Differential Diagnosis Practice Questions

Most of the information needed to determine the cause of symptoms is contained in the: a. Subjective examination b. Family/Personal History Form c. Objective information d. All of the above e. a and c

(a) Although all details obtained from the Family/Personal History form, interview, and objective examinations provide important information, it is well documented that 80% (or more) of the information needed to determine the cause of symptoms is actually gathered during the Core Interview of the Subjective Examination.

Bone pain associated with neoplasm is characterized by: a. Increases with weight bearing b. Negative heel strike c. Relieved by Tums or other antacid in women d. Goes away after eating

(a) Bone pain would be accompanied by a positive heel strike test. Symptoms of angina are sometimes relieved by antacids in women. Even if bone pain were caused by metastases from the GI tract, eating would not alleviate the symptoms.

Referred pain patterns associated with impairment of the spleen can produce musculoskeletal symptoms in: a. The left shoulder b. The right shoulder c. The mid-back or upper back, scapular, and right shoulder areas d. The thorax, scapulae, right shoulder, or left shoulder

(a) Left shoulder pain associated with damage or injury to the spleen is called Kehr's sign.

Which statement is the most accurate? a. Arterial disease is characterized by intermittent claudication, pain relieved by elevating the extremity, and history of smoking. b. Arterial disease is characterized by loss of hair on the lower extremities and throbbing pain in the calf muscles that goes away by using heat and elevation. c. Arterial disease is characterized by painful throbbing of the feet at night that goes away by dangling the feet over the bed. d. Arterial disease is characterized by loss of hair on the toes, intermittent claudication, and redness or warmth of the legs that is accompanied by a burning sensation.

(c) Pain from arterial disease is relieved by dangling (not elevating) the extremity to help blood flow distally; the feet are cold and demonstrate pallor from loss of blood flow.

When assessing the abdomen, what sequence of physical assessment is best? a. Auscultation, inspection, palpation, percussion b. Inspection, percussion, auscultation, palpation c. Inspection, auscultation, percussion, palpation d. Auscultation, inspection, percussion, palpation

(c) Percussion and palpation can change bowel sounds. Look and listen before you palpate.

Common symptoms of respiratory acidosis would be most closely represented by which of the following descriptions? a. Presence of numbness and tingling in face, hands, and feet b. Presence of dizziness and lightheadedness c. Hyperventilation with changes in level of consciousness d. Onset of sleepiness, confusion, and decreased ventilation

(d)

You should assess clients who are receiving NSAIDs for which physiologic effect associated with increased risk of hypertension? a. Decreased heart rate b. Increased diuresis c. Slowed peristalsis d. Water retention

(d) Water retention. Look for sacral and pedal edema.

A 23-year-old female presents with new onset of skin rash and joint pain followed 2 weeks later by GI symptoms of abdominal pain, nausea, and diarrhea. She has a previous history of Crohn's disease, but this condition has been stable for several years. She does not think her current symptoms are related to her Crohn's disease. What kind of screening assessment is needed in this case? a. Vital signs only. b. Vital signs and abdominal auscultation. c. Vital signs, neurologic screening examination, and abdominal auscultation. d. No further assessment is needed; there are enough red flags to advise this client to seek medical attention.

(d) You may decide to conduct additional tests and provide the information to the physician. This should include a review of past medical history, current medications, and any pharmaceuticals she may be taking, as well as any other symptoms present but unnoticed or unreported. Carry out a screening interview using Special Questions for Joint Pain (see Appendix B-16).

Dyspnea associated with emphysema is the result of: a. Destruction of the alveoli b. Reduced elasticity of the lungs c. Increased effort to exhale trapped air d. a and b e. All of the above

(e)

Medical referral for a problem outside the scope of the physical therapy practice occurs when: a. No apparent movement dysfunction exists b. No causative factors can be identified c. Findings are not consistent with neuromuscular or musculoskeletal dysfunction d. Client presents with suspicious red-flag symptoms e. Any of the above f. None of the above

(e)

Renal pain is aggravated by: a. Spinal movement b. Palpatory pressure over the costovertebral angle c. Lying on the involved side d. All of the above e. None of the above

(e)

A 52-year-old woman with shoulder pain tells you that she has pain at night that awakens her. After asking a series of follow-up questions, you are able to determine that she had trouble falling asleep because her pain increases when she goes to bed. Once she falls asleep, she wakes up as soon as she rolls onto that side. What is the most likely explanation for this pain behavior? a. Minimal distractions heighten a person's awareness of musculoskeletal discomfort. b. This is a systemic pattern that is associated with a neoplasm. c. It is impossible to tell. d. This represents a chronic clinical presentation of a musculoskeletal problem.

