Differential Diagnosis

For

Physical Therapists
Introduction to screening for
referral in Physical Therapy
Screening

It is a method for detecting disease or

body dysfunction before an
individual would normally seek
medical care.
Screening for referral in Physical Therapy

 Itis the Therapist’s responsibility is to have an appropriate

patient for physical therapy

 Inorder to be Cost effective…we must determine NMS

dysfunction…Treat specifically

 PT must be able to identify sign and symptoms of systemic

disease that can mimic neuromuscular or musculoskeletal
dysfunction…shoulder and back pain
 Cancer is major part of medical screening
Reason for Medical Disease Screening

 Direct access

 Quicker & sicker

 Signed prescription

 Medical specialization

 Progression of time & disease

 Patient /client disclosure

 Presence of one or more yellow or red flags

DIRECT ACCESS
Direct access is the right of the public to
obtain examination , evaluation, and
intervention from a licensed physical
therapist with out previous examination
by, or referral from, a physician , or other
practitioner.
Signed Prescription
clients may obtain a signed prescription
for physical therapy from their primary
care physician or other health care
provider, based on similar past complaints
of musculoskeletal symptoms, without
actually seeing the physician or being
examined by the physician.
F o l l o w - U p Questions

Always ask a client who provides a

signed prescription:
• Did you actually see the physician
(chiropractor,dentist, nurse practitioner,
physician assistant)?
Did the doctor (dentist) examine you?
Case 1-1
 A patient visited physiotherapy clinic with signed prescription
of physician without detailed examination. Actually the patient
had telephonic conversation with physician and described the
same previous pain history and recovery with physiotherapy.

 The patient presented with hip and bilateral leg pain , during
examination it is observed that there is swelling in both legs,
chest pain and low blood pressure. There is also history of
heart disease.

 What would be the next step of therapist?

 What treatment options?
 What is the most appropriate way to handle this situation?
Suggestions:
Good idea is to call
Best idea is to write a brief but complete
report.
Highlight significant findings: B/L edema,
low BP that day…
Open ended comment like “please advice”
or what do u think
Some physician ask for your opinion.
Medical Specialization
With increasing specialization of
medicine, client evaluated by Medical
specialists who does not immediately
recognize underlying systemic disease.

or the specialist may assume that the

referring primary care physician has ruled
out other causes
Case
Progression of Time and Disease
In some cases, early signs and symptoms
of systemic disease may be difficult or
impossible to recognize until the disease
has progressed enough to create
distressing or noticeable symptoms

Case 1-3
Quicker and Sicker
"Quicker" refers to how health care
delivery has changed in the last 10 years
to combat the rising costs of health care.
The therapist must be alert to red flags of
systemic disease at all times but
especially in those clients who have been
given early release from the hospital or
transition unit.
 Cont…
"Sicker" refers to the fact that patient/clients
in acute care, rehabilitation, or
outpatient/client setting with any orthopedic
or neurologic problems may have a past
medical history of cancer or a current
personal history of diabetes, liver disease,
thyroid condition, peptic ulcer, and/or other
conditions or diseases.

So, the need to view the whole patient and

not just the body part in question.
Patient/Client Disclosure

Finally, sometimes p a t i e n t / c l i e n t s
tell the therapist things about their current
health and social h i s t o r y
u n k n o w n or u n r e p o r t e d to the
physician.
Yellow or Red Flags
A yellow flag is a cautionary or warning
symptom that signals " slow down" and
think about the need for screening.

A red-flag symptom requires immediate

attention , either to pursue further
screening questions and/or tests , or to
make an appropriate referral .
 RED flags
 Factors that require immediate medical attention
 - Blood in sputum
 - LOC or altered mental status
 - Neurological deficit not explained by
monoradiculopathy
 - Numbness or paresthesia in the perianal region (aka
saddle anesthesia)
 - Pathological changes in bowel and bladder
 - Patterns of symptoms not compatible with
mechanical pain (on physical exam)
 - Progressive neurological deficit

Yellow Flags
Depression

o Screened for within general health questionnaire and

followed-up with physical therapist if considered
positive
 “During the past month, have you often been
bothered by feeling down,
depressed, or hopeless?”
 “During the past month, have you often been
bothered by little interest or
pleasure in doing things?”
- Anxiety
Past Medical History

