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DIFFERENTIAL DIAGNOSIS

HOME STUDY COURSE

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Objectives

After finishing this home study course, the fellow student will be able to:

• Describe the type of patient data that fall under the category of symptom investigation, including the information that constitutes a red flag requiring physician contact

• Summarize signs and symptoms associated with medical disorders that may result in patient pain syndromes common to the practice of physical therapy

• Describe medical screening questionnaires and incorporate them into an examination scheme for patients with common pain syndromes

At the end of this homestudy course is a 10 question written exam in multiple-choice format. I have posted a spreadsheet you will be using to fill out your quiz answers. You can find the form in Document Library/Homestudy courses/Homestudy Quiz Answers sheet. When you have completed the exam, e-mail that form to mtiquizanswers@ for grading.

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Many patients that seek out a physical therapist for relief of complaints such as back pain, knee pain and shoulder pain assume that the symptoms are related to sprains, strains, poor posture or arthritic conditions. For some patients however, the symptoms are related to a more serious medical condition.

A primary objective of the examination process is deciding whether:

• PT intervention is appropriate

• Consultation with another health care provider is required along with PT intervention

• PT intervention is not indicated and the patient needs to be managed by another provider.

The patient’s symptom description can indicate suspicion of potentially serious pathology. That suspicion is based on an atypical description of symptoms; a description that does not make sense based on basic and clinical sciences, and the PT’s clinical experience.

The location of symptoms should alert the PT to other possible pain generators that would warrant a referral if present. The PT must know what diseases could produce local pain or referred pain in a region s you can screen for other signs and symptoms associated with these conditions.

Pain from visceral structures typically is thought to be located in the anterior chest wall or abdominal regions. However, structures like pancreas, kidneys, ascending and descending colon will refer pain to the back rather than the belly. This leads to considerable overlap between pain location patterns associated with visceral disorders and common muskuloskeletal problems.

In addition, many pain generating diseases simply present as a dull ache, stiffness, or mild to moderate soreness in their early or middle stages; these are also very common conditions for may patient populations. The location of the symptoms by itself is rarely significant in deciding whether a referral is in order. Exceptions to the rule are the patient with symptoms of chest pain or pressure with pain extending into the left upper extremity. You should suspect possible involvement of the heart in such a case. Descriptions such as throbbing, pulsating and pounding also suggest involvement of the vascular system rather than pain of muskuloskeletal origin.

Knowledge of potential pain patterns associated with viscera can guide you in selecting the organ systems to screen.

Knowing the pain patterns associated with various diseases will help you know which disorder should be suspected when you carry out the examination.

Symptom history

For many patients, the current episode of symptoms is not their first episode, but the

most relevant information in the initial visit is a description of the most recent injury or flare up.

Impairment related symptoms usually are associated with intrinsic trauma, extrinsic trauma, sustained posture or repeated micro trauma. However, many patients cannot relate the onset of their symptoms to any particular incident. Careful questioning will frequently reveal a likely cause though, such as the patient beginning to run after not running for 3 months, being promoted to an administrative position that requires sitting for 8 hours/day, or doing yard work after a winter of inactivity. If the onset of symptoms is truly insidious, or if resolved symptoms return for no apparent reason, the PT should be concerned about the underlying nature of the condition.

When patients have a flare up of previous existing problems, it could very well be that the current episode is related to the previous condition. However, any change in the symptom descriptors, onset of symptoms, or 24-hour report of symptoms compared with previous episodes should alert you that this condition may have a different etiology.

Behavior of symptoms

The patient report of symptom site and intensity changes over a defined period of time produces information vital to the medical screening process. For many patients with neuromuscular disorders, a description of how symptoms do or do not change over as 24-hour period is adequate. For patients with disorders such as multiple sclerosis, stroke or a heads injury, the time frame may be 3-6 months.

Besides insidious onset of symptoms, a report of unexpected or atypical behavior of symptoms may be the initial clue that raises the suspicion of a serious underlying condition. Symptoms associated with impairments or movement disorders typically fluctuate accordingly as the mechanical loads on the body increase or decrease with time of day, specific activities and certain postures.

If the symptom pattern reveals no pattern, you should begin to question whether physical therapy intervention is warranted.

Symptoms associated with visceral disease will vary in their behavior depending on the severity of the disorder and the function of the structure. Therefore a patient report of intermittent pain does not rule out the possibility of disease. If the patient’s thoracic pain is the result of a duodenal ulcer, GI system activity may alter the symptoms. The pain associated with the ulcer probably will be reduced shortly after the patient eats, as the food acts like buffer, and a few hours after eating the pain will return or intensify.

An inconsistent pattern of change in symptom intensity is not the only warning sign that may be discovered during the history taking. Symptoms that move from one body location to another for no apparent mechanical reason are also an atypical report for many patients seeking therapy services. Neurologic, endocrine or rheumatic disorders may account for a symptom pattern such as this.

Nightpain

Nightpain has been associated with serous diseases such as cancer and infection. Many studies also describe nightpain as being associated with degenerative joint disease. In addition, a significant percentage of patients with low back pain reported night pain with no evidence of serious disease. So when is nightpain a red flag? When night pain is reported, follow up questions should be:

• How many nights per week?

• Is there a consistent time when you wake up?

• How does the intensity of the night pain compare with the pain experienced at other times of the day?

• What do you have to do to fall back asleep?

It has been reported that more than half of the patients with back pain reported nightpain. However, almost 80% of those stated that they simply had to change positions in bed to fall back asleep. This pattern can be expected for the patient with non-acute low back pain. Low back discomfort wakes them up, but they fall back asleep with minimal effort after repositioning. More concern would be warranted if the nightpain was the patient’s most intense pain and if it took more than minimal effort to fall back asleep.

Another reason for concern would be that the nightpain episodes were becoming more frequent and severe without any mechanical explanation for the worsening. Based on the current evidence, one must conclude that the presence of nightpain as the sole red flag has little diagnostic value but must be considered in context of the other examination findings.

In summary, symptom investigation is often the first step that will alert you to the possible need of patient referral. Careful questioning will reveal a pattern of symptoms that is unusual for patients with muskuloskeletal conditions.

Identifying red flags

Low back pain

Back-related tumor

Lack of improvement for a patient over the age of 50 with acute low back pain is a red flag, raising the index of suspicion that the patient’s low back pain is caused by a tumor, rather than by a less serious muskuloskeletal disorder. When patients fail to improve, make sure to verify their age, previous history of cancer and recent unexplained weight loss. Deyo and Diehl reported that, of the 13 patients whose low back pain was caused by cancer (out of a total subject pool of 1975 patients with low back pain), all 13 were over 50 years of age, had a history of cancer, had experienced unexplained weight loss, or had failed to improve with conservative therapy.

