Chapter 9 Differential Diagnosis. Overview Differential diagnosis involves the ability to quickly differentiate those problems of a serious nature from

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  • Chapter 9 Differential Diagnosis
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  • Overview Differential diagnosis involves the ability to quickly differentiate those problems of a serious nature from those that are not Differential diagnosis involves the ability to quickly differentiate those problems of a serious nature from those that are not Problems of a serious nature include, but are not limited to visceral diseases, cancer, infections, fractures and vascular disorders Problems of a serious nature include, but are not limited to visceral diseases, cancer, infections, fractures and vascular disorders
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  • Referred Pain The term referred pain is used to describe those symptoms that have their origin at a site other than where the patient feels the pain The term referred pain is used to describe those symptoms that have their origin at a site other than where the patient feels the pain
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  • Referred pain Referred pain can be generated by: Referred pain can be generated by: Convergence of sensory input from separate parts of the body to the same dorsal horn neuron via primary sensory fibers Convergence of sensory input from separate parts of the body to the same dorsal horn neuron via primary sensory fibers Secondary pain resulting from a myofascial trigger point Secondary pain resulting from a myofascial trigger point Sympathetic activity elicited by a spinal reflex Sympathetic activity elicited by a spinal reflex Pain-generating substances Pain-generating substances
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  • Referred Pain Macnab recommends the following classification for referred pain: Macnab recommends the following classification for referred pain: Viscerogenic Vasculogenic Neurogenic Psychogenic Spondylogenic
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  • Viscerogenic Pain Viscerogenic pain may be produced when the nociceptive fibers from the viscera, synapse in the spinal cord, with some of the same neurons that receive pain from the skin. Viscerogenic pain may be produced when the nociceptive fibers from the viscera, synapse in the spinal cord, with some of the same neurons that receive pain from the skin.
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  • Viscerogenic Pain Visceral pain has five important clinical characteristics: Visceral pain has five important clinical characteristics: 1.It is not evoked from all viscera 2.It is not always linked to visceral injury 3.It is diffuse and poorly localized 4.It is referred to other locations 5.It is accompanied with autonomic reflexes, such as the nausea, and vomiting
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  • Vasculogenic Pain Vasculogenic pain tends to result from venous congestion or arterial deprivation to the musculoskeletal areas Vasculogenic pain tends to result from venous congestion or arterial deprivation to the musculoskeletal areas Tends to mimic a wide variety of musculoskeletal, neurologic, and arthritic disorders, as this type of pain is often worsened by activity Tends to mimic a wide variety of musculoskeletal, neurologic, and arthritic disorders, as this type of pain is often worsened by activity
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  • Neurogenic Pain Neurogenic pain is pain that is referred from a neurological structure. Neurogenic pain is pain that is referred from a neurological structure. Neurogenic causes of pain may include: Neurogenic causes of pain may include: A tumor compressing and irritating a neural structure of the spinal cord, meninges A spinal nerve root irritation Peripheral nerve entrapment Neuritis
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  • Scanning Examination The tests of the Cyriax upper or lower quarter scanning examination can be used to: The tests of the Cyriax upper or lower quarter scanning examination can be used to: Examine the patients neurological status Examine the patients neurological status Highlight the presence of a lesion to the central or peripheral nervous systems Highlight the presence of a lesion to the central or peripheral nervous systems Help rule out any serious pathology such as a fracture or tumor Help rule out any serious pathology such as a fracture or tumor
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  • Scanning Examination The upper quarter scanning examination is appropriate for upper thoracic, upper extremity, and cervical problems The upper quarter scanning examination is appropriate for upper thoracic, upper extremity, and cervical problems The lower quarter scanning examination is typically used for thoracic, lower extremity, and lumbosacral problems The lower quarter scanning examination is typically used for thoracic, lower extremity, and lumbosacral problems
