47 Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
CASE STUDY
Client is a 70-year-old white female with complaints of thoracic pain for 1 month that has been getting progressively worse. She denies trauma or fall and states that she also has balance impairment fatigue and LE weakness. She is now ambulating with a walker due to new onset of symptoms. Client also reports insomnia due to pain. She went to her primary care doctor, who prescribed physical therapy (PT) for endurance training, pain relief, and balance training.
Examination Findings • Past medical history: Type 2 DM, hyperlipidemia, hypertension • Family history: Unremarkable • Medications: Metformin, Glyburide, Lovastatin, Lisinopril • Clinical presentation ○ Vitals: BP: 127/76; HR: 74 ○ Integumentary: Grossly intact ○ Cognition: A &O x 4 • Palpation: Tender to palpation between shoulder blades • Posture: Forward head, rounded shoulders • ROM: Within normal limits (WNL) for age • Pain (NPS score): 5/10 without movement and 8/10 with movement • Strength: Bilateral UE: grossly 5/5; bilateral LE: grossly 3+/5 • 5x sit to stand: 27 seconds with complaints of pain • Sensation: Paresthesia left LE • Reflexes: 2+ bilateral UE/LE • Endurance: 2 minute walking test with Borg of 6 and complaint of pain • Balance: Berg 41/56 • Participation: Oswestry Disability Index 41 • Thoracic compression test: Negative • Thoracic foraminal closure test: Positive Sacrum and SI Joint Evaluating SI joint can be difficult in that no single finding can predict a disorder of the SI joint. Pain can mimic pain referred from lumbar disk herniation, spinal stenosis, facet joint impairment, or even a disorder of the hip. Most common presentation is associated with a memorable physical event. SACRUM, SACROILIAC JOINT AND PELVIS
Evaluation Patient presents with pain in thoracic spine as well as weakness in bilateral LE and impaired balance which is limiting function. Yellow/red flags • Pain pattern
• Fatigue • Balance • Weakness Treatment
• Pain reduction • Balance training • Strength and endurance training Re-evaluation (4 weeks) Strength increased ½ grade in bilateral LE, however, pain remained unchanged Differential Diagnosis
• Pain pattern • Mechanical • Nonmechanical • Visceral Result
Patient seen by physician who ordered MRI. Patient diagnosed with neoplasm in thoracic spine and referred to neurosurgeon. With a complete workup, patient was found to have primary pancreatic cancers with mets to spine and liver. SI Movement Tests Evidence indicates that palpatory/movement tests have extremely low inter-rater reliability— namely, the Gillet, seated flexion, standing flexion, prone knee flexion, and long-sitting test. SI Provocation Tests 1. Distraction test: In supine examiner applies pressure to “spread” the ASISs ○ Positive test: Patients with buttock pain, with or without lumbar or LE symptoms
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