Back-related infection

Red flags that raise suspicion of osteomyelitis as a cause of back pain are all factors that put the patient at risk for spinal infection. These factors are current or recent bacterial infections (e.g. urinary tract- or skin infection), intravenous drug use, and concurrent suppression of the patient’s immune system. The following questions should be asked:

• Have you recently had a fever

• Have you recently taken antibiotics

• Have you been diagnosed with an immunosuppressive disorder

Spinal fracture

Ask whether any trauma to the spine triggered the onset of back pain. Ask whether the patient has any history of osteoporosis, as minor strains or falls can produce an unsuspected spinal fracture in patients with osteoporosis. As whether the patient has other problems that increase the risk of decreased bone density: renal failure, chronic GI disorders, and long-term use of corticosteroids.

Cauda equina syndrome

Rely on both historical and physical examination data. The following questions should be asked:

• Have you noticed any weakness in the legs

• Have you noticed a recent onset of bladder problems

• Have you noticed a recent onset of numbness in the area of your bottom where you would sit on a bicycle seat

A positive response to any of these questions increases the suspicion that the patient has a cauda equina syndrome. Subsequent physical examination should include testing of dermatomes and myotomes L4-S1.

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Pelvis, hip and thigh pain

The serious medical conditions that may mimic common muskuloskeletal disorders of the pelvis, hip and thigh include colon cancer, pathologic fractures of the femoral neck, and avascular necrosis of the femoral head, Perthes disease and a slipped capital femoral epiphysis.

Colon cancer

Most common in people > 50 years and who have a family history of colon cancer. The initial symptoms usually are a change in bowel habits (blood in stool or black stool). It is a deadly disease because the neoplasms can develop undetected fro many years before the onset of symptoms. Routine screening examinations for colon cancer are important for individuals with a family history of the disorder. Remember that the most common metastasis presentation of colon cancer includes the thoracic spine and rib cage. The following information from the history could be red flags fro colon cancer:

• Age greater than 50 years

• History of colon cancer in immediate family

• Bowel disturbances

• Unexplained weight loss

• Back or pelvis pain that is unchanged by positions or movement

Pathologic fractures of the femoral neck

They occur secondary to disease and often in the absence of trauma. Most common in people older than 50 years (women more often than men) who have a history of metabolic bone disease (osteoporosis or Paget’s disease) a fall from a standing position is often reported, along with a sudden painful snap in the hip area. Pain is usually located in the groin, anteromedial thigh or trochanteric region. The involved extremity appears shortened and typically is held in an externally rotated position.

Avascular necrosis

Avascular necrosis is the result of insufficient arterial supply to the femoral head. This results in the death of bony tissue and can be associated with hip trauma, like fractures or dislocations. Non-traumatic conditions associated with avascular necrosis include corticosteroids use and sickle cell disease.

Legg-Calve-Perthes disease

This occurs in children, most common in 5-8 year old boys, and results from an idiopathic loss of blood supply to the femoral head. Both patients with avascular necrosis and Perthes disease often report pain in the groin, thigh and knee that worsens with weightbearing activities, resulting in an antalgic gait. Clinical findings in Perthes disease include shortening of the involved extremity, decreased internal rotation and abduction of the involved hip.

Slipped capital femoral epiphysis

This condition occurs in adolescents and involves progressive displacement of the femoral head relative to the neck through the open growth plate. It is more common in males (male-to-female ratio 2.5:1) who are typically, but not always overweight. There usually is a history of trauma or a recent growth spurt. They usually experience groin, thigh or knee pain that is diffuse and vague. Common findings: antalgic gait; involved extremity placed in external rotation; limited hip internal rotation.

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Knee, lower leg and ankle/foot pain

Peripheral arterial occlusive disease (or peripheral vascular disease)

Common disease. Risk factors: smoking, sedentary lifestyle, type II diabetes. Clinical features include intermittent claudication and coldness of the distal extremities. Signs include decreased posterior tibialis and dorsalis pedis pulse, a unilateral cool extremity, and wounds and sores on the toes or feet.

A test that can be performed to aid in confirming the presence of peripheral vascular disease is the reactive hyperemia test. It assesses the integrity of the vascular system in redistributing blood with postural changes. The patient lies supine. Elevate the leg to 45 degrees and hold for 1-3 minutes, or until the color of foot, ankle and lower leg is blanched. Then lower the leg and measure the time it takes for the leg to turn to pink again. The normal time is 1-2 seconds. A venous filling time >20 seconds indicates peripheral vascular disease. When screening examination suggests peripheral vascular disease, you must also assume the presence of ischemic heart disease until proven otherwise. A physician evaluation and medical management are essential.

One of the major therapies for these patients is aerobic exercise, such as progressive walking.

Deep vein thrombosis (DVT)

A DVT is a spontaneous obstruction of the popliteal vein of the calf and may present as a gradual or sudden onset of calf pain, typically intensified with standing or walking and reduced with rest and elevation. Up to 50 % of the patients with DVT will not experience calf pain. The risk factors that expose an individual to DVT are recent surgery, malignancy, trauma, prolonged immobilization of the extremities (including casting, long car ride or plane trip), and pregnancy. Signs: localized calf tenderness, calf swelling and edema, and skin warmth. The diagnosis is confirmed with imaging procedures. The potential that the blood cloth may travel proximally toward or into the pulmonary vessels is the risk that makes a DVT a serious condition that requires referral to a physician from medical examination.

Compartment syndrome

This is an abnormal rise in pressure in one of the fascial compartments of the leg, resulting from acute swelling. The vascular occlusion and nerve entrapments that are possible sequlae of a compartment syndrome make this condition a medical emergency.

There is often a history of blunt trauma, crush injury or of participation in an unaccustomed physical activity involving the lower extremities such as rapidly increasing the amount of the running distance. The patient often reports severe persistent leg pain that is intensified when stretch is applied to the involved muscles. Signs: swelling, exquisite tenderness and palpable tension of the involved compartment. The nerve entrapment or compression can result in paresthesiae and potentially in paresis or paralysis. The vascular compromise can result in diminished peripheral pulses. Look for the five “P’s”: pain, palpable tenderness, paresthesiae, paresis and pulselessness.

Infection

There are two kinds of infections that can mimic lower extremity muskuloskeletal disorders. Septic arthritis is an inflammation in a joint caused by a bacterial infection, and the other is cellulitis, which is an infection in the skin and the underlying tissues following a bacterial contamination of a wound.