(a) Pain that wakes a client up as soon as he or she rolls onto that side is indicative of an acute inflammatory process. Night pain associated with neoplasm is more likely to wake the client up after he or she falls asleep, when the tumor keeps normal tissue from obtaining essential blood and nutrients, thus creating tissue ischemia and subsequent pain. With chronic musculoskeletal conditions, the client can often get to sleep with just the right positioning and may even be able to sleep on that side for up to an hour or two before pressure and ischemia develop, causing pain.

Screening for alcohol use would be appropriate when the client reports a history of accidents. a. True b. False

(a) True

Associated signs and symptoms are a major red flag for pain of a systemic or visceral origin compared to musculoskeletal pain. a. True b. False

(a) True. See Table 3-2.

Referred pain from the viscera can occur alone but is usually preceded by visceral pain when an organ is involved. a. True b. False

(a) True. Visceral involvement can occur without preceding or prodromal symptoms, but most often, associated signs and symptoms are present. Because visceral pain can be referred to the neck, back, or shoulder, the client who experiences gastrointestinal (GI) or genitourinary (GU) symptoms does not report these additional symptoms to the therapist when providing information about the musculoskeletal condition.

Body temperature should be taken as part of vital sign assessment: a. For every client evaluated b. For any client who has musculoskeletal pain of unknown origin c. For any client reporting the presence of constitutional symptoms, especially fever or night sweats d. b and c

(a) or (d) Some physicians and physical therapists advocate taking the body temperature as part of a vital sign assessment in all clients (answer [a]). Others suggest that this may not be necessary in cases in which a clear musculoskeletal cause is noted for the clinical presentation, as well as an absence of any systemically associated signs and symptoms. As a general guideline, vital sign assessment can provide valuable screening and overall health information. For the student and inexperienced clinician, we highly recommend this practice. For further discussion of this topic, see Chapter 4.

A patient/client gives you a written prescription from a physician, chiropractor, or dentist. The first screening question to ask is: a. What did the physician (dentist, chiropractor) say is the problem? b. Did the physician (dentist, chiropractor) examine you? c. When do you go back to see the doctor (dentist, chiropractor)? d. How many times per week did the doctor (dentist, chiropractor) suggest you come to therapy?

(b)

Name two of the most common medications taken by clients seen in a physical therapy practice likely to induce GI bleeding. a. Corticosteroids b. Antibiotics and antiinflammatories c. Statins d. None of the above

(b)

Physical therapists are qualified to make a human movement system diagnosis regarding primary neuromusculoskeletal conditions, but we must do so in accordance with: a. The Guide to Physical Therapist Practice b. The State Practice Act c. The screening process d. The SOAP method

(b)

Pursed-lip breathing in the sitting position while leaning forward on the arms relieves symptoms of dyspnea for the client with: a. Orthopnea b. Emphysema c. CHF d. a and c

(b)

The presence of pain and anxiety in a client can often lead to hyperventilation. When a client hyperventilates, the arterial concentration of carbon dioxide will do which of the following? a. Increase b. Decrease c. Remain unchanged d. Vary depending on potassium concentration

(b)

What is the best follow-up question for someone who tells you that the pain is constant? a. Can you use one finger to point to the pain location? b. Do you have that pain right now? c. Does the pain wake you up at night after you have fallen asleep? d. Is there anything that makes the pain better or worse?

