MI complex regional pain syndrome TOS bacterial endocarditis pericarditis aortic aneurysm
angina/MI
can appear as arm and shoulder pain
-misdiagnosed as arthritis or MS pathology
shoulder pain starts 3-5 minutes after starting activity even with isolated LE activity
pain is unaffected by position, breathing, movement
stage 1 complex regional pain syndrome (type 1)
stage 1: acute lasting several weeks
- burning, aching, throbbing pain
- sensitivity to touch
- swelling
- muscle spasm
- stiffness, loss of motion, and function
- skin changes (warm, red, dry)
- accelerated hair growth (dark hair in patches)
stage 2 complex regional pain syndrome (type 1)
subacute, lasting 3-6 months
- severity of pain increases
- swelling may spread; tissue goes from soft to boggy to firm
- muscle atrophy
- skin becomes cool, pale, bluish, sweaty
- nail bed changes (cracked, grooved, ridges)
- bone demineralization (early onset of osteoporosis)
stage 3 complex regional pain syndrome (type 1)
chronic, lasting >6 months
- pain may stay the same, improve or get worse
- irreversible tissue damage
- muscle atrophy and contractures
- skin becomes thin and shiny
- nails are brittle
- osteoporosis
TOS
compression of neurovascular bundle
-variety of symptoms affecting arm, hand, shoulder girdle, neck, chest
bacterial endocarditis
most common symptom is arthralgia (usually in proximal joints)
usually only 1 or 2 painful joints in the following order:
- shoulder
- knee
- hip
- wrist
- ankle
- MTP
- MCP
- AC
onset of pain is sudden with warmth, tenderness and redness
pericarditis
accompanied by inflammatory process
accumulation of fluid in pericardial sac
-causes chest pain mimicking MI
pain may be relieved by kneeling with hands on floor, leaning forward, sitting upright
pain may be worsened by deep breathing, swallowing, belching
MI pain is unaffected by position, breathing, or movement