Patients with septic arthritis complain of a constant aching or throbbing pain and swelling in the joint. The joint is usually tender and warm when palpated. Patients who develop septic arthritis often are immunosuppressed or have a preexisting joint disease. This immunosuppression may be a result of corticosteroid use, alcohol abuse, renal failure, malignancy, diabetes, intravenous drug abuse, organ transplantation or AIDS.

Examples of preexisting joint diseases that predispose you to septic arthritis are rheumatoid arthritis, osteoarthritis and psoriatic arthritis. The cause of septic arthritis is usually associated with a local or distant site of infection, or a history of a recent joint surgery or intraarticular injection.

Cellulitis exhibits the classic signs of pain, skin swelling, warmth and an advancing irregular margin of erythema or reddish streaks. They may also report other classic signs of infection: fever, chills, malaise and weakness. Individuals predisposed to developing cellulitis are those with congestive heart failure, lower extremity venous insufficiency, diabetes, renal failure, liver cirrhosis and advancing age. The precipitating factor to developing cellulitis is typically a recent skin ulceration or abrasion.

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Thoracic pain

Cardiac and pulmonary disorders

The thoracic spine and rib cage lie close to many organ systems that, when diseased, usually result in local or referred pain to the thoracic region. In addition, both metastatic disease and bone diseases usually manifest as pathological fractures of the thoracic vertebrae and ribs. So be aware that there can be underlying serious medical problems when back pain is reported in the thoracic region.

Myocardial infarction

This is an acute blockage of a coronary artery resulting in death to a portion of the myocardium. The main clinical feature is angina (chest symptoms described as discomfort, pressure, tightness or squeezing with potential referral in the arms, neck or jaw region). However, one of three patients diagnosed with MI does not have chest pain on initial presentation to the ER. Instead of pain as the primary manifestation, symptoms can include dyspnea, nausea, vomiting, palpitations, syncope or cardiac arrest. Risk factors include: history of diabetes, older age, female, nonwhite racial or ethnic group, and history of congestive heart failure and stroke.

Stable angina

Stable angina is substernal chest pain or pressure with possible pain referral to the left UE that occurs with predictable exertion or known precipitating events, such as exercise or exertion at an intensity level higher than usual. The symptoms are also predictably alleviated with change in the precipitating event (e.g. ret) or with self-administration of sublingual nitroglycerin. Chest pain that occurs with stable angina is relatively benign.

Unstable angina

Unstable angina is chest pain that occurs outside of a predictable pattern and that does not respond to nitroglycerin. Individuals experiencing unstable angina must be closely monitored. Signs suggesting MI (including angina lasting>30 minutes, shortness of breath, pallor, substernal squeezing, crushing pressure, pain radiating to the arms and diaphoresis) should alert you that this is an emergency condition. Immediate transportation to an appropriate ER is indicated.

Pericarditis

Pericarditis is an inflammation of the pericardium. This is a sac around the heart to keep it in place, to prevent overfilling with blood, and to protect the heart from chest infections. It can become inflamed by bacterial, viral or systemic diseases such as kidney failure, systemic lupus, rheumatoid disease, and heart failure. This inflammation around the heart prevents complete expansion, because the additional pressure from the resulting inflammation results in less blood leaving the heart. To make up fro the reduced stroke volume and to get enough oxygen to the tissue, the heart beats faster. If increased hart rate cannot compensate enough, the person may start to breath heavily, the veins in the neck may distend, and blood pressure may drop drastically during inhalation. This condition is termed cardiac tamponade and is often a medical emergency.

Pulmonary embolism

This is a pulmonary condition that may produce angina like pain. An acute massive pulmonary embolism can produce crushing chest pain. The location of the chest pain is usually substernal, but it can be located anywhere in the thorax depending on the location of the embolus. This may include shoulder pain or upper abdominal pain. Patients may also develop dyspnea, wheezing and a marked drop in blood pressure. Factors that increase the risk of blood clots in the lower extremities or pelvis and subsequent embolus include immobilization or recent surgery. Pulmonary embolism has a high mortality rate, so if you suspect this condition you should refer the patient to the ER.

Pleurisy

This is an irritation of the pleural membranes that make up the lining between the lungs and the inner surface of the ribcage. The pain is usually described as sharp and stabbing and is worsened by deep inspiration, coughing and other ribcage movements. Passive motion testing of the ribs and T spine may also reproduce pain. Pleurisy has multiple causes , such as viral infections or tumors, and is also associated with disorders such as rheumatoid arthritis. Auscultation over the thorax produces a “pleural rub” sound. This occurs when the inflamed and thickened visceral and parietal layers of the pleural sac rub against each other during movement of the chest wall. The friction between inflamed pleural tissues produces a lower pitched sound and may be heard during both exhalation and inhalation

Pneumothorax

A pneumothorax is air in the thoracic cage. It can be a spontaneous, usually pathologic event associated with rupture of the wall of the lung lining. Such a rupture prevents the lung from maintaining negative pressure during breathing. A simple pneumothorax can begin without any precipitating event, or may follow a bout of extreme coughing or strenuous physical activity. Signs include limited ability of the affected side of the chest to expand, hyperresonance of the affected area upon percussion and markedly reduced breath sounds. A small pneumothorax may resolve within a few days without therapy. A large pneumothorax will require aspiration of the air from the lung. Predisposing factors: asthma, COPD, lung cancer and cystic fibrosis.

A tension pneumothorax usually results from trauma, such as a penetrating wound to the ribcage or a severe blow to the ribcage that may occur in contact sports or during an MVA with the patient hitting the steering wheel. Signs: severe pleuritic type chest wall pain, extreme shortness of breath, tracheal deviation, distended neck veins, tachycardia, hypertension and hyperresonance to percussion of the involved side. This can be an extreme emergency requiring insertion of a chest tube.

Pneumonia

A bacterial or viral infection of the lungs which can cause pleuritic type chest pain. The signs of systemic infection such as chills, fever, malaise, nausea and vomiting typically accompany the pleuritic pain. A distinguishing characteristic of pneumonia is a cough that produces sputum of varying colors, form light green to dark brown.

Renal and urinary tract problems

Renal pain is typically felt in the posterior subcostal and costovertebral regions. Ureteral pain is felt in the groin and genital area. Kidney problems such as pyelonephritis or kidney stones result in pain in the posterior lateral aspect of the thoracic cage and upper lumbar area. Both conditions present with chills, fever, nausea, vomiting and renal colic. Renal colic is excruciating intermittent pain from the costovertebral angle or flank that spreads across the lower abdomen into the genital area, and may extend as far down as the inner thighs.

Inflammatory disorders of the kidney and urinary tract can be caused by bacterial infection, by changes in immune response and by toxic agents such as drugs and radiation.

