Download Differential Diagnosis for Physical Therapists: Screening for Referral 4th Edition (Differential Diagnosis In Physical Therapy) PDF

TitleDifferential Diagnosis for Physical Therapists: Screening for Referral 4th Edition (Differential Diagnosis In Physical Therapy)
File Size23.3 MB
Total Pages932
Table of Contents
                            Front Cover
Back Cover
Inside Front Cover: Tables
Front Page
Title Page
Section I: Introduction to the Screening Process
Chapter 1: Introduction to Screening for Referral in Physical Therapy
Chapter 2: Introduction to the Interviewing Process
Chapter 3: Pain Types and Viscerogenic Pain Patterns
Chapter 4: Physical Assessment As A Screening Tool
Section II: Viscerogenic Causes of Neuromusculoskeletal Pain and Dysfunction
Chapter 5: Screening for Hematologic Disease
Chapter 6: Screening for Cardiovascular Disease
Chapter 7: Screening for Pulmonary Disease
Chapter 8: Screening for Gastrointestinal Disease
Chapter 9: Screening for Hepatic and Biliary Disease
Chapter 10: Screening for Urogenital Disease
Chapter 11: Screening for Endocrine and Metabolic Disease
Chapter 12: Screening for Immunologic Disease
Chapter 13: Screening for Cancer
Section III: Systemic Origins of Neuromuscular or Musculoskeletal Pain and Dysfunction
Chapter 14: Screening the Head, Neck and Back
Chapter 15: Screening the Sacrum, Sacroiliac and Pelvis
Chapter 16: Screening the Lower Quadrant: Buttock, Hip, Groin, Thigh and Leg
Chapter 17: Screening the Chest, Breasts and Ribs
Chapter 18: Screening the Shoulder and Upper Extremity
Answers for Practice Test Questions
Inside Back Cover: Tables
Document Text Contents
Page 466


examination are the most reliable methods of
detection and diagnosis.

Older adults (both men and women) are at
increased risk for UTI. They may present with non-
specific symptoms, such as loss of appetite, nausea
and vomiting abdominal pain, or change in mental
status (e.g., onset of confusion, increased confu-
sion). Watch for predisposing conditions that can
put the older client at risk for UTI. These may
include diabetes mellitus or other chronic diseases,
immobility, reduced fluid intake, catheterization,
and previous history of UTI or kidney stones.

Obstruct ive D i so rders
Urinary tract obstruction can occur at any point in
the urinary tract and can be the result of primary
urinary tract obstructions (obstructions occurring
within the urinary tract) or secondary urinary tract
obstructions (obstructions resulting from disease
processes outside the urinary tract).

A primary obstruction might include problems
such as acquired or congenital malformations,
strictures, renal or ureteral calculi (stones), poly-
cystic kidney disease, or neoplasms of the urinary
tract (e.g., bladder, kidney).

Secondary obstructions produce pressure on the
urinary tract from outside and might be related to
conditions such as prostatic enlargement (benign
or malignant); abdominal aortic aneurysm; gyne-
cologic conditions such as pregnancy, pelvic inflam-
matory disease, and endometriosis; or neoplasms
of the pelvic or abdominal structures.

Obstruction of any portion of the urinary tract
results in a backup or collection of urine behind the
obstruction. The result is dilation or stretching of
the urinary tract structures that are positioned
behind the point of blockage.

Muscles near the affected area contract in an
attempt to push urine around the obstruction.
Pressure accumulates above the point of obstruc-
tion and can eventually result in severe dilation of
the renal collecting system (hydronephrosis) and
renal failure. The greater the intensity and dura-
tion of the pressure, the greater is the destruction
of renal tissue.

Because urine flow is decreased with obstruc-
tion, urinary stagnation and infection or stone for-
mation can result. Stones are formed because urine
stasis permits clumping or precipitation of organic
matter and minerals.


CASE EXAMPLE 1 0 - 2 B l a d d e r In fec t ion

A 55-year-old woman came to the clinic with
back pain associated with paraspinal muscle
spasms. Pain was of unknown cause (insidious
onset), and the client reported that she was "just
getting out of bed" when the pain started. The
pain was described as a dull aching that was
aggravated by movement and relieved by rest
(musculoskeletal pattern).

No numbness, tingling, or saddle anesthesia
was reported, and the neurologic screening
examination was negative. Sacroiliac (SI)
testing was negative. Spinal movements were
slow and guarded, with muscle spasms noted
throughout movement and at rest. Because of
her age and the insidious onset of symptoms,
further questions were initiated to screen for
medical disease.

This client was midmenopausal and was not
taking any hormone replacement therapy
(HRT). She had a bladder infection a month ago
that was treated with antibiotics; tests for this
were negative when she was evaluated and
referred by her physician for back pain. Two
weeks ago she had an upper respiratory infec-

tion (a "cold") and had been "coughing a lot."
There was no previous history of cancer.