(b)

Which of the following are clues to the possible involvement of the GI system? a. Abdominal pain alternating with TMJ pain within a 2-week period b. Abdominal pain at the same level as back pain, occurring either simultaneously or alternately c. Shoulder pain alleviated by a bowel movement d. All of the above

(b)

A risk factor for NSAID-related gastropathy is the use of: a. Antibiotics b. Antidepressants c. Antihypertensives d. Antihistamines

(b) Antidepressants Antidepressants are divided into three groups: tricyclics, monoamine oxidase inhibitors (MAOIs), and miscellaneous antidepressants. The tricyclics work by blocking reuptake of norepinephrine and serotonin into nerve endings and increasing the action of norepinephrine and serotonin in nerve cells. Any of the antidepressants can have gastrointestinal adverse effects, but especially, the selective serotonin uptake inhibitors (SSRIs) such as Paxil, Zoloft, Prozac, and Celexa.

Pain of a viscerogenic nature is not relieved by a change in position. a. True b. False

(b) False. Some types of viscerogenic pain can be relieved by a change in position early in the disease process. For example, pain from an inflammatory or infectious process that affects the kidney may be reduced by leaning toward the involved side and applying pressure to that area. Gallbladder pain is sometimes relieved by leaning forward. Cardiac pain brought on by use of the upper extremities overhead may be relieved by bringing the arms back down to the sides.

Alcohol screening tools should be: a. Used with every client sometime during the episode of care b. Brief, easy to administer, and nonthreatening c. Deferred when the client has been drinking or has the smell of alcohol on the breath d. Conducted with one other family member present as a witness

(b) It may not be necessary to screen every client for alcohol use. You may not conduct a full screening assessment when someone appears to have been drinking, but it may still be appropriate to ask, "I smell alcohol on your breath. How many drinks have you had?" Screening questions should be asked privately and confidentially without other family and friends listening.

Bleeding in the gastrointestinal (GI) tract can be manifested as: a. Dysphagia b. Melena c. Psoas abscess d. Tenderness over McBurney's point

(b) Melena

What is the effect of NSAIDs (e.g., Naprosyn, Motrin, Anaprox, ibuprofen) on blood pressure? a. No effect b. Increases blood pressure c. Decreases blood pressure

(b) Nonsteroidal antiinflammatory drugs (NSAIDs) can be potent renal vasoconstrictors that cause increased blood pressure and resultant lower extremity edema as sodium and water are conserved by the body.

In the context of screening for referral, primary purpose of a diagnosis is a. To obtain reimbursement b. To guide the plan of care and intervention strategies c. To practice within the scope of physical therapy d. To meet the established standards for accreditation

(b) The function of a diagnosis and diagnostic classifications is to provide information (i.e., identify as closely as possible the underlying neuromusculoskeletal [NMS] pathology) that can guide efficient treatment and effective management of the client.

Words used to describe neurogenic pain often include: a. Throbbing, pounding, beating b. Crushing, shooting, pricking c. Aching, heavy, sore d. Agonizing, piercing, unbearable

(b) Throbbing, pounding, and beating are more often associated with pain of a vascular nature. Aching, heavy, and sore are words used to describe musculoskeletal pain. According to the McGill Pain Questionnaire, words like agonizing, piercing, and unbearable convey more emotional content than is communicated by actual descriptors of organic disease. See Table 3-1

After interviewing a new client, you summarize what she has told you by saying, "You told me you are here because of right neck and shoulder pain that began 5 years ago as a result of a car accident. You also have a 'pins and needles' sensation in your third and fourth fingers but no other symptoms at this time. You have noticed a considerable decrease in your grip strength, and you would like to be able to pick up a pot of coffee without fear of spilling it." This is an example of: a. An open-ended question b. A funnel technique c. A paraphrasing technique d. None of the above

(c)

During auscultation of an adult client with rheumatoid arthritis, the heart rate gets stronger as she breathes in and decreases as she breathes out. This sign is: a. Characteristic of lung disease b. Typical in coronary artery disease c. A normal finding d. Common in anyone with pain

(c)

Neurologic symptoms such as muscle weakness or muscle atrophy may be the first indication of: a. Cystic fibrosis b. Bronchiectasis c. Neoplasm d. Deep vein thrombosis

(c)

Pulse strength graded as 1 means: a. Easily palpable, normal b. Present occasionally c. Pulse diminished, barely palpable d. Within normal limits

(c)

Screening for medical disease takes place: a. Only during the first interview b. Just before the client returns to the physician for his/her next appointment c. Throughout the episode of care d. None of the above

(c)

When would you advise a client in physical therapy to take his/her nitroglycerin? a. 45 minutes before exercise b. When symptoms of chest pain do not subside with 10 to 15 minutes of rest c. As soon as chest pain begins d. None of the above e. All of the above

(c)

Instruct clients with a history of hypertension and arthritis to: a. Limit physical activity and exercise b. Avoid over-the-counter medications c. Inform their primary care provider of both conditions d. Drink plenty of fluids to avoid edema

(c) Inform the primary care provider of both conditions; the therapist can also screen for potential adverse effects of NSAIDs and can monitor blood pressure.