• Personal or family history of cancer

• Recent (last 6 weeks) infection
 Recent history of trauma such as motor
vehicle accident or fall (fracture; any age)
or minor trauma in older adult with
osteopenia/osteoporosis
• History of immunosuppression (e.g.,
steroids, organ transplant, HIV)
• History of injection drug use (infection
Risk Factors
Substance abuse
Tobacco use
Sedentary lifestyle
Age
Obesity
Gender
Domestic violence
 Clinical Presentation
No known cause/insidious onset
Cyclical presentation:Better/worse/better
Weight loss/gain within 10-21days
Unrelieved by rest/positional change
Unrelieved by PT intervention
Persist longer than expected
Growing mass
Unable to alter symptoms during
examination
Cont…
Postmenopausal vaginal bleeding
Bilateral symptoms:
◦ Edema
◦ Numbness/tingling
◦ Clubbing
◦ Skin rash
Change in muscle tone or ROM for individuals
with neurological symptoms (CP, SCI, TBI, MS)
Pain pattern
Back or shoulder pain
Pain with full and painless ROM
Night pain
Constant and intense
Poorly localized
Vascular/ neurological/ musculoskeletal/
emotional
Associated Signs and
Symptoms
Recent report of confusion (or
increased confusion
Presence of constitutional symptoms
Proximal muscle weakness, especially if
accompanied by change in DTRs
Joint pain with skin rashes, nodules
Constitutional Symptoms
Fever
Diaphoresis
Night sweats
Nausea
Vomiting
Diarrhea
Pallor
Dizziness/syncope (fainting)
Fatigue
Weight loss
Important Question to end

Are there any symptom anywhere else in

your body that may not seem related to
your current problem??
Physical Therapist Role in
Disease Prevention
 Primary Prevention:
Stopping the processes) that lead to the development of diseases),
illness(es), and other pathologic health conditions through
education, risk-factor reduction, and general health promotion

 Secondary Prevention:
Early detection of disease(es), illnesses), and other pathologic
health conditions through regular screening; this does not prevent
the condition but may decrease duration and/or severity of disease
and thereby improve the outcome, including improved quality of
life

 Tertiary Prevention:
Providing ways to limit the degree of disability while improving
function in patients/clients with chronic and/or irreversible diseases
 Definitions:
• Diagnose: is to distinguish, to identify a
disease by an investigation of the signs &
symptoms.

• Diagnosis: is the process of evaluating the

patient’s health, as well as the resulting
opinions formulated by the clinician.
 Diagnosis ???

A label encompassing a cluster of sign &

symptoms commonly associated with a
disorder or syndrome or category of
impairment ,functional limitation or
disability.
Definition of Physical
Therapy Diagnosis
Medical diagnosis
Based on the pathologic or
pathophysiologic state at the cellular level.

Physical therapy diagnosis

Based on Model of disablement :
impairment ,functional limitation or
disability.
 Differential Diagnosis

Definition:

• It is the determination of which of two or

more diseases with similar signs &
symptoms is the one that the patient is
suffering.
Differential diagnosis

A process of identifying all of the possible

diagnoses that could be connected to the signs,
symptoms, and lab findings, and then ruling
out diagnoses until a final determination can
be made.

List of diaganosis
 Concepts of Differential Diagnosis

 The Diagnostic Sequence

i. Categorization of the Abnormality by Primary

Manifestation.
ii. Listing of Secondary Clinical Features.
iii. Listing of Conditions Known to Cause the Primary
Manifestation.
iv. Elimination of Unlikely Causes.
v. Ranking of Possible Causes by Probability.
Purpose of the Diagnosis
Treat as specifically as possible by
determining the most appropriate
intervention strategy for each patient /
client

Recognize the need for a medical referral

 DIAGNOSIS BY THE
PHYSICAL THERAPIST
It is the policy of the (APTA) that PT shall
establish a diagnosis for each patient.
PTs use diagnostic labels that i d e n tify the
impact of a condition on function at the level
of the system (especially the movement
system) and the level of the whole person.
The PT is qualified to make a diagnosis
regarding primary NMS conditions though
we must do so in accordance with the state
practice act.
How do you dignose your patients?
Guide to physical therapy practice
Autonomous Practice

" self - governing ; "not controlled by

others .
Autonomous practice is defined as
independent, self - determining professional
judgment and action.
Autonomous practice for the physical
therapist does not mean practice
independent of collaborative and collegial
communication with other health care team
members
Attributes of A u t o n o m o u s Practice

