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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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Mrs. SR is a 79-year-old Asian female referred to physical therapy by an anesthesiologist who specializes in pain management with a referral diagnosis of "left shoulder pain, decreased range of motion, and lymphedema." Her chief concern is further loss of motion and increasing pain, which she describes as "dull, achy upper arm pain" that radiates down to the left elbow and occasionally radiates up to the left side of her neck. She reports skin and muscle tightness of the anterior chest region, which prevents her from moving her arm above her head. Three cortisone injections within the past 3 weeks did not change her pain concerns or limitations. Her physician advised her to rest, but this did not seem to help the pain. Additionally, she reports occasional lower back pain and left hip pain with symptoms of general fatigue. She denies feeling more ill than usual lately.

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SR was diagnosed with stage IIIC left invasive lobular carcinoma approximately 10 months prior to this physical therapy consult. Medical treatment included a left modified radical mastectomy with axillary lymph node dissection followed by Arimidex (hormonal therapy) and 5 to 6 weeks of radiation therapy. The radiated field included the left chest wall, axilla, and supraclavicular fossa. The onset of left shoulder pain began during the fourth week of radiation therapy. Present cancer treatment includes only Arimidex therapy, and she has taken an antihypertensive medication "for years." SR began physical therapy and occupational therapy toward the end of her radiation treatments.

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Interventions to date included lymphedema management such as manual lymphatic drainage, compression bandaging, light exercises, and issuance of a compression garment. Physical therapy interventions included soft tissue mobilizations and general stretching and range-of-motion ...

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