A 56-year-old client was referred to PT for pelvic floor rehab. His primary symptoms are obstructed defecation and puborectalis muscle spasm. He wakes nightly with left flank pain. The pattern is low thoracic, laterally, but superior to iliac crest. Sometimes he has buttock pain on the same side. He doesn't have any daytime pain but is up for several hours at night. Advil and light activity do not help much. The pain is relieved or decreased with passing gas. He has very tight hamstrings and rectus femoris. Change in symptoms with gas or defecation is possible with: a. Thoracic disk disease b. Obturator nerve compression c. Small intestine disease d. Large intestine and colon dysfunction

(d)

Important functions of the kidney include all the following except: a. Formation and excretion of urine b. Acid-base and electrolyte balance c. Stimulation of red blood cell production d. Production of glucose

(d)

Percussion of the costovertebral angle that results in the reproduction of symptoms: a. Signifies radiculitis b. Signifies pseudorenal pain c. Has no significance d. Requires medical referral

(d)

What areas of the body can GI disorders refer pain to? a. Sternum, shoulder, scapula b. Anterior neck, mid-back, lower back c. Hip, pelvis, sacrum d. All of the above

(d)

What is the significance of sweats? a. A sign of systemic disease b. Side effect of chemotherapy or other medications c. Poor ventilation while sleeping d. All of the above e. None of the above

(d)

Peripheral vascular diseases include: a. Arterial and occlusive diseases b. Arterial and venous disorders c. Acute and chronic arterial diseases d. All of the above e. None of the above

(d) Arterial and occlusive diseases are synonymous for the same thing: Occlusion of the arteries produces arterial disease; occlusion of the veins produces venous disorders. Arteries and veins constitute the major peripheral blood vessels; therefore, any diseases or disorders of the arteries and/or veins are included in peripheral vascular disorders.

Direct access is the only reason physical therapists must screen for systemic disease. a. True b. False

False—See Box 1-1.

Back pain with radiating numbness and tingling down the leg past the knee does not occur as a result of: a. Postoperative thrombus b. Bronchogenic carcinoma c. Pott's disease d. Trigger points

In accordance with our screening model, we always take a look at past medical history, risk factors, clinical presentation, and associated signs and symptoms. This patient's age, history of tobacco use, and previous history of breast cancer are red flags and risk factors for cancer recurrence and other systemic disorders. The following tests and measures can help the therapist to differentiate musculoskeletal from systemic origin of symptoms in this case: • Vital signs and pulmonary auscultation • Palpation (Can symptoms be reproduced with palpation? [Bone mets are not usually painful to palpation, whereas trigger points or impaired soft tissue structures may be painful upon palpation.]). Are the intercostal spaces symmetric? Asymmetry may be noted with rib dysfunction. • Active and passive spinal motion (Can symptoms be reproduced, alleviated, or changed in any way with active spinal movement? Are the accessory motions within normal limits?) • Ask about the presence of other pulmonary signs and symptoms. • Is the pattern of symptoms consistent with a musculoskeletal disorder? Because breast cancer can metastasize to the bone, and especially, to the thoracic spine, a neurologic screening examination may be in order, depending on the client's response to previous questions and tests.

Why does postural orthostatic hypotension occur upon standing for the first time in a young adult who has been supine in skeletal traction for 3 weeks?

The patient's blood pressure (vasomotor) system is "untuned"; peripheral blood vessels do not constrict properly, so venous pooling may occur. The patient also may be receiving medication(s) that have the potential to reduce blood pressure directly or as an adverse effect of the drug or drugs in combination. Other factors may include dehydration, if the patient has not been on intravenous fluids and has not maintained adequate fluid intake.

What are the 3Ps? What is the significance of each one?