Upper urinary tract lesions include kidney or ureteral infections. Lower urinary tract infections include bladder infection or urethral infection. Upper urinary tract infections arte considered to be more serious because these lesions can be a direct threat to renal tissue itself.

Urine in the bladder and kidney is normally sterile, but urine itself is a good medium for bacterial growth. The presence of residual or stagnant urine or obstruction of urinary excretion can promote bacterial growth. Routes of entry of bacteria in the urinary tract can be ascending (up the urethra in the bladder and then into the ureters and kidney), bloodborne (bacterial invasion through the bloodstream), or lymphatic (bacterial invasion through the lymph system, the least common route). Lower UTI occurs most commonly in women because of the short female urethra.

Pyelonephritis is an infection of the kidney, usually caused by an infection of the urinary tract.

Kidney stones are hard masses of salts that precipitate from the urine when it becomes supersaturated with a particular substance. Most stones are composed of calcium. Risk factors for developing kidney stones are warm humid weather, and diseases that involve high cell turnover, like leukemia. The incidence of kidney stones in men is four times greater than in women. About 5-15% of the population is expected to have kidney stones during their lifetime. Still, the best predictor for kidney stones is a past episode, as about 50% of patients experience at least one recurrence.

Hepatic and biliary disease

The musculoskeletal symptoms associated with hepatic and biliary systems include thoracic pain between the scapulae, right shoulder, and right upper trapezius pain. Referred shoulder pain may be the only presenting symptom of hepatic or biliary disease.

When liver dysfunction results in increased serum ammonia and urea levels, peripheral nerve function can be impaired. When the liver does not detoxify ammonia, the ammonia is then transferred to the brain, where it reacts with glutamate, producing glutamine. The reduction of brain glutamate impairs neurotransmission, leading to altered central nervous system function and intrinsic nerve pathology. Asterixis and numbness/tingling in both hands can occur. The numbness/tingling in both hands is often misinterpreted as carpal tunnel syndrome. To test for asterixis, or “liver flap”, have the patient extend the arms, spread the fingers, extend the wrists and observe for the abnormal “flapping” tremor at the wrist

Signs and symptoms of liver disease

• Sense of fullness in abdomen

• Anorexia, nausea and vomiting

• Skin changes and nailbed changes (jaundice, bruising, spider angioma, palmar erythema)

• Right upper quadrant abdominal pain

• Muskuloskeletal pain, especially right shoulder pain

• Neurologic symptoms (bilateral carpal/tarsal tunnel, asterixis, muscle tremors, hyperactive reflexes)

• Dark urine and light colored stool

Evaluating carpal tunnel syndrome associated with liver impairment

• Ask about the presence of similar symptoms in the feet (tarsal tunnel syndrome)

• Ask about personal history of liver disease

• Look for history of alcoholism

• Ask about current or previous use of statins

• Look for other signs and symptoms of liver impairment (see above)

Clues to screening for hepatic disease

• Right shoulder/scapular and/or upper mid back pain of unknown cause

• Shoulder motion is not limited by painful symptoms; patient is unable to localize or pinpoint pain

• Presence of GI symptoms, especially if there is any correlation between eating and painful symptoms

• Bilateral carpal/tarsal tunnel syndrome; especially of unknown origin

• Personal history of cancer, liver or gallbladder disease

• Personal history of hepatitis

• Recent history of statin use

• Changes in skin

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Cervical pain

Before attempting to manipulate the cervical spine, two factors need to be taken into consideration. Ruling out the presence of cardinal signs and symptoms is a priority. They are considered to be extremely important as they suggest either vertebral/basilar artery insufficiency, or cervical cord compression. If such symptoms can be initiated, reproduced or aggravated by stressing the vertebral artery or by passive linear motions to the craniovertebral joints, then it’s reasonable to assume that there is possible insufficiency of the vertebral artery or that instability exists within the craniovertebral joint complex.

We think it’s prudent to test for upper cervical instability prior to testing the vertebral artery, as this involves sustained endrange rotation, which can possibly compromise the spinal cord if there would be underlying instability.

Differential diagnosis

Vertebral/basilar artery insufficiency

Alar ligament insufficiency

Transverse ligament or dens insufficiency

Jefferson fracture

Balance difficulties from loss of propriocepsis secondary to immobilization or injury of the cervical spine

Autonomic reactions

Symptom magnification

Signs/symptoms suggestive of vertebral/basilar artery insufficiency:

Drop attacks

Dizziness

Difficulty swallowing

Facial lip paresthesiae, reproduced by active or passive movements.

Lateral nystagmus produced by active or passive movements of the head or neck.

Neck pain and headaches

Double vision or blurriness of vision

Nausea

Signs/symptoms suggestive of cervical cord compression:

Bilateral or quadrilateral limb paresthesiae, either constantly or reproduced/aggravated by head or neck movements.

Hyperreflexia

Clonus

Positive Babinski or Hoffman’s

Reproduction of pain is of questionable importance when stress testing for instability. Ask the patient: “tell me if you feel anything other than pain”. If a stress test produces no reaction from the patient other then pain, the test can be considered negative. If a cardinal sign or symptom is produced, the test is positive.

Keep in mind that the inert tissues being stressed are heavily innervated by the trigeminal nucleus (adjacent to C2-3), which in turn is being joined by a branch of the vagus nerve. Therefore, “obscure” or “bizarre” complaints may occur during stress testing of the upper cervical spine. They are not cardinal symptoms, but definitely warrant caution: headaches, reluctance to move the head, difficulty lying down or lifting head from the pillow, vomiting, dizziness, disorientation, nausea, anxiety and a feeling of “a lump in the throat”.

When treating the upper cervical spine, stress tests should be done routinely, much like stress tests for knee ligaments are done routinely in a knee examination. The original discovery of life threatening complications due to high velocity trauma is rare. Even as rare as it is, if there exists even the suspicion of a life threatening instability, then the appropriate stress tests should obviously be performed. Instability in the upper cervical region can result from a number of causes:

• Trauma, especially hyper flexion injuries

• Rheumatoid arthritis. Non-traumatic hypermobility or frank instability of the OA joint has been reported in association with RA

• Gout. The usual presence of gout is a monoarticular arthritis mainly affecting the great toes, feet or ankles. Its occurrence in the vertebral axis is distinctly uncommon.

• Corticosteroid use. Prolonged exposure to this drug can produce a softening of the dens and transverse ligament by deteriorating the Sharpey fibers that attach the ligament to the bone. Steroid use also promotes osteoporosis.

• Down’s syndrome. Non-traumatic hypermobility or frank instability of the OA joint has been reported in association with Down’s syndrome. As it is recognized that Down’s syndrome is associated with generalized soft tissue laxity, laxity of the tectorial membrane may play a role in the OA hypermobility.

