Table 3. Clinical Decision Making Process for Differential Diagnosis” Conditions/Diseases Ruled Out Early in the Exemination Process ‘Musculoskeletal Venebral or rib ‘rocture Inveertbrol dik romusion hernition Spinal sonose Difse idiopathic skeliol hyperestosis (Os) Inercosol neurlgio Ta synchome: Aalylosing spandyltis 260. Fru ‘Typical Signs and Symptoms Fecal pain inthe oo of he roc; val the rex of oun, poi on inspiron (ib frac); pon reproduced wih movoren, sna spinal motions, very pail ino recon [piel ache); # ntact, pin wil subside ot; pin viol subs in Suz waco Ver roe inh thoracic sire (sol 19 or Tower frac), en heres xa trauma”; ofen couse nbs region and bdoriel wal pain: nerve fot compression tray cause porehesios, wecknes, or senory changes; bandit lower chest wal poi’; dematonal sensory chonges possible? Rein the horace spine! yell cus in abe ett Acc ety aretore ato, ren! when sanding eee! oF walking, point Prefers floxed postion; refes ton hyperactive di to cord compression rom a ‘ickened ligamentum fawn’ ‘Affects older men {>40 y of age}, morning spinal sires, spina enderess;oeophytes evident ‘on plain fm radiograph, unk exon limited, lose f normal lumbar lordoss* (Often fellows injury or thoracic surgery, burning ‘ain ond poresesis inthe thorax ce ‘2bdamen hat usvally follow the path ofthe nerve, focal tendamess over afected intercostal Constort or interment difise bileteral upper ‘horacic poin, affected spinous processes very tender, blotera upper extremity poreshesios with glovelike preseniaton, headache wualy ‘prezen, more prevalent in women thon in men by0 4: ratot? Jecidenceis 3:1 for men to women, insidious ‘onset, spinal pain and stiffness worse inthe morning or afer res, pan decreoses wih mild ‘ctvty or exercise, limited spinal and hip motion, limited chest expansion, bilateral pain in socroac/hip jis? Weight loss, pain of unknown origin, increased ‘ain a nigh, malozo; consort pin no! toleved ly ret, night west, enlorged hmph nodes Subseral poin; shores of broth increased ‘ain wih exertion: Frequent le shoulder, medial arm, ond jaw paint” Referral pater is to the ipsilateral subcostal ‘ond costovertebral region atthe level of T10-112, pain i ypcaly dll ond aching, may reper! changes in urinary Kequency or Cuppa 7-2 ie Tests oF Criteria Decision and Rationale for Used to Rule In or Rule out Ruling In or Ruling Out Condiions/Diseases Conditions/Diseases Reentgerogram, CT scon, MRP Low liklthood: no raume, plain fim radiographs urremexkable, pein present 3 mo MR, CT scan’? low likelihood: no trauma, no Tombar oF abdomin6! wal pa, ro moter or sensory changes, 1 dermotomal or bond ike pein pater Roenigenagram, CT son, MR Low tthod:paen 40 y of ee eee ese tera lat, no change in toons wih soning woking Roenigenogram, CT scan Low liethood: no moming spinal siffess, loin fn radiographs Lecemarkable, unk flexion WNL Clinical findings and patient Low ikthood: no injury oF presentation "surgery, pain wih ipilotral ‘de bending, pain sharp ond cochy Clinical findings and potion! Low likelihood: no sensory presentation changes or UE poresesias, no headache Loboratery evaluation, ow litalhood: pain worsaned reenigenogram, CT scan®” wih activity or exercze, no {acto ot hip porn, pon lateral othe spine alegre kde lr aki py at ‘loco, bepeySe™0'64 preted pono igh cleo cea a Elecrocaciogon cho. Low kloan ede pin, ‘ardgam radonacide no hones o brea, cleo imagegooes 2 frovke pan wi ied rg oc tonk maton erated al er ic epee See tey a teehee eae Fak cerns. ‘cheng ery copeler frequency (continued) Physical Therapy . Volume 86 . Number 2 . February 2006Table 