May 16, 2014

Top 5 Fridays! 5 Differential Diagnosis Cases

I don't know how to use an assistive device, but I am one hell of a diagnostician


A recent Top 5 Fridays request was 5 patients that surprisingly improved after plateauing. I thought hard about that one and could not think of 5.



Instead, I thought I would recount 5 memorable cases that required differential diagnosis/referral out to resolve their symptoms. They all have something in common, failure to improve or plateauing after a short time despite my best efforts and their compliance.

1) Chronic Headaches and Tinnitus

  • male mid 40s, referred for chronic headaches and tinnitus
  • the usual MDT education and soft tissue work to upper quarter rapidly resolved the HA and cervical pain
  • no change in tinnitus for the next 3 weeks (this was a long time ago - my leash obviously shorter)
  • at the time, I had finished my differential diagnosis for PT course for my DPT through the University of St. Augustine
  • I remembered learning about a side effect of "overdosing" on aspirin was tinnitus
  • upon questioning, he was eating aspirin like people eat M&M's
  • since his other complaints were better, I had him discontinue and his tinnitus gradually resolved within a week
2) Chronic bilateral leg aching and fatigue
  • male, early 60s referred for bilateral leg fatigue greater than aching
  • unable to reproduce the complaints with movement, position, or treadmill/bike endurance testing
  • all neurodynamics were WNL
  • tried for 3-4 visits to improve his complaints, and had him try to gradually walk through it
  • at first mild improvement, then back to baseline
  • referred back to his podiatrist, who eventually found out it was his statins causing the LE pain
  • for the record, I asked him this, but he denied taking any medication
3) Chronic UE numbness/pain
  • male, mid 50s, referred for chronic radiating UE pain
  • Sx were worse in the morning
  • mildly responded to MDT and neurodynamics
  • I noticed he reeked of alcohol on very early morning appointments
  • on the days he smelled worse, were also the days his Sx were exacerbated
  • I asked him if drank to the point where he passed out in the chair, the answer was yes - Saturday Night Palsy
  • morale of the story, gluten intolerance is something that may effect up to 20-30% of individuals according to some studies
  • the only way to "test" for it, is to go gluten free and see if unexplained symptoms improve
5) Severe LBP with Radiating LE Pain
  • former patient, male, mid 60s
  • previously responded well to PT for LBP, knee pain, shoulder pain, neck pain
  • very compliant
  • comes in with lateral shift, 4 sessions with me, 2 sessions with my business partner, sometimes mild improvement, sometimes left feeling worse, overall no change, Sx remained peripheralized
  • I referred him to a neurologist who ordered an MRI, there was a large cyst in L5-S1 foramen, it was removed with a minimally invasive procedure, and he was immediately Sx free
  • this actually happened with 2 other patients, very similar cases, only I referred out after 4 visits, and all had similar very large cysts
  • why do these findings matter in some, but not in others? I don't know, but the periphery matters in some cases
  • this was actually 3 cases in 18 months... knowing how all 3 responded in the past, also being very compliant, I just knew something was amiss
  • in the end, all were pleased with the referral, and returned for a little conditioning after the surgeon cleared them for rehab

We often think that we can do everything, but remember not all symptoms can be helped with education, manual therapy, and exercise.

Job Posting!

Looking for a change in atmosphere? Mountain Physical Therapy Services in Asheville, NC is looking to hire. The listing is on The Manual Therapist Job Posting Page here.

Keeping it Eclectic...

2 comments:

Elaine Lonnemann said...

Erson, thank you for sharing these cases or synopses thereof. I enjoyed reviewing them and wanted to let you know that another tDPT student from USA is working on her Capstone and looking at the patterns related to PT Cases referred out for more appropriate intervention/diagnostics. Failure to improve has been a significant pattern. The caveat is making sure you are providing the best care (evidence-informed) for the client.

Dr. Erson Religioso III, DPT said...

Your welcome Elaine. What has the USA student found in terms of length of care prior to referral? The Systematic Review for Red Flags recently found failure to improve after one month was one of the only factors, along with previous history of CA.

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