• Osteoporosis

• Congenital. Bony malformations can lead to hypermobility or frank instability

Stability of C1-2 depends on normal and intact dens. However, there are some reasons why this may not be the case in certain individuals:

• Developmental considerations. The dens is not of sufficient size to be retained in the osseoligamentous ring of the atlas until a child is approximately 12 years old. Therefore it must be assumed that C1-2 of a child under this age is naturally unstable, so great care should be taken with any mobilization or manipulation.

• Anomalies of the dens

▪ congenital absence of the dens

▪ underdeveloped dens

• Pathologies affecting the dens

▪ demineralization or resorption of the dens (RA)

▪ old, non-displaced fractures

• Postural changes. Cadaver studies have indicated that people with marked forward head posture in life have had anatomic changes in the dens and transverse ligament. So be careful when using upper cervical manipulation on elderly patients with forward head posture.

Shoulder pain

Entrapment spinal accessory nerve

Patient presents with weakness of shoulder abduction, cannot shrug the shoulder. Patient will complain of dull pain, weakness and drooping of the shoulder. Winging of the scapula is present. The accessory nerve can be injured by blunt trauma to the posterior triangle of the neck, or a traction injury (depression of the shoulder with sidebending the head away). It can also result from cervical surgery.

Entrapment axillary nerve

The nerve comes from C5,6. Typically caused by trauma, either a direct blow to the shoulder or a dislocation that stretches the nerve where it curves around the humerus. Sensation is may be unaffected. There will be weakness in shoulder flexion, abduction.

Entrapment suprascapular nerve

The nerve comes from C5,6. Often confused with a rotator cuff tear, a s both have wasting of the supraspinatus and infraspinatus with loss of strength in abduction and external rotation of the shoulder. The suprascapular nerve is a motor nerve. Complaints of pain are deep and poorly localized. Entrapment most often occurs at the suprascapular notch and can be caused by repeated micro trauma, or as a result of a fall. Conservative treatment of rest, NSAIDs and PT is often unsuccessful, and surgical decompression may be necessary.

Long thoracic nerve

The long thoracic nerve comes from C5,6,7. The nerve can be damaged by excessive use of the shoulder, prolonged traction to the nerve or trauma to the lateral chest wall. It can also be damaged by improper palpation of the first rib, so be careful when practicing your palpation and joint mobilizations. Symptoms: pain in the shouldergirdle. Signs: loss of active shoulder ROM and scapular winging.

Pancoast tumor

Malignant tumor in the upper apices of the lung. Highest occurrence in men over 50 with a history of cigarette smoking. In more than 90% of patients, shoulder pain, rather than pulmonary symptoms appears first. Pulmonary symptoms are rare, and shoulder or disc problems are suspected because the tumor grows in the thoracic inlet, affecting the eight cervical and first thoracic nerve roots, the subclavian artery and vein, and the sympathetic ganglions. The patient initially suffers from “nagging” pain in the shoulder and along the vertebral b0rder of the scapula as the tumor irritates the pleura. As the tumor grows and invades the thoracic inlet, the pain becomes more burning, extending down the arm and into the ulnar nerve distribution. It is during this progressive decline that the patient seeks medical attention and the disorder is misdiagnosed for an average of 6.8 months. If you treat a patient for neck/shoulder pain, that fits the patient profile and no change in status is noted after 3-4 visits, a referral back to the doctor may be warranted.

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Screening for GI disorders

Any disruption of the digestive system can create symptoms such as pain, diarrhea and constipation. Visceral pain occurs in the midline because the digestive organs arise embryologically in the midline and receive sensory afferents from both sides of the spinal cord. The abdominal viscera are ordinarily insensitive to many stimuli, such as cutting, tearing or crushing, that when applied to the skin would evoke severe pain. Visceral pain fibers are sensitive only to stretching or tension in the wall of the gut from neoplasm, distension, or forceful muscular contraction secondary to bowel obstruction or spasm.

Sometimes visceral pain from a digestive organ is felt in a location remote from the usual anterior midline presentation. The referred pain still lies within the dermatomes of the dorsal nerve roots serving the painful viscera. For example, visceral afferent nerves from the liver, diaphragm and pericardium are derived from C3-5 sympathetics and reach the CNS via the phrenic nerve. The visceral pain associated with these structures is referred to the corresponding somatic area.

At the same time, impairment of these GI structures can cause muscle dysfunction in the thoracic and lumbar spine, with loss of motion of the involved spinal segments. The clinical picture is one that is easily confused with primary pathology of the spinal segment.

Peptic ulcer

A peptic ulcer is a loss of the tissue lining the lower esophagus, stomach or duodenum. Most ulcers are caused by infection with the H. pylori bacterium that bores its way through the layer of mucus that protects the stomach cavity from acid. Ten percent of peptic ulcers are due to chronic NSAID use and are typically located on the posterior stomach wall. This can account for back pain. If left untreated, erosion can move into the stomach arteries and cause life-threatening bleeding or stomach perforation. H. pylori-induced ulcers can reoccur after treatment. The incidence of ulcers is highest in those who smoke, consume alcohol and use NSAIDS.

Signs/Symptoms: the ‘telltale sign’ of peptic ulcer is heartburn, which can be described as burning, gnawing, cramping or aching at midline in the area near the xiphoid. Pain is typically located at the upper epigastrium about one to two inches to the right of midway between xiphoid and umbilicus. Pain will come in waves and last several minutes, typically not hours and may radiate below the costal margins in to the back and occasionally to the right shoulder. The pain pattern is related to acid secretion and the presence of food in the stomach, which acts as a buffer. Duodenal ulcer pain is present when the stomach is empty (early AM or between meals). It may last from minutes to hours and antacids might relieve it. Gastric ulcers are more likely to cause pain in the presence of food. Symptoms often appear for 3-4 days or weeks and then subside coming back weeks or months later.

Other common symptoms include: nausea, vomiting, loss of appetite, weight loss and occasional back pain (at the area between T6-10 with radiation to the right upper quadrant). If stomach perforation into the GI wall blood vessels occurs, there could be vomited bright red blood or vomit of coffee ground appearance or by dark stools.

If H. pylori is the cause, the individual may also present with bad breath and/or facial acne known as rosacea.

Stress or spicy food do not cause ulcers, but can make symptoms worse. Drinking milk can temporarily decrease symptoms, but actually then increases stomach acid, which will worsen the complaints of pain.

