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Note

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NOTE: This case demonstration was developed using the diagnostic process described in Chapter 4 and demonstrated in Chapter 5. The reader is encouraged to use this diagnostic process in order to ensure thorough clinical reasoning. If additional elaboration is required on the information presented in this chapter, please consult Chapters 4 and 5.

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THE DIAGNOSTIC PROCESS

  • Step 1 Identify the patient's chief concern.

  • Step 2 Identify barriers to communication.

  • Step 3 Identify special concerns.

  • Step 4 Create a symptom timeline and sketch the anatomy (if needed).

  • Step 5 Create a diagnostic hypothesis list considering all possible forms of remote and local pathology that could cause the patient's chief concern.

  • Step 6 Sort the diagnostic hypothesis list by epidemiology and specific case characteristics.

  • Step 7 Ask specific questions to rule specific conditions or pathological categories less likely.

  • Step 8 Re-sort the diagnostic hypothesis list based on the patient's responses to specific questioning.

  • Step 9 Perform tests to differentiate among the remaining diagnostic hypotheses.

  • Step 10 Re-sort the diagnostic hypothesis list based on the patient's responses to specific tests.

  • Step 11 Decide on a diagnostic impression.

  • Step 12 Determine the appropriate patient disposition.

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Case Description

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Robert is a 41-year-old male, tall and slender, who presents without notable physical distress. His chief concern is of pain in the right infrascapular region. He is an avid weekend basketball player. He reports that his symptoms began about 1 month ago when he was struck from behind while attempting to rebound a missed shot. He denies falling to the ground and continued to play that day. His symptoms have worsened overall since their onset, which led him to seek physical therapy. He is currently not participating in his exercise program due to the pain. Robert is very anxious about returning to his exercise routine in order to control his work-related stress. Robert is the chief financial officer of a local television production company. He started taking 800 mg ibuprofen twice daily beginning the day after his injury, which was prescribed by his internist. However, he stopped 4 days following his injury secondary to no effect on symptoms. In general, Robert reports he has been healthy without history of recent illness.

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Steps

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STEP #1: Identify the patient's chief concern.

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  • Pain in the right infrascapular region

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STEP #2: Identify barriers to communication.

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  • Inability to collect diagnostically relevant information due to the patient's eagerness to return to recreational basketball. The patient may be less willing to share the full extent of symptoms or demonstrate a bias against musculoskeletal causes of pain secondary to the level of his desire to return to activity.

  • Presence of trauma. May lead the physical therapist to deprioritize atraumatic causes of symptoms in this patient too early in the process.

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STEP ...

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