3. continued ‘Conditions/Diseases Ruled Out after Further Assessment Diagnostic Tests or Criteria Decision and Rotionale for During the Used fo Rule In or Rule out Ruling In or Ruling Out Examination Typical Signs and Symptoms Conditions/Diseases __Conditions/Diseases ‘Muaceaeltl TMusGe sain eecor fen he ress roumo or heavy exerhon, Ce indigo patent Low eood no rauna, pain spinor, lower and tenderness rough muscle bel, point resisted preentaion net localized, poincxcosonaly middle wopezs, motions of specie muscles, pain wally refered to th ight should ‘homboidevs, Ioclzed w afeced muscle, Wpicaly responds or 2 musces, no pain lfssimus doi, 4s dows not pial refer pain" 202 ‘edn wih enonded es levator scopolee, and inercol muse Visceral Pulmonary Inreosed poi wih dep inspiration or coughing: Rodogrophic exoninaton, tow bethood: no cough, ‘ain ofen wal ecaized; pain con relrfo—spitamey, bop, ebertey — dyspnea, or ohgu: pain shop Cntr, lle, r posterior chest may have ealuohen 0s od protelod ae Le orto perisioncough, dyspnea, ard oigu deep mations; lain fim vdiographs ‘hen enshing ype pain” remarkable Bondite pain around midhorac ot level of _Etophogeacopy, radionuclide tow Kaood: no change in pain lesion, feferred pain fo he mid horaic area, maging w>"0 ‘ih ecing: pain ot smploms con improved or worsened by snbanal no noon, ong, nouseo/vomiing, weight los, berbum vomiting, ¢ weight es; 90 ‘or edna poi, stabbing x buning chest bondite pin pei Pain in he right midepigasic region [8-19 Ulrsonogrophy Low tkelnood: no fever, cil, level pin refered tthe migback between scinigrophy-"i#74 unde, nausea; ro change the scopulae, ight upper Rapecivs muscle, and pain wih ingestion of fy ‘igh ubscopulr are, rund eve, chil food indigestion; reuse vomiing,nelerace of fy ods Sete Hepobiliony Fein in ight upper quads of abdomen; pain Ukasonogrphy, CT scan, Low iklhoed: no anorex, refered ight inerscopuar ond subscapular Bopy, loro ‘nausea, vomiting, jaundice, ‘90 righ shoulder pai; crore, nausea, _evelutons” 24 caches, or foigue ‘ering jodie; ota; signieant Tetguesion ne Conditions /Disoases Remaining os Diagnostic Tests or Possibiltes for Criteria Used to Rule In Decision and Rationale for Clinical Working ‘oF Rule Out Conditons/ Ruling In or Ruling Out Hypothesis Typical Signs and Symptoms Diseases Conditions/Diseases ‘yacpophysedl joint More commen in upper ond lower vers mid) lineal ndings and paint Moderate possi pin reset atopathy ‘hotel region,unisera pin ures bier presentation, odvonced in he spinal region, pain [pis ofc) ixonssert nd oveiopping agers chonges evident, meyer reo ‘egnentol eral paterns along te ise! on redogrophic of pain ‘pina rag, el pn refered infrcy kom exominaon'= the lval ofthe jit Cosoversbrol/ Pai localized to the posterior horax pain moy Clinical ndings and patent Song possi: nearly ol Costoranserse joint recat the anterior ches wall sympioms presentation ‘gr/symptons presen), exept dyhincton Unita: pain with deep breathing, coughing/ ron wos nt partly “noezng:neeozed pain wth Hexion, ration pail rd pole side benlng; ppoble pono! esioronsvese on ond bangles ‘Active igge points Pobable ond poirfl ight Bands win muscles, Cline findings and patient Song posibily: patent reported ‘elered pai in chorale paters fer preseason ‘efered pain in choratriste Isc] wih pressure ovr the oil ot terns with poipaton of bbnd, presence ofa al Mh esponse or pinfl bonds within he mide “jump sign'600- tropesivs muscle, be ieee verily he sora posterior superior muscle [MRt=magnei ecnance aging 1 Physical Therapy . Volume 86. Number 2. February 2006 Fruh 261