Peptic ulcer may present as a musculoskeletal disorder. Back pain or R shoulder pain is the most common referral site. This pain will follow a pattern based on time of day/eating schedule rather than physical exertion, range of motion or positioning. Occasionally back pain may be the first or only symptom but complications of hemorrhage, perforation and obstruction may lead to additional symptoms that the patient does not relate to back pain

Crohn’s disease

Crohn’s disease is an ongoing disorder that causes inflammation of the digestive tract. Crohn’s disease can affect any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine, and the swelling extends deep into the lining of the affected organ. This swelling can cause pain and can make the intestines empty frequently, resulting in diarrhea.

Because the symptoms of Crohn’s disease are similar to other intestinal disorders, such as irritable bowel syndrome and ulcerative colitis, it can be difficult to diagnose. Ulcerative colitis causes inflammation and ulcers in the top layer of the lining of the large intestine. In Crohn’s disease, all layers of the intestine may be involved, and normal healthy bowel can be found between sections of diseased bowel.

Crohn’s disease affects men and women equally and seems to run in some families. About 20 percent of people with Crohn’s disease have a blood relative with some form of inflammatory bowel disease. Crohn’s disease can occur in people of all age groups, but it is more often diagnosed in people between the ages of 20 and 30. People of Jewish heritage have an increased risk of developing Crohn’s disease, and African Americans are at decreased risk for developing Crohn’s disease. One of the thoughts is that the body’s immune system reacts abnormally in people with Crohn’s disease, mistaking bacteria, food and other substances for being foreign and for reacting to these foreign bodies (antigens). Scientists have found that high levels of a protein produced by the immune system, called tumor necrosis factor (TNF), are present in people with Crohn’s disease.

Signs and symptoms: The most common signs and symptoms are abdominal pain, often in the lower right quadrant and diarrhea (some people may go 10 to 20 times a day). Constipation, rectal bleeding, fever, night sweats, decreased appetite, weight loss, nausea, skin lesions, arthritis, uveitis (inflammation of the eye), migratory arthralgias and hip pain may occur as well. Children with Crohn’s may suffer delayed development and stunted growth. It is important to note that the range and severity of symptoms varies. Flare ups are accompanied by abdominal pain, nausea, diarrhea and fever. Other symptoms include mouth ulcers, rashes and joint pain

Crohn’s disease can present as a musculoskeletal disorder as well. Patients may present with referred pain to the low back, pain in the right lower abdominal quadrant and hip pain caused by an associated psoas abcess. Sacroilitis is common and may progress to ankylosing spondylitis.

Diverticular Disease

Diverticular disease encompasses both diverticulosis and diverticulitis. These terms are used interchangeably but are clinically differentiated. Diverticulosis is considered a benign condition that is most common in people over the age of 65 with an onset beginning in the 5th through 7th decades. Diverticulosis is a weakening of the mucosal lining of the colon producing marble sized pockets. Diverticulitis is an infection of these sac-like pockets as a result of micro-perforations. Diverticulitis occurs in only 10-25% of people with diverticulosis.

Controversy exists as to whether diverticulosis is symptomatic, but diverticulitis presents with left lower abdominal and/or pelvic pain, tenderness and bloody stools. In addition to the pain, the patient might experience bowel distention, bowel changes including alternating hard stools and diarrhea, mucus in the stools, rectal bleeding, nausea/vomiting and fever. Diverticulosis is the major reason for lower intestinal bleeding. A telltale sign is the rapid onset of left lower abdominal pain, fever and changes in bowel function.

The diverticula (pouches) can occur anywhere in the digestive system from the esophagus through the large intestine but is most often in the large intestine. Milder cases are treated with rest, diet changes and antibiotic but severe cases may require surgery for bowel resection. It is unclear as to why these occur but theories include increased colon pressure results in a breakdown of the diverticula and trapped matter leads to infection or a decrease in blood supply, which leads to inflammation.

Risk factors include aging >40 years old, obesity, lack of exercise and too little fiber.

Complications that can arise include: peritonitis, scarring in the intestine causing blockage, abscess, rectal bleeding, and fistula

Previously, diet restrictions were advised including avoidance of nuts, seeds, popcorn and corn as these were thought to be trapped in the pouches. Research has not supported diet as a cause of inflammation.

Diverticular disease may present as a psoas/left oblique spasm/strain radiating into the left lower back if it is slow in onset over a couple of weeks. Aggressive, rapid onset of pain will not mimic a musculoskeletal issue. With assessment, it does not demonstrate a cause effect relationship with a muscular pathology.

Irritable Bowel Syndrome (IBS)

IBS has been called the “common cold of the stomach”. It is a “functional disorder” related to abnormal peristalsis of the large and small intestine due to abnormal muscle contraction. This should not be mistaken with inflammatory bowel disease. People with IBS have been found to have a lower threshold of visceral pain with c/o bloating and distention at lower volumes of food in the intestine than controls. They experience unpleasant/inappropriate sensory experiences without any identifiable abnormality in the bowel. It rarely progresses and is never fatal.

Other descriptive names for this condition are spastic colon, irritable colon, nervous indigestion and spastic colitis.

It is the most common GI disorder and is responsible for approximately 50% of subspecialty referrals in Western society. It is linked to psychosocial factors. People with the most severe symptoms and those who do not respond to treatment are suspected to have some type of physical, mental, or sexual abuse present. IBS is most common in early adult females and is associated with dysmenorrhea (painful cramping with menstruation).

Primary symptoms occur with stress, smoking, eating and alcohol abuse. Normal bowel peristalsis is disrupted which creates an obstruction to the natural flow of stool/gas. It leads to pressure building up and pain and spasm follow.

Signs and symptoms: These are variable and intermittent. There does not seem to be a specific telltale sign. Nausea, vomiting, foul breath, sour stomach, possible white mucus in the stool, flatulence, cramps, abdominal bloating, constipation and/or diarrhea. Pain is steady or intermittent with dull deep discomfort with sharp cramps after eating in the morning. The typical pain pattern is in left LQ (lower quadrant) with constipation and diarrhea. Symptoms come and go without reason and usually are off during sleep, and relieved by BM.

Gastroesophageal Reflux Disease (GERD)

GERD is an array of problems related to the backward movement of stomach acids and other stomach contents such as pepsin and bile into the esophagus, a phenomenon called acid reflux. This produces symptoms that point to tissue injury in the esophagus and sometimes the respiratory tract. It is usually caused by intermittent relaxation of the lower esophageal sphincter.

Symptoms can include heartburn, chest pain, dysphagia, sore throat, and a sense of a lump in the throat. Symptoms are sometimes mistaken for a hear attack. Sleep disturbance from night time coughing and heartburn can lead to fatigue and decreased daytime functioning.

GERD should be treated in order to prevent a chronic condition from occurring with more serious consequences. Symptoms may be mild at first, but have a cumulative effect with increasing symptoms after the age of 40. Chronic GERD is a major risk factor for adenocarcinoma, an increasingly common cancer in white males in the United States.