The three Ps include: • Pleuritic pain (exacerbated by respiratory movement involving the diaphragm, such as sighing, deep breathing, coughing, sneezing, laughing, or the hiccups; this may be cardiac with pericarditis, or it may be pulmonary); have the client hold his or her breath, and reassess symptoms—any reduction or elimination of symptoms with breath holding or the Valsalva maneuver suggests a pulmonary or cardiac source of symptoms. • Pain on palpation (musculoskeletal origin) • Pain with changes in position (musculoskeletal or pulmonary origin; pain that is worse when lying down and that improves when sitting up or leaning forward is often pleuritic in origin).

Spontaneous uterine bleeding after 12 consecutive months without menstrual bleeding requires medical referral. a. True b. False

True. This includes any woman who has experienced a surgical menopause (e.g., oophorectomy for ovarian cancer) or any postmenopausal woman who is not taking hormone replacements.

Body temperature should be taken as part of vital sign assessment: a. Only for clients who have not been seen by a physician b. For any client who has musculoskeletal pain of unknown origin c. For any client reporting the presence of constitutional symptoms, especially fever or sweats d. b and c e. All of the above

We confess this is a bit of a "trick" question. Thoughts on this topic vary. Some therapists advocate taking each client's body temperature (answer "e") as one of the simplest and most inexpensive ways to screen for the presence of systemic problems. Others are more selective in the screening process and advise answer "d" (b and c) as the most appropriate response. The decision may depend, in part, on the type of practice or clinical setting in which you practice. For the new graduate, it is highly recommended that all vital signs be taken on all clients until the therapist is proficient in this skill area. With experience, each clinician will develop the decision-making skills needed to determine when additional screening, and which screening tests, should be carried out.

The presence of a persistent dry cough (no sputum or phlegm produced) has no clinical significance to the therapist. True or false?

False. However, medical referral is usually not considered necessary when a client presents with a singular systemic sign or symptom, especially in the presence of a clear clinical presentation of a musculoskeletal pattern.

A line drawn down the middle of a lesion with two different halves suggests: a. A malignant lesion b. A benign lesion c. A normal presentation d. A skin reaction to medications

(a)

Physical therapy evaluation and intervention may be part of the physician's differential diagnosis. a. True b. False

(a)

What are the primary signs and symptoms of CHF? a. Fatigue, dyspnea, edema, nocturia b. Fatigue, dyspnea, varicose veins c. Fatigue, dyspnea, tinnitus, nocturia d. Fatigue, dyspnea, headache, night sweats

(a)

What is the significance of Kehr's sign? a. Gas, air, or blood in the abdominal cavity b. Infection of the peritoneum (peritonitis, appendicitis) c. Esophageal cancer d. Thoracic disk herniation masquerading as chest or anterior neck pain

(a) Kehr's sign (left shoulder pain) can occur as the result of blood (e.g., following trauma to the spleen, ruptured ectopic pregnancy) or air (laparoscopy) in the abdomen. Kehr's sign following a laparoscopy will resolve within 24 to 48 hours as the gas bubble is absorbed or passed. The physician must be notified of shoulder pain associated with traumatic injury, nonsteroidal antiinflammatory drug (NSAID)-associated gastrointestinal bleeding, or possible ectopic pregnancy for possible medical evaluation (even if the clinical presentation is consistent with musculoskeletal dysfunction) (see Shoulder, Chapter 18).

Pain (especially intense bone pain) that is disproportionately relieved by aspirin can be a symptom of: a. Neoplasm b. Assault or trauma c. Drug dependence d. Fracture

(a) Neoplasm, in particular, primary bone cancer.

A 48-year old man presented with low back pain of unknown cause. He works as a carpenter and says he is very active, has work-related mishaps (accidents and falls), and engages in repetitive motions of all kinds using his arms, back, and legs. The pain is intense when he has it, but it seems to come and go. He is not sure if eating makes the pain better or worse. He has lost his appetite because of the pain. After conducting an examination including a screening exam, the clinical presentation does not match the expected pattern for a musculoskeletal or neuromuscular problem. You refer him to a physician for medical testing. You find out later he had pancreatitis. What is the most likely explanation for this pain pattern? a. Toxic waste products from the pancreas are released into the intestines causing irritation of the retroperitoneal space. b. Rupture of the pancreas causes internal bleeding and referred pain called Kehr's sign. c. The pancreas and low back structures are formed from the same embryologic tissue in the mesoderm. d. Obstruction, irritation, or inflammation of the body of the pancreas distends the pancreas, thus applying pressure on the central respiratory diaphragm.

