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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
• Cancer signs and symptoms ○ Pectoralis major muscle spasm with no known cause; limited active shoulder flexion but with full passive shoulder motions and mobile scapula ○ Presence of localized warmth felt over the scapular area ○ Severe muscular weakness and pain with resisted movements Cardiac Signs and Symptoms • Exacerbation by exertion unrelated to shoulder movement • Shoulder pain relieved by leaning forward, kneeling with hands on the floor, sitting upright • Shoulder pain accompanied by dyspnea, toothache, nausea, or pressure behind the sternum (angina) Pulmonary Signs and Symptoms • Presence of a pleuritic component such as a persistent, dry, hacking, or productive cough; blood-tinged sputum; chest pain; symptoms are aggravated by respiratory movements • Exacerbation by recumbency despite proper positioning of the arm in neutral alignment • Presence of associated signs and symptoms (eg, tachypnea, dyspnea, wheezing) • shoulder pain of unknown cause in older adults with accompanying signs of confusion or increased confusion (pneumonia) Gastrointestinal Signs and Symptoms • Coincident nausea, vomiting, dysphagia; presence of other GI complaints such as anorexia, early satiety, epigastric pain • Shoulder pain relieved by belching or antacids and made worse by eating • History of previous ulcer, especially in association with the use of NSAIDs
LEARNING TIP! For any client presenting with bilateral CTS, ask about: • Presence of similar symptoms in the feet • Personal history of liver or hepatic disease • History of hepatotoxic drugs • History of alcoholism • Current or previous use of statins
• Look for other signs and symptoms associated with liver ○ Skin color changes ○ Spider angiomas ○ Palmar erythema ○ Nail bed changes ○ Asterixis Guidelines for Referral • Guidelines for immediate medical attention ○ Presence of suspicious lymph nodes, especially hard, fixed nodes in a client with a previous history of cancer ○ Trauma followed by failure of symptoms to resolve with treatment; pain out of proportion to the injury Clues to Screening Upper Quadrant Pain • Simultaneous or alternating pain in other joints, especially in the presence of associated signs and symptoms • Presence of hepatic symptoms • Lack of improvement after treatment, including trigger point therapy • Left shoulder pain within 24 hours of abdominal surgery, injury, or trauma (Kehr’s sign, ruptured spleen)
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