suggestive of serious medical pathology and/or adverse drug reactions. At the conclusion of this course, the learner will be able to increase the effectiveness of his or her screening techniques
with new and current patients. As a result, the therapist should be able to more accurately identify patients in need of medical referral while reducing the number of unnecessary referrals.
DIFFERENTIAL DIAGNOSIS
Traditional terminology The terms medical diagnosis and differential diagnosis are no longer considered to be synonymous. Historically the terms medical diagnosis and differential diagnosis were both used to refer to what physicians did: take a history, examine the patient, and review clinical test results in order develop a diagnosis that was used to guide treatment and/or identify additional testing Current terminology The term differential diagnosis is used currently to describe a process in which therapists try to determine if the patient’s condition is within their scope of practice (e.g., a mechanical problem within the musculoskeletal system), or if the examination findings suggest that the problem may be outside the therapist’s scope of practice and requires consultation with another health care provider (Boissonnault & Umphred, 2013). Differential diagnosis occurs in two phases. ● Phase 1 of differential diagnosis involves differentiating clusters of signs, symptoms, and clinical findings (tests and measures) that warrant communication with the patient’s physician because the findings suggest that the best intervention for the patient’s condition is outside the therapist’s scope of practice. If the patient’s cluster of signs, symptoms, and other findings is found to lie within the therapist’s scope of practice (e.g., the findings are consistent with a mechanical problem within the musculoskeletal system), then the therapist should proceed to the second phase of the differential diagnostic process. ● Phase 2 of differential diagnosis refers to the process of grouping the signs, symptoms, and clinical findings into a specific diagnostic category that guides an intervention plan that is within the therapist’s scope of practice (e.g., low back pain associated with joint mobility deficits) (Boissonnault & Umphred, 2013). The focus of this course is on Phase 1 of the differential diagnostic process. The goal of Phase 1 of the differential diagnostic process is to determine the most appropriate intervention plan for the patient’s condition. Several questions must be answered: 1. Does the condition warrant referral to another healthcare practitioner? 2. Is the most appropriate treatment for the condition within the examiner’s scope of practice? 3. Is the best strategy to begin treatment while a referral is initiated for the same or another condition? For example, consider a patient who presents with a primary complaint of shoulder pain. If the therapist determines that the source of the shoulder pain is primarily mechanical in origin, then the therapist initiates treatment aimed at alleviating the mechanical problem. Medical history The initial evaluation of a new patient should include a variety of questions designed to acquire historical information essential to making an accurate differential diagnosis, including questions regarding the personal and family history of medical conditions. The range of questions should be thorough enough to provide the practitioner with the information required to accurately determine the presence or absence of risk factors for a variety of disorders.
procedures needed to give a specific diagnosis. The physician’s goal was to determine an accurate and specific diagnosis that would lead to the best available intervention plan. Current terminology now refers to this entire process as making a medical diagnosis (Boissonnault & Umphred, 2013).
However, if the therapist determines that the only way to reproduce the shoulder pain is with physical exertion such as walking or climbing stairs, he or she should reasonably conclude that the primary source of the shoulder pain may not be mechanical in origin and proceed to initiate a referral to the patient’s physician. Yet another scenario might include a clear finding of a mechanical problem in the shoulder, but the therapist notes that some of the patient’s other ( adjunct ) symptoms may be related to a separate problem such as epigastric pain. In this instance, some of the patient’s symptoms are clearly related to the mechanical problem in the shoulder, while other signs and symptoms (e.g., intermittent epigastric pain) are clearly not associated with the mechanical problem. The best plan of intervention in this third scenario may be for the therapist to begin treatment for the mechanical problem in the shoulder while initiating a referral of the patient to a physician or another healthcare provider for further evaluation of the atypical and suspicious findings (i.e., the epigastric pain). As noted above, Phase 1 of differential diagnosis involves distinguishing clusters of signs, symptoms, and clinical findings that are within the therapist’s scope of practice from those findings that are considered atypical and warrant communication with the patient’s physician or another healthcare provider. A referral to another healthcare provider should be initiated in cases in which the findings suggest that the best intervention is outside the therapist’s scope of practice. Determining if a patient’s condition is outside the therapist’s scope of practice is accomplished by: a. Taking a thorough medical history. b. Determining the patient’s risk factor profile. c. Evaluating the patient’s responses to the general health questions,. d. Recognizing the cluster of signs, symptoms, and clinical findings as typical or atypical for a mechanical problem. (Boissonnault & Umphred, 2013; Goodman et al., 2018) These factors will be discussed in the following section.
INITIAL EVALUATION
After this information is acquired, the therapist should conduct a thorough investigation of the symptoms. Thoughtful analysis of this information will be used to guide the use of the other elements of the Phase 1 differential diagnostic process (e.g., the review of physiological systems that will be described and discussed later). According to the Guide to Physical Therapist Practice (APTA, 2014), each new patient examination should include a discussion of the patient’s medical history prior to conducting a physical examination.
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Book Code: PTOH1324
EliteLearning.com/Physical-Therapy
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