62 Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
○ Not affected by specific movements but gets worse toward the end of the day or after standing for a long time ○ Pelvic pain that is described as “achy” or “comes and goes in waves” and poorly localized ○ Aggravated by walking, sexual intercourse, coughing, or straining ○ Not clearly affected by position changes ○ Not reduced or eliminated by tissue mobilization or release of trigger points Physician Referral • Guidelines for immediate medical attention ○ Signs and symptoms that point to fracture, infection, or neoplasm
○ Suspicion of any infection (e.g., STD, pelvic inflammatory disease [PID]) ○ A sexually active female with shoulder or back pain of unknown cause may need to be screened for ectopic pregnancy ○ Blood after bowel movement ○ Lateral wall pelvic pain referred down the anteromedial side of the thigh to the knee ○ A history of cancer with recent surgical removal of tumor followed by back, hip, sacral, or pelvic pain within 6 months of surgery is a red flag for possible cancer recurrence
CASE STUDY
The patient is a 32-year-old woman whose symptoms began three weeks prior to the initial evaluation when she awoke in the morning with the sudden and severe onset of left-sided sacral pain. Patient stated that onset occurred the day after lifting boxes at work. Patient saw her primary care doctor which ordered both radiographs and an MRI which were negative. She reported constant pain on the left lumbosacral region that occasionally radiated into the left lower abdominal quadrant and left buttock. The pain was worse during ambulation and at the end of the day, and sometimes with coughing and sneezing.
Examination Findings • Past medical history: Intermittent low back pain over the past 2 years • Family history: Fibromyalgia and Type 1 DM (maternal) • Medications: Flexaril, Percocet, birth control pills, multivitamin • Clinical presentation ○ Vitals: BP: 118/75; HR: 85 bpm ○ Integumentary—intact • Palpation: Revealed marked tenderness over the left lower abdominal quadrant and over the left lumbar paraspinal region • Posture: Increased lordosis • ROM: bilateral LE/UE and trunk—WNL • Pain (NPS score): 7/10 at rest, and increased to 9/10 after 30 minutes of standing or walking • Strength: Bilateral LE/UE: 4+/5 • 5x sit to stand: 11 seconds • Sensation: Grossly intact • Reflexes: 2+ bilateral UE/LE • Endurance: 6 minute walk test—1,400 feet with Borg of 3 • Patrick test—negative • Distraction/compression/thigh thrust: negative • Sacral thrust: positive with pain in left flank and SI • Participation: Oswestry Disability Index—38%
Evaluation Patient presents with left lumbar and sacral pain which is
limiting function. Yellow/red flags • Pain chronicity • Pain pattern • Pain unrelieved by rest Treatment • Pain reduction • Postural training • Spinal stabilization exercises • Home ex program Re-evaluation (2 weeks)
Patient stated that she has been compliant with home program but she feels pain remained unchanged. Differential Diagnosis • Visceral Result Patient seen by primary care physician and referred to gynecologist and was diagnosed with endometriosis.
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