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Acknowledgment: Susan Layfield, PT, DPT, OCS


NOTE: This case demonstration was developed using the diagnostic process described in Chapter 4 and is designed to demonstrate that process. As Chapter 4 discussed, the diagnostic process begins with identification of the patient's chief concern. Communication barriers are then identified in order to establish features of the case that may influence the ability to gather information during the diagnostic process. Features of the case that raise special concerns are then established, in order to prioritize the additional information gathering required.

The process continues with the formation of a diagnostic hypothesis list consisting of all possible local and remote causes of the symptom. The hypothesis list is then sorted by probability on the basis of epidemiology, specific questions, and specific physical examination findings. The reader is encouraged to use this diagnostic process in order to ensure that thorough diagnostic clinical reasoning has been applied to all patient encounters. A brief list of the steps in the diagnostic process is given next. If more elaboration is required on the information presented in this chapter, please consult Chapters 1,2,3,4.


  • 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.

Case Description

Charles T. is a 58-year-old male with a referral to physical therapy by an orthopedic surgeon with the diagnosis of Left Rotator Cuff Tendinitis. His chief concern is an intermittent sharp left anterior shoulder pain, the onset of which was 2 weeks ago. He seems concerned because he cannot recall a mechanism of injury nor does he comment on any swelling in his shoulder or arm. The pain is aggravated by initial exposure to a cold draft, for example, when taking out the trash, and when square dancing with his wife during the first two to three twirls with his left arm lifted up and outstretched. Over the past 2 weeks, he believes his symptoms have not changed in frequency or intensity. He denies any associated pain or symptoms in his midback or upper extremity.

Mr. T is ...

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