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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.
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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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Mr. K.D. is a 57-year-old male accountant referred to physical therapy with a diagnosis of "jaw pain secondary to left temporomandibular joint dysfunction." He stated that the jaw discomfort began about 8 months earlier after eating popcorn. There were several unpopped kernels in the bag and he felt the pain in his left lower jaw immediately after biting down on one. The discomfort occurred only with chewing for the next few days and he went to see his primary care physician who prescribed ibuprofen and a soft diet for 1 week. Mr. K.D. states that over the course of the next several weeks, the discomfort resolved completely.
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Approximately 6 months ago, he again felt left lower jaw discomfort after helping his brother move heavy furniture. At the time, he thought that he had "strained some jaw muscles" because he remembers clenching his teeth during the strenuous lifting. He mentioned this in passing to his primary care physician who advised him to begin taking ibuprofen again and return in 2 weeks if the jaw discomfort did not resolve. Mr. K.D. stated that he did not find the ibuprofen helpful this time, but he did not return for a follow-up visit.
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Over the course of the next 6 months, he noted that his jaw discomfort would come on when he would push his lawnmower or push trashcans to the curb, though these activities would not always provoke his symptoms. He described the severity of the symptoms as 4/10 on a visual analog scale (VAS), with 10 being the most unbearable discomfort that he could imagine. The symptom required 3 to 5 minutes to dissipate after stopping the activity, but he would be left with a dull ache that persisted for 10 minutes. At a yearly dental cleaning visit ...