(d) Irritation of the retroperitoneal space begins when bleeding occurs behind the stomach, most often from a posterior duodenal ulcer. Rupture of the spleen causes Kehr's sign. The pancreas and low back structures are not formed from the same embryologic tissue. Disease of the pancreas, whether it involves the head, the body, or the tail, can put pressure on the corresponding portion of the respiratory diaphragm, resulting in shoulder or low back pain according to the location of the diaphragmatic irritation. Central diaphragmatic pressure results in referred pain to the ipsilateral shoulder; peripheral involvement of the diaphragm results in low back pain. This can occur in the right shoulder when the head of the pancreas is distended far enough, but it is more likely to affect the left shoulder via disease in the tail of the pancreas.

A 65-year-old client is taking OxyContin for a "sore shoulder." She also reports aching pain of the sacrum that radiates. The sacral pain can be caused by: a. Psoas abscess caused by vertebral osteomyelitis b. GI bleeding causing hemorrhoids and rectal fissures c. Crohn's disease manifested as sacroiliitis d. Pressure on sacral nerves from stored fecal content in the constipated client taking narcotics

(d) Psoas abscess can affect the hip, buttock, groin, and parts distal but does not cause sacral pain; hemorrhoids and rectal fissures may cause rectal or anal pain, but not sacral pain; Crohn's disease can be accompanied by sacroiliitis, but this client does not have a reported history of Crohn's disease; narcotics are well known for constipation as a common adverse effect, especially in the older adult.

Which of the following are red flags to consider when screening for systemic or viscerogenic causes of neuromuscular and musculoskeletal signs and symptoms: a. Fever, (night) sweats, dizziness b. Symptoms are out of proportion to the injury c. Insidious onset d. No position is comfortable e. All of the above

(e) All of these are red flags, along with previous history of cancer, symptoms that last longer than expected (beyond physiologic time period for healing), age, gender, comorbidities, bilateral symptoms, other constitutional symptoms, unexplained falls, substance use/abuse, unusual vital signs, and constant and intense pain

Joint pain can be a reactive, delayed, or allergic response to: a. Medications b. Chemicals c. Infections d. Artificial sweeteners e. All of the above

(e) Artificial sweeteners have come under fire, primarily by manufacturers of artificial sweeteners. Evidence supplied by two prominent board certified neurosurgeons (see text) combined with the author's own clinical experience is sufficient to include this agent as a causative factor in joint pain.

Pain associated with pleuropulmonary disorders can radiate to the: a. Anterior neck b. Upper trapezius muscle c. Ipsilateral shoulder d. Thoracic spine e. a and c f. All of the above

(f) Pain can also radiate to the costal margins or upper abdomen (see Figs. 7-9 and 7-10).

A 76-year-old man was referred to physical therapy after a total hip replacement (THR). The goal is to increase his functional mobility. Is a health assessment needed since he was examined just before the surgery 2 weeks ago? The physician conducted a systems review and summarized the medical record by saying the client was in excellent health and a good candidate for THR.

Yes. The therapist must be familiar with past medical history and any factors that could put the client at risk for a medical incident of any type. Health status can change for any client within a 2-week period, but especially, the aging adult. Surgery is a major event that is traumatic to the physiologic body, despite the client's previous excellent health. Surgery can trigger the onset of new health problems or may bring to fulmination something that was present only subclinically before the operation. Some postoperative complications do not develop until 10 to 14 days later. Exercise is an additional physiologic stressor. Symptoms may not be seen when the client is at rest or sedentary and may occur only after exercise has been initiated. Time pressure and the complexities of today's health care delivery system can also result in conditions remaining unnoticed by the examining health care professional. Systemic diseases often develop slowly and gradually over time. It is not until the disease has progressed enough that the client shows any signs and symptoms of visceral or systemic involvement. What the physician, physician's assistant, nurse, or nurse practitioner observed preoperatively may not be the clinical presentation seen by the therapist postoperatively.