Some patients may need surgical treatment, but most can be treated with some simple changes in eating pattern, positioning and medications. Drug treatment includes antacids; H2 receptor blockers and proton pump inhibitors (PPIs). Antacids (Mylanta, Tums, Maalox and Rolaids) do not reduce the acid, but merely neutralize it. H2 receptor blockers (Tagamet, Zantac and Pepcid) reduce the amount of stomach acid produced by the stomach. PPIs (Prilosec, Prevacid and Nexium) actually inhibit acid formation rather than just neutralize it.

Appendicitis

Appendicitis is an inflammation of the vermiform appendix that occurs most commonly in adolescents and young adults. It is usually requires surgery. When the appendix becomes obstructed, inflamed and infected, rupture may occur, leading to peritonitis.

The main symptoms are pain, fever, nausea and vomiting. Pain starts usually in the umbilical area, shooting to right lower quadrant of the abdomen. At times pain in the groin and/or testicular pain may be the only complaint, especially in young healthy men. Pain starts in waves and becomes steady as symptoms worsen, to the point where the patient adopts a flexed posture to alleviate complaints.

Signs: abdominal muscular rigidity, positive McBurney’s point, rebound tenderness (peritonitis), positive hop test, nausea, vomiting, anorexia, dysuria, low grade fever and coated tongue and bad breath

McBurneys point is located by palpation with the patient in fully supine position. Palpate for tenderness at the right side of the abdomen, halfway between the ASIS and the umbilicus

Pancreatic Carcinoma

Pancreatic carcinoma is the fourth most common cause of death from cancer for men and the fifth most common for women. About 70% of pancreatic cancers arise in the head of the gland and 20-30% in the body and tail

Initially symptoms are non-specific and vague, which contributes to the delay in diagnosis and high mortality rate. Symptoms do not normally occur until the tumor grows large enough to cause abdominal pressure/pain or obstructs nearby bile ducts.

Most common symptoms:

Anorexia and weight loss

Loss of appetite

Epigastric/upper abdominal pain which and radiate to the back

Pain worse after person eats or lays down

Sitting up and leaning forward may cause relief (this usually indicates the lesion has spread beyond the pancreas, and at this point may be inoperable.)

Light colored stool

Constipation

Nausea and vomiting

Vomiting

Weakness

No specific “tell tale sign” is distinguished, but the sitting and leaning forward relieving pain seems significant.

The patient may present with weakness, low back pain and thoracic pain around the T5-T9 area or L shoulder pain. The epigastric pain is often vague and diffuse.

Ulcerative Colitis

Ulcerative Colitis (UC), like Crohn’s Disease, is a type of inflammatory bowel disease (IBD) which causes inflammation and ulceration. Unlike Crohn’s, which can affect any part of the digestive tract, UC by definition only affects the large intestine (colon) and rectum. There are several types of UC, but the region most often affected is the left colon, which is also known as “left-sided colitis”

The primary symptoms include rectal bleeding and frequent diarrhea as often as 20 or more times per day. Additional symptoms include abdominal cramping, nausea, vomiting, anorexia, weight loss, and decreased serum potassium; anemia can be a problem if bleeding is significant

Common referral patterns for UC that may mimic musculoskeletal pain include shoulder, back, or groin regions.

Pancreatitis

Pancreatitis is an inflammation of the pancreas that may result in autodigestion f the pancreas by its own enzymes. Acute pancreatitis can arise from a variety of etiologic factors, but in most instances the specific cause is unknown. Chronic pancreatitis is caused by long standing alcohol abuse in more than 90% of adult cases.

The clinical course for acute pancreatitis follows a self limiting pattern in most cases. Abdominal pain begins abruptly in the midepigastrium , increases in intensity for several hours and can last from days to more than one week. There can be nausea, vomiting, fever, sweating, malaise and weakness.

Symptoms associated with chronic pancreatitis include persistent or recurrent episodes of epigastric and left upper quadrant pain with referral to the upper left lumbar region. Other symptoms include nausea and vomiting, constipation, weight loss and flatulence

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Abdominal examination

Essential conditions for a good abdominal examination include:

• Good light

• Relaxed patient

• Full exposure of abdomen

Palpation

Before palpation ask the patient to point to any areas of pain and examine painful or tender areas last. Light palpation is especially helpful in identifying muscular resistance, abdominal tenderness, and some superficial organs and masses. It also helps to relax the patient. Keep your hand and forearm on a horizontal plane, with fingers together and flat on the abdominal surface. Palpate with a light, gentle, dipping motion. Identify any superficial organs or masses, any area of tenderness or increased resistance to palpation.

Deep palpation is usually required to delineate abdominal masses. Again using the palmar surfaces of your fingers, feel in all 4 quadrants. Identify any masses and note their location, size shape, consistency, tenderness, and pulsations.

The liver

To ascertain the position of the liver, you can alternate percussion with palpation.

Percussion

Percussion is useful for orientation to the abdomen and also for measuring the liver. Measure the vertical span or height, of liver dullness in the right midclavicular line. Starting at a level below the umbilicus, lightly percuss upward toward the liver. Ascertain the lower border of liver dullness in the midclavicular line. Next, identify the upper border in the midclavicular line. Lightly percuss from lung resonance down to the liver dullness.

Now measure in centimeters the vertical span, or height, of liver dullness. In the mid sternal line it should be 4-8 cm. In the right midclavicular line it should be 6-12 cm.

They are generally greater in men than in women, in tall people than in short.

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Palpation

Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs. By pressing your left hand forward, the patient’s liver is felt in front more easily. Then place your right hand on the patient’s right abdomen lateral to the rectus muscle, with your fingertips well below the lower border of liver dullness. Press gently in and up. The liver below is palpable about 4 cm below the right costal margin in the midclavicular line. If palpable at all, the edge of the normal liver is soft, sharp and regular. The normal liver may be slightly tender. The liver may also be felt by the hooking technique. Stand to the right of the patient’s chest. Place both hands, side by side, on the abdomen below the border of liver dullness. Press in with your fingers and up toward the costal margin. Ask the patient to take a deep breath. Firmness and hardness of the liver, bluntness or rounding of its edge and irregularity of the contour suggest an abnormality of the liver.

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The spleen

With your left hand reach over and around the patient to support and press forward the lower rib cage. With your right hand below the left costal margin, press in toward the spleen. Begin palpation low enough to be sure you’re below a possibly enlarged spleen. Ask the patient to take a deep breath. Try to feel the tip or edge of the spleen as it comes down to meet your fingertips. Tenderness suggests inflammation, as in hepatitis.

