MODULE 2: PRINCIPLES OF DIFFERENTIAL DIAGNOSIS: SECTION 1 ...



MODULE 2: DIFFERENTIAL DIAGNOSIS: 3

Introduction 3

Part 1 General Principles: 4

Pre-Study Questions 4

Is the term "pain disorder" a valid diagnosis? 10

The management of chronic neck pain in general practice. A retrospective study. 11

Musculoskeletal chronic pain in general practice. Studies of health care utilisation in comparison with pain prevalence. 12

Nerve trunk pain: physical diagnosis and treatment. 12

Post-Study Questions 15

PART 2: OBSERVATION 16

Pre-Study Questions 16

Abstracts 19

Clin Biomech (Bristol, Avon) 1995 Sep;10(6):318-322    (ISSN: 0268-0033) 19

URLs 20

Congenital Scoliosis Robert b. Winter, M.D. 20

20

Scoliosis is a lateral curvature of the spine. Congenital Scoliosis is therefore a lateral curvature of the spine due to congenital anomalies of the vertebrae. These are usually easily seen on standard x-rays, but on rare occasions are discovered only on MRI or at the time of surgery. 20

Adolescent Idiopathic Scoliosis:Prevalence, Natural History, Treatment Indications Stuart L. Weinstein, M.D. 20

Congenital anomalies: Structural defects present at birth. Merck Manual. 20

Klippel-Feil Syndrome. National Institute of Neurological Disorders and Strokes 21

Correct Posture Aikido Kokikai of Rochester 21

Correcting Faulty Posture Advanced Chiropractic, Ottawa 21

Integrating neck posture and vision at VDT workstations Dennis R. Ankrum 22

Absolute Beginner’s Guide to the Alexander Technique. 22

The Feldenkrais Method Shai Silberbusch 22

Post-Study Questions 24

PART 3: SUBJECTIVE EXAMINATION 25

Subjective Examination 25

Materials 25

Pre-Study Questions 25

ARTICLES 28

The stages of pain processing across the adult lifespan. Riley JL 3rd : 28

Abstracts 31

A study on relative contributions of the history, physical examination and investigations in making medical diagnosis. 31

Occupational low back pain: history and physical examination. 32

Where are the history and the physical? 32

Spine 1996 Dec 15;21(24 Suppl):10S-18S   (ISSN: 0362-2436) 32

Post-Study Questions 35

Part 4: Objective Examination 36

Pre-Study Questions 36

Abstracts 38

Intertester reliability of the cyriax evaluation in assessing patients with shoulder pain. 38

Cyriax Re-examined 38

An examination of the selective tissue tension scheme, with evidence for the concept of a capsular pattern of the knee. 42

Prognostic values of physical examination findings in patients with chronic low back pain treated conservatively: A systematic literature review [In Process Citation] 43

Construct validity of Cyriax's selective tension examination: association of end-feels with pain at the knee and shoulder. 43

Differential diagnosis of the hip vs. lumbar spine: five case reports. 44

Assessment of exercise-induced minor muscle lesions: the accuracy of Cyriax's diagnosis by selective tension paradigm. 45

Validity of Cyriax's concept capsular pattern for the diagnosis of osteoarthritis of hip and/or knee. 46

Measuring passive cervical motion: a study of reliability. 46

Interexaminer reliability in physical examination of the cervical spine. 47

Classification of shoulder complaints in general practice by means of cluster analysis. 47

Instrumented measurement of glenohumeral joint laxity and its relationship to passive range of motion and generalized joint laxity. 48

Movement diagram and "end-feel" reliability when measuring passive lateral rotation of the shoulder in patients with shoulder pathology. 49

The interexaminer reliability of measuring passive cervical range of motion, revisited. 49

Reliability of physical examination items used for classification of patients with low back pain. 50

Post-Study Questions 52

MODULE 2: DIFFERENTIAL DIAGNOSIS:

Introduction

In the following pages of this text of Module 2 you will find pre and post study tests. You should answer the pre-study test before studying (love to state the obvious). This will give you an indication of your current level of knowledge, don’t get depressed. After studying all of the distributed materials for this module answer the questions again and hopefully you will get a nice surprise and an idea of how much progress you have made. The post-study questions are more a test of your ability to use the information while the pre-study questions are recall and recognition indications. Both are important.

Also in the following pages are some abstracts and web addresses. The abstracts are very much background unless you have a real need to go further I would not access the full text as a preparation for the examination. You will not be questioned in that much detail. Similarly, the URLs are a nice resource for a deeper understanding of a particular topic but again do not study them in great depth but go to them, read and print them out. If you want more depth, there is no end to how deep you can go on the web.