Local treatment to reduce paraspinal muscle
spasms was initiated, but the client did not
respond as expected over the course of five treat-
ment sessions. Because of her recent history of
upper respiratory and bladder infections, ques-
tions were repeated related to the presence of
constitutional symptoms and changes in bladder
function/urine color, force of stream, burning on
urination, and so on. Occasional "sweats"
(present sometimes during the day, sometimes
at night) was the only red flag present. The
combination of recent infection, failure to
respond to treatment, and the presence of
sweats suggested referral to the physician for
early reevaluation.

The client did not return to the clinic for
further treatment, and a follow up telephone call
indicated that she did indeed have a recurrent
bladder infection that was treated successfully
with a different antibiotic. Her back pain and
muscle spasm were eliminated after only 24
hours of taking this new antibiotic.

Page 467


Lower urinary tract obstruction can also result
in constant bladder distention, hypertrophy of
bladder muscle fibers, and formation of herniated
sacs of bladder mucosa. These herniated sacs
result in a large, flaccid bladder that cannot
empty completely. In addition, these sacs retain
stagnant urine, which causes infection and stone

Obstructive Disorders of the Upper
Urinary Tract
Obstruction of the upper urinary tract may be
sudden (acute) or slow in development. Tumors of
the kidney or ureters may develop slowly enough
that symptoms are totally absent or very mild ini-
tially, with eventual progression to pain and signs
of impairment. Acute ureteral or renal blockage by
a stone (calculus consisting of mineral salts), for
example, may result in excruciating, spasmodic,
and radiating pain accompanied by severe nausea
and vomiting.

Calculi form primarily in the kidney. This
process is called nephrolithiasis. The stones can
remain in the kidney (renal pelvis) or travel down
the urinary tract and lodge at any point in the
tract. Strictly speaking, the term kidney stone
refers to stones that are in the kidney. Once they
move into the ureter, they become ureteral stones.

Ureteral stones are the ones that cause the most
pain. If a stone becomes wedged in the ureter,
urine backs up distending the ureter and causing
severe pain. If a stone blocks the flow of urine,
urine pressure may build up in the ureter and
kidney causing the kidney to swell (hydronephro-
sis). Unrecognized hydronephrosis can sometimes
cause permanent kidney damage.9

The most characteristic symptom of renal or
ureteral stones is sudden, sharp, severe pain. If the
pain originates deep in the lumbar area and radi-
ates around the side and down toward the testicle
in the male and the bladder in the female, it is
termed renal colic. Ureteral colic occurs if the stone
becomes trapped in the ureter. Ureteral colic is
characterized by radiation of painful symptoms
toward the genitalia and thighs (see Fig. 10-8).

Since the testicles and ovaries form in utero in
the location of the kidneys and then migrate at full
term following the pathways of the ureters, kidney
stones moving down the pathway of the ureters
cause pain in the flank. This pain radiates to the
scrotum in males and the labia in females. For the
same reason ovarian or testicular cancer can refer
pain to the back at the level of the kidneys.

Renal tumors may also be detected as a flank
mass combined with unexplained weight loss,

fever, pain, and hematuria. The presence of any
amount of blood in the urine always requires refer-
ral to a physician for further diagnostic evaluation
because this is a primary symptom of urinary tract

Clinical Signs and Symptoms of

Obstruction of the Upper
U r i n a r y Tract

• Pain (depends on the rapidity of onset and on
the location)
• Acute, spasmodic, radiating
• Mild and dull flank pain
• Lumbar discomfort with some renal diseases

or renal back pain with ureteral obstruction
• Hyperesthesia of dermatomes (T l 0 through L I )
• Nausea and vomiting
• Palpable flank mass
• Hematuria
• Fever and chills
• Urge to urinate frequently
• Abdominal muscle spasms
• Renal impairment indicators (see inside front

cover: Renal Blood Studies; see also Table

Obstructive Disorders of the Lower
Urinary Tract
Common conditions of (mechanical) obstruction
of the lower urinary tract are bladder tumors
(bladder cancer is the most common site of urinary
tract cancer) and prostatic enlargement, either
benign (benign prostatic hyperplasia [BPH]) or
malignant (cancer of the prostate). An enlarged
prostate gland can occlude the urethra partially or

Mechanical problems of the urinary tract result
in difficulty emptying urine from the bladder.
Improper emptying of the bladder results in
urinary retention and impairment of voluntary
bladder control (incontinence). Several possible
causes of mechanical bladder dysfunction include
pelvic floor dysfunction, UTIs, partial urethral
obstruction, trauma, and removal of the prostate

The nerves that carry pain sensation from the
prostate do not localize the source of pain very pre-
cisely, and therefore it may be difficult for the
man to describe exactly where the pain is coming
from. Discomfort can be localized in the suprapu-
bic region, in the penis and testicles, or it can be
centered in the perineum or rectum (see Fig.