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The kidneys

For the right kidney. Stand the patients right side. Place your left hand just below and parallel to the 12th rib, with your fingertips just reaching the costovertebral angle. Lift, trying to displace the kidney anteriorly. Place your right hand gently in the right upper quadrant, lateral and parallel to the rectus muscle. Ask the patient to take a deep breath. At the peak of inhalation, press your right hand firmly and deeply in the right upper quadrant, just below the costal margin, and try to “capture” the kidney between your 2 hands. A normal kidney may or may not be slightly tender. The lower pole of the kidney is rounded. A normal right kidney may be palpable, especially in thin, well-relaxed women. A normal left kidney is rarely palpable.

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palpation right kidney palpation left kidney

Kidney tenderness may be noted during abdominal palpation, but search for it also in each costovertebral angle. Pressure from your fingertips may be enough to reveal tenderness here; if not, use indirect fist percussion (Murphy’s percussion). Place one hand over the costovertebral angle and strike it with the ulnar surface of the other your fist. Use force sufficient to cause a perceptible but painless jar or thus in a normal person. Pain with pressure or with fist percussion in the costovertebral angle suggests kidney infection.

Assessment for peritoneal irritation

Abdominal pain and tenderness, especially when associated with muscular spasm, suggest inflammation of the parietal peritoneum. Localize it as accurately as possible. First, even before palpation, ask the patient to cough and determine where the cough produced pain.

Thus guided, palpate gently with one finger to map the tender area. Pain produced by light percussion has similar localizing value. This might be all you need to establish an area of peritoneal inflammation

If not, look for rebound tenderness. Press your fingers in firmly and slowly, and then quickly withdraw them. Watch and listen to the patient for signs of pain. Ask th e patient to compare which hurt more: the pressing or the letting go, and to show you exactly where it hurt. Pain induced or increased by quick withdrawal constitutes rebound tenderness. It results from movement of inflamed peritoneum.

To assess possible appendicitis

Ask the patient to point to where the pain began and where it is now. Ask the patient to cough. Determine whether and where pain results. The pain of appendicitis classically begins near the umbilicus and then shifts to the right lower quadrant, where coughing increases it.

Search for localized tenderness. Localized tenderness anywhere in the right lower quadrant, even in the right flank, may increase appendicitis.

Feel for muscular rigidity. Early voluntary guarding may be replaced by involuntary rigidity.

Acute diverticulitis most often involves the sigmoid colon and then resembles a left sided appendicitis.

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To asses possible ascites (accumulation of serous fluid in the spaces between tissues and organs in the cavity of the abdomen)

A protuberant abdomen with bulging flanks suggests the possibility of ascetic fluid. Because ascetic fluid characteristically sinks with gravity while gas filled loops of bowel float to the top, percussion gives a dull note in the dependent areas of the abdomen. Test for shifting dullness. Ascitic fluid seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. The umbilicus may protrude. Turn the patient on 1 side to detect the shift in position of the fluid level. Percuss and mark the borders again. In a patient without ascites, the borders between tympani and dullness usually stay pretty constant.

Test for a fluid wave: tap one flank sharply with your fingertips and feel on the opposite flank for an impulse transmitted through the fluid.

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Literature

Goodman, CC, Snyder, TE. Differential diagnosis for Physical Therapists. Screening for referral. 4th Edition. Saunders Elsevier 2007

Boissonnault, WG: Primary Care for the Physical therapist: Examination and Triage. Elsevier 2005

Bates, Barbara. A guide to physical examination and history taking. 5th edition. J.B. Lippincott 1991

Deyo RA, Diehl AK: Cancer as a cause of low back pain: frequency, clinical presentation, and diagnostic strategies, J Gen Intern Med 1988

Aspinall, W. Clinical testing for the craniovertebral hypermobility syndrome. Journal of Orthopedic and Sports Physical Therapy, 1990

Childs, J. et al. Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision making in the presence of uncertainty. JOSPT Vol. 5, No. 5, 2005

Childs, J. et al. Physical Therapy for the cervical spine and TMJ.

APTA Home Study Course 13.3.1, 2002

DiFabio, R. Manipulation of the cervical spine: risks and benefits. Physical Therapy Vol. 79, No. 1, 1999

Grant R . Premanipulative testing of the cervical spine - reappraisal and update. Physical Therapy of the Cervical and Thoracic Spine, 3rd edition. Elsevier 2002

Grieve’s Modern Manual Therapy, 3rd Edition. Boyling, J and Jull, G. editors. Elsevier 2004

Haldeman S, Kohlbeck FJ, McGregor M: Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation, Spine 24(8): 785, 1999

Written exam

1. Referred pain from the kidney is located in:

A. Groin and upper abdominal region

B. Ipsilateral L spine, lower abdominal and upper abdominal region

C. Right middle and lower thoracic spine

D. Scapula, middle and lower thoracic spine

2. According to Deyo and Diehl, what factors raise the index of suspicion that the patient’s low back pain is caused by a tumor?

A. Long term use of corticosteroids, bowel an bladder problems, weakness of the legs, recent fever

B. Diagnosed with immunosuppressive disorder

C. Renal failure, chronic GI disorders

D. Over 50 years of age, had a history of cancer, had experienced unexplained weight loss, or had failed to improve with conservative therapy.

3. Besides trauma, what other non-traumatic conditions are associated with avascular necrosis?

A. Paget’s disease

B. Family history of avascular necrosis

C. Corticosteroid use and sickle cell disease

D. Immunosuppressive disorder

4. True or false: up to 50% of patients with deep vein thrombosis (DVT) will not experience calf pain.

A. True

B. False

5. What is typically the precipitating factor to developing cellulitis?

A. Recent skin ulceration or abrasion

B. Fever

C. Malaise and weakness

D. History of recent joint surgery

6. True or false: septic arthritis is an infection of the skin and the underlying tissues following a bacterial contamination of a wound

A. True

B. False

7. One of three patients diagnosed with Myocardial infarction (MI) does not have chest pain on initial presentation to the ER. Instead of pain as the primary manifestation, what other symptoms can be indicative of a MI?

A. Sharp shooting pain with coughing

B. Pain produced with rib and T spine movement

C. Nausea and dyspnea

D. Distended neck veins

8. Which kind of ulcer causes pain that is relieved with eating?

A. Gastric ulcer

B. Duodenal ulcer

C. Esophageal ulcer

9. What percentage of the population is expected to have kidney stones during their lifetime?

A. 50%

B. Less than 3%

C. 20-25%

D. 5-15%

10. Facial lip paresthesiae, reproduced by active or passive movement, is a symptom of:

A. Vertebral/basilar artery insufficiency

B. Cervical cord compression

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