I would suggest that you take an initial and fairly shallow look at the PowerPoint presentation before doing anything else and then study this text and the textbook on differential diagnosis. Having done that go back to the PowerPoint presentations and then the video tapes 1A and B and then answer the questions.

Email me if you have problems.

Part 1 General Principles:

Textbook: Orthopedic Differential Diagnosis in Physical Therapy. Preface and Introduction and Pages 1-5

Manual: Manual Therapy: Differential diagnosis

Review the Video: Volume 1 (A and B)

Pre-Study Questions

Answer these question as best you can before beginning this Part and then re-answer them when ALL materials are finished. This will give you an idea of the degree of improvement in you knowledge.

1. List 10 conditions that would be considered inappropriate for physiotherapy

2. List 7 clinical indications that would suggest serious pathology and require referral back to a physician

3. Which general health tests should you do if you are seeing a patient on primary contact status

4. List 10 findings about general health from the subjective examination that would concern you enough to send the patient to a physician

5. List 10 findings about general health from the observation examination that would concern you enough to send the patient to a physician

6. List 10 findings from the general health objective examination that would concern you enough to send the patient to a physician

7. List 6 cardinal signs that would cause you to immediately send the patient to physician

8. List 6 non-cardinal signs/symptoms that would cause you to act very cautiously during the remainder of the examination

9. What is the significance of true constant pain (that is pain that you cannot change at all with physical stress)

10. What is the significance of lancinating pain

11. What is the forbidden area

12. How would the patient describe urinary retention

13. Discuss the sequence of the differential diagnostic examination

14. Define “special test”

15. Contractile tests test what tissues (list 4)

16. Active tests test what tissues (list 4)

17. Passive tests test what tissues (list 4)

18. Are the dural tests neurological or passive tests

URLs

Approaches To Differential Diagnosis In Musculoskeletal Imaging

Michael L. Richardson, M.D.



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The Universal Differential Diagnosis

If you are reading this book, chances are that you are fairly smart and already know lots of useful medical stuff. In becoming a radiology resident, you have clawed your way to the top of the medical food chain (in my opinion), and are a force to be reckoned with. Even so, when you are shown cases in conferences, you probably still stumble around a bit coming up with any kind of plausible differential diagnosis. If you don't do this in case conferences, it is probably because:

1. you have seen a case of that disorder before.

2. your mother had that disorder.

3. you read this syllabus.

4. you are a Vulcan, and so inhumanly smart and organized that you don't need this syllabus. If so, go away, and pass this syllabus on to someone who really needs it.

So, how can it be that someone as smart and knowledgeable as you undoubtedly are still blows cases in teaching conference? Generally, it's because under stress, you have trouble accessing the information that's already in your head. Chances are that you already know many pertinent facts about most of the disorders in the differential for the cases that you miss -- it's just that you can't pull them out in an organized fashion when you're on the spot.

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Diagnosis of Disk Disease Georges Y. El-Khoury, M.D.



In the evaluation of disk disease by MRI or CT it is best if the term "disk herniation" is avoided. Jensen et al (1) consider the term "herniation" as being too generic for clinical relevance; "herniation" has been used to describe a wide spectrum of abnormalities involving the disk. On the other hand, using a well-defined morphologic nomenclature is more useful and may correlate better with symptoms. The following terms have been proposed by Jensen et al (1):

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ABSTRACTS

|Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care.|

Med Care 2000 Apr;38(4):383-91   (ISSN: 0025-7079)

Solomon DH; Schaffer JL; Katz JN; Horsky J; Burdick E; Nadler E; Bates DW [Find other articles with these Authors]

Division of Rheumatology, Immunology, and Allergy, Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

BACKGROUND: The medical record serves as an important source of information regarding the care process, but few studies have examined whether thoroughness of documentation is associated with outcomes. OBJECTIVE: The objectives of this study were to analyze the initial visit note for 513 patients presenting with acute musculoskeletal pain, compare thoroughness of documentation by physician specialty, and determine whether thoroughness of documentation was associated with clinical improvement or patient satisfaction. METHODS: A structured medical record abstraction was performed to examine whether treating physicians documented key historical and physical exam findings. Satisfaction with care, symptom relief, and functional improvement were assessed after 3 months with validated survey instruments. RESULTS: In the initial visit note, 43+/-16% of selected historical findings and 28+/-17% of physical examination findings were documented. Orthopedic surgeons documented 2 to 4 more historical and physical examination items (P ................
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