Page 931


Vascular disease, 231-232, 232*, 309-

arterial, 309-311, 310*
diabetes mellitus and, 487
hip pain in, 735*
hypertension and, 3-6
leg pain in, 278, 763
lymphedema and, 315
pelvic pain in, 704*, 714-716, 715/;

peripheral vascular assessment in,

Raynaud's phenomenon and, 311
shoulder pain in, 822*
venous, 311-315, 3126

Vascular pain
in neck and back, 646-647, 6476
patterns of, 121*

Vascular spider, 409-411, 410/
Vasovagal syncope, 277
VDS. See Verbal Descriptor Scale.
Vegetations, 298
Venous disorders, 311-315, 3126
Venous insufficiency, 2016
Venous stasis, 312
Venous thromboembolism, 232-233,

233*, 234*
Ventilation, 334
Ventricular fibrillation, 303-305
Ventricular gallop, 236
Ventricular septal defect, 299, 300/
Verapamil, 318
Verbal Descriptor Scale, 115, 1186
Verification of medical diagnosis, 16
Vertebral artery syndrome, 641
Vertebral compression fracture, 647
Vertebral osteomyelitis, 677-678
Vertebrobasilar insufficiency, 641
Vertical transmission of human

immunodeficiency virus, 520
Vestibulocochlear nerve, 229*
Violence, 806, 80-82, 826
Viral infection

depression associated with, 1546
Guillain-Barre syndrome and,

in hepatitis, 414-418, 415*, 416*,

joint pain in, 139
shoulder pain in, 837

Virchow's node, 223
Visceral obstruction in cancer, 593
Visceral pain

characteristics of, 149-151, 1516
chest, 777
gastrointestinal, 368/ 368-369
mechanisms of, 110-112, 111/ 112/
multisegmental innervation and,

112-114, 113/
in neck and back, 630-631*, 643-

645, 644/
pelvic, 705
referred, 148*
screening for, 166-168
sources of, 127-129

Visceral pericardium, 275/ 290/
Visceral pleura, 333
Viscero-somatic reflex responses,

Viscero-viscero reflex responses, 129
Viscerosensory fibers, 110-111
Viscerosomatic pain, 127
Visual Analog Scale, 116-117/ 120

Visual impairment in multiple
sclerosis, 547

Vital signs, 183-196, 1846, 184*
blood pressure in, 187-195, 1886,

assessment of, 187-190, 1896
changes with exercise, 191
hypertension and, 191-193, 1926
hypotension and, 193
postural orthostatic hypotension

and, 193-195, 1946
pulse pressure and, 190
variations in, 190-191

in cardiovascular disease, 278-279
core body temperature in, 195*,

in health status assessment, 31
physician referral and, 31, 248-250
pulse oximetry in, 187
pulse rate in, 185/ 185-186, 1866
respirations in, 187

Vitamin C, smoking and, 67
Vitamin D deficiency, 508
Vitamins, hepatotoxicity of, 4196
Vitiligo, 204, 206/ 222*

in appendicitis, 389
cardiac chest pain and, 276
in cholecystitis, 425
in chronic pancreatitis, 391
in hepatitis, 416
in hyperparathyroidism, 483
in irritable bowel syndrome, 393
metabolic alkalosis and, 497
in myocardial infarction, 288
in peptic ulcer, 383
renal pain and, 439
in thyroid storm, 479
in ulcerative colitis, 393


Waddell's nonorganic signs, 163, 164*
Walk-through angina, 285
Warfarin, 318
Warning signs and symptoms, 10
Wart, 211/
Water intoxication, 496
Water retention, 471
Weakness, 133

in acute leukemia, 605
in anemia, 262
in arrhythmias, 302-303
in cancer, 574-575, 575/
in congestive heart failure, 292
in Cushing's syndrome, 475
in endocrine disorders, 468-469
in Guillain-Barre syndrome, 548
in heart disease in women, 284
in hyperparathyroidism, 483
in hypoparathyroidism, 484
in hypothyroidism, 481
in immune system disorders, 518
in multiple sclerosis, 547
in myasthenia gravis, 549, 5496
in osteomalacia, 508
in rheumatic fever, 297
in spinal cord compression, 583
in thyroid disorders, 475
Waddell's nonorganic signs and, 164*

