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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
• Swelling • Muscle spasm • Stiffness, loss of motion and function • Skin changes • Accelerated hair growth Stage II (subacute, lasting 3 to 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 Stage III (chronic, lasting more than 6 months) • Pain may stay same, improve, or get worse; variable • Muscle atrophy and contractures • Skin becomes thin and shiny • Nails are brittle • Osteoporosis Carpal Tunnel Syndrome (CTS) There are many potential causes CTS, both musculoskeletal and systemic. Careful evaluation is required. The presence of bilateral CTS warrants a closer look.
• 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) • 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)
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
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