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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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CD was a 43-year-old male who was referred to physical therapy by an orthopedic surgeon with a diagnosis of "right hip rectus femoris tendinosis." He presented with a 1-year history of hip pain that was originally diagnosed as avascular necrosis of the femoral head of unknown etiology with subsequent surgical replacement of the femoral head. Postsurgical therapy was discontinued after 1 month (patient self-discharged). However, the patient returned to therapy now due to his reports of an inability to return to prior level of function, discomfort with simple daily activities, and, although working, he was unable to resume full duties independently (climbing ladders and on his feet more than 8 hours per day).

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He described the pain as feeling "stiff and achy," located mostly on the anterior and lateral area surrounding the right hip (not including groin) and denied any pain or pathology of the left lower extremity. He rated his minimum pain as 0/10 and his maximal pain during the last month at about 7/10 to 8/10. The morning and evenings were the worst because he felt the stiffest at these times. Pain did not usually wake him up at night. His pain and stiffness started immediately upon moving and took about 3 to 4 minutes to decrease while weight bearing. However, if he sat or laid down, the pain immediately decreased. He reported Advil had a mild effect on pain relief. Walking (especially trying to take "longer/faster" steps and pain with the first several minutes of walking were the worst), squatting, using the elliptical, and going upstairs (more than down) all aggravated his pain.

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Recent radiographs were taken 1 month prior to check placement of the femoral ...

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