Direct and unrestricted access: The physical therapist has the professional
capacity and ability to provide to all individuals the physical therapy services
they choose without legal, regulatory, or payer restrictions

Professional ability to refer to other health care providers:

The physical therapist has the professional capability and ability to refer
to others in the health care system for identified or possible medical needs
beyond the scope of physical therapist practice

Professional ability to refer to other professionals:

The physical therapist has the professional capability and ability to refer to
other professionals for identified or patient^client needs beyond the scope of
physical therapy services

Professional ability to refer for diagnostic tests:

The physical therapist has the professional capability and ability to refer for
diagnostic tests that would clarify the patient/client situation and enhance the
provision of physical therapy services
Decision making process

 Past medical history

 Risk factor assessment

 Clinical presentation

 Associated sign and symptoms of systemic diseases

 Review of systems

 Documentation
Systems Review Versus
Review of Systems
briefor limited exam of the anatomical
and physiological status of the CV
/PULMO , Integ,MSK and NM systems.

The therapist conducts a Review of

Systems in the screening process by
categorizing all of the complaints and
associated signs and symptoms.
Case referral
Referral. A 32-year-old female university student was referred for
physical therapy through the student health service 2 weeks ago.
The physician's referral reads: "Possible right oblique abdominis
tear/possible right iliopsoas tear.
" A faculty member screened this woman initially, and the diagnosis
was confirmed as being a right oblique abdominal strain.

History. Two months ago, while the client was running her third mile,
she felt "severe pain" in the right side of her stomach. She felt
immediate nausea and had abdominal distension.

She cannot relieve the pain by changing the position of her leg.
Currently, she still cannot run without pain.
Presenting Symptoms. Pain increases during sit-ups,
walking fast, reaching, turning, and bending. Pain is
eased by heat and is reduced by activity. Pain in the
morning versus evening depends on body position. Once
the pain starts, it is intermittent and aches.

The client describes the pain as being severe, depending

on her body position. She is currently taking aspirin
when necessary.
 SAMPLE LETTER
John Smith, M.D.
University of Montana Heolth Service
Eddy Street
Missoula, MT59812
Re: Jone Doe

Dear Dr. Smith,

Your client, Jane Doe, was evaluated in our clinic on 5 / 2 / 0 6 with the
following pertinent findings:

Subjective. She has severe pain in the right lower abdominal quadrant
associated with nausea and abdominal distension Although the onset of
symptoms started while the client was running, she denies any
precipitating trauma. She describes the course of symptoms as having
begun 2 months ago with temporary resolution and now with exacerbation
of earlier symptoms. Additionally, she reports chronic fatigue and frequent
Objective. Presenting pain is reproduced by resisted hip or
trunk flexion with accompanying tenderness/tightness on
palpation of the right iliopsoas muscle (compared with the
left iliopsoas muscle). There are no implicating neurologic
signs or symptoms,

Assessment. A musculoskeletal screening examination is

consistent with your diagnosis of a possible iliopsoas or
abdominal oblique tear.
Jane appears to have a combination of musculoskeletal and
systemic symptoms, such as those outlined earlier. Of
particular concern are the symptoms of fatigue, night sweats,
abdominal distension, nausea, repeated episodes of
exacerbation and remission, and severe quality of pain and
location (right lower abdominal quadrant].
These symptoms appear to be of a systemic nature rather than
caused by a musculoskeletal lesion.
Recommendations. I suggest that the client return to you for further
medical follow-up to rule out any systemic involvement before the
initiation of physical therapy services. I am concerned that my
proposed intervention of ultrasound, soft tissue mobilization, and
stretching may aggravate an underlying disease process.

I will contact you directly by telephone by the end of the week to discuss
these findings and to answer any questions that you may have.

Thank you for this interesting referral.

Sincerely,

Catherine C. Goodman, M.B.A., P.T.

R e s u l t . This client returned to the physician, who then ordered

laboratory tests. After an acute recurrence of the symptoms described
earlier, she had exploratory surgery. A diagnosis of a ruptured appendix
and peritonitis was determined at surgery. In retrospect, the proposed
ultrasound and soft tissue mobilization would have been
???
The primary purpose of a diagnosis by the
physical therapist is ????

Direct access is the only reason physical

therapists must screen for systemic disease ??

A patient/client gives you a written

prescription from a physician, chiropractor,
or dentist. The first screening question to
ask is??