WebMD: Medical tests, 5046
Weight gain in hypothyroidism, 479
Weight lifting, abdominal aortic

aneurysm and, 295

Weight loss
in acute leukemia, 605
in chronic pancreatitis, 391
early satiety and, 666
in hepatitis, 416
in Hodgkin's disease, 608
in human immunodeficiency virus

infection, 521
in hyperparathyroidism, 483
in hyperthyroidism, 477
in lung cancer, 346
in pancreatic cancer, 392
in peptic ulcer, 383
in rheumatic fever, 297
in ulcerative colitis, 393
in uterine cancer, 717

Wells' Clinical Decision Rule, 232,

Wheezing, 235
in asthma, 341
in gastroesophageal reflux disease,

in lung cancer, 347

Whispered pectoriloquy, 236
White blood cell, 261

leukemia and, 267, 568*, 604*, 604-
605, 615

metastasis and, 570*
musculoskeletal manifestations

of, 585*
statistics in, 559/

leukocytosis and, 266-267
leukopenia and, 261-262, 267, 594

White-coat hypertension, 191
White nail syndrome, 218/ 218-219
White nails of Terry, 411, 411/
Wilson's disease, 418

from alcohol, 62
from caffeine, 68

Women. See Female.
Women's Health Initiative, 55
Work history, 45/ 69-71, 71*

in pulmonary disorders, 361
Workplace violence, 83
Wound healing

Cushing's syndrome and, 475
diabetes mellitus and, 487

carpal tunnel syndrome and, 469*,

in acromegaly, 471
cancer and, 591-592
in diabetes mellitus, 489
hypothyroidism and, 470, 479
liver disease and, 412, 413, 4136
in multiple myeloma, 607

rheumatoid arthritis of, 530
X-ray keratosis, 210
Xanthelasma, 208/
Xanthoma, 208, 208/ 222*, 487, 488/
Xiphodynia, 797

Yellow flag symptoms, 10-116, 136, 33

Head's, 128
Looser's transformation, 412, 508
of prostate, 438/


Page 932

From Chernecky C, Berger B: Laboratory tests and diagnostic procedures, ed 4, Philadelphia, 2003, WB Saunders.

Fasting Blood Glucose (FBG)
Impaired glucose tolerance (insulin resistance)
Diabetes mellitus
Red flag values

Glycosylated Hemoglobin (A1C)
Normal reference range

100-125 mg/dl
>126 mg/dl (measured on 2 separate days)
<70 mg/dl or >250 mg/dl at the start of exercise

4% to 6%
Maintain consistent A1C levels below 7%; this correlates to an average

daily blood glucose level below 170 mg/dl



pC0 2 (partial pressure of 35-45 mm Hg

carbon dioxide)
HC0 3 (bicarbonate ion) 22-26 mEq/L
p0 2 (partial pressure of oxygen) 75-100 mm Hg
02 saturation (oxygen saturation) 96%-100%

Panic Values
pH <7.20 or >7.6
pC0 2 <20 or >70mmHg
HC0 3 <10 or >40 mEq/L
p 0 2 <40 mm Hg
0 2 saturation <60%

Adapted from Chernecky C, Berger B: Laboratory tests and diagnostic
procedures, ed 4, Philadelphia, 2003, WB Saunders.

From Chernecky C, Berger B: Laboratory tests and diagnostic proce-
dures, ed 4, Philadelphia, 2003, WB Saunders.


Platelet count <50,000/mm3 (<20,000-exercise

Hemoglobin <10g/dl
White blood cell count <3000/mm3 (<1000-exercise

Absolute granulocytes <2500/mm3

From Winningham ML et al: Exercise for cancer patients. Guidelines
and precautions, The physician and sports medicine 14:121-134, 1986.

Test Normal Values

Serum potassium 3.5-5.3 mEq/L
Serum sodium 136-145 mEq/L
Serum calcium 8.2-10.2 mg/dl

(4.5-5.5 mEq/L)
Serum magnesium 1.8-3 mg/dl

1.5-2.5 mEq/L)

Serum Bilirubin

Direct (conjugated)
Indirect (unconjugated)
Total amount

0.1-0.3 mg/dl
0.2-0.8 mg/dl
0.1-1.0 mg/dl

Urine Bilirubin 0

Serum Cholesterol 150-250 mg/dl; elevated when its excretion is blocked by bile duct obstruction;
reduced when severe liver damage prevents its synthesis

Total Protein

6-8 g/dl; decreased when liver is damaged—synthesis is impaired
Serum Albumin 3.5-5.5 g/dl; decreased in liver damage

Blood Ammonia <75 ug/dl; increased in severe liver damage; liver unable to break down ammonia

Coagulation Functions
Prothrombin time (PT)

INR (International normalized ratio)

12-15 seconds; prolonged with liver damage
150,000-400,000/mm3; may drop when spleen is enlarged from portal

0.9-1.1 (ratio)

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