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  • Scanning Examination The tests included in the scanning examination include strength testing, sensation testing (light touch and pin- prick), deep tendon reflexes, and the pathological reflexes The tests included in the scanning examination include strength testing, sensation testing (light touch and pin- prick), deep tendon reflexes, and the pathological reflexes
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  • Scanning Examination At the end of each of the scanning examinations, either a medical diagnosis (disc protrusion, prolapse, or extrusion, acute arthritis, specific tendonitis, or muscle belly tear, spondylolisthesis or stenosis) can be made, or the scanning examination is considered negative At the end of each of the scanning examinations, either a medical diagnosis (disc protrusion, prolapse, or extrusion, acute arthritis, specific tendonitis, or muscle belly tear, spondylolisthesis or stenosis) can be made, or the scanning examination is considered negative
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  • Psychogenic Pain Psychogenic (non-organic) pain is characterized by abnormal illness behaviors Psychogenic (non-organic) pain is characterized by abnormal illness behaviors Commonly exhibited by patients suffering from depression, emotional disturbance, or anxiety states Commonly exhibited by patients suffering from depression, emotional disturbance, or anxiety states All patients should be given the benefit of the doubt until the clinician, with a high degree of confidence, can rule out an organic cause for the pain All patients should be given the benefit of the doubt until the clinician, with a high degree of confidence, can rule out an organic cause for the pain
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  • Spondylogenic Pain Spondylogenic pain is pain referred from a vertebral lesion Spondylogenic pain is pain referred from a vertebral lesion Characteristics of a spondylogenic lesion include: Characteristics of a spondylogenic lesion include: Severe and unrelenting pain The presence of a fever Bone tenderness Unexplained weight loss
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  • Generalized Body Pain Two conditions that can cause generalized body pain: Two conditions that can cause generalized body pain: Fibromyalgia Myofascial pain syndrome (MPS)
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  • Fibromyalgia Poorly understood complex of generalized body aches that can cause pain or paresthesias, or both, in a non-radicular pattern Poorly understood complex of generalized body aches that can cause pain or paresthesias, or both, in a non-radicular pattern Not a disease, but rather a syndrome with a common set of characteristic symptoms, including widespread pain and the presence of a defined number of tender points Not a disease, but rather a syndrome with a common set of characteristic symptoms, including widespread pain and the presence of a defined number of tender points
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  • Fibromyalgia A positive tender point count of 11 or more of 18 standardized sites, when present in combination with the history of widespread pain, yields a sensitivity of 88.4% and a specificity of 81.1% in the diagnosis of fibromyalgia A positive tender point count of 11 or more of 18 standardized sites, when present in combination with the history of widespread pain, yields a sensitivity of 88.4% and a specificity of 81.1% in the diagnosis of fibromyalgia
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  • Myofascial Pain Syndrome Characterized by the presence of myofascial trigger points (MTrPs) Characterized by the presence of myofascial trigger points (MTrPs) A MTrP is a hyperirritable location, approximately 2 to 5 cm in diameter, [86]within a taut band of muscle fibers, that is painful when compressed and that can give rise to characteristic referred pain, tenderness, and tightness
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  • Causes of Head and Facial Pain Trauma Trauma Headaches Headaches Migraine Two types of migraine headaches: migraine without aura (common migraine), and migraine with aura Two types of migraine headaches: migraine without aura (common migraine), and migraine with aura Migraine without aura: Symptoms are typically unilateral with a pulsating quality of moderate or severe intensity. Aggravated by routine physical activity, and is associated with nausea, auras, photophobia, and phonophobia Migraine with aura: Characterized by reversible aura symptoms, which typically develop gradually over more than 4 minutes, but last no longer than 60 minutes
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  • Causes of Head and Facial Pain Headaches Headaches Cluster Severe unilateral retro orbital headaches Severe unilateral retro orbital headaches Often accompanied by nasal congestion, eye-lid edema, rhinorrhea, miosis, lacrimation, and ptosis (drooping eyelid) on the symptomatic side Often accompanied by nasal congestion, eye-lid edema, rhinorrhea, miosis, lacrimation, and ptosis (drooping eyelid) on the symptomatic side Patients feel better during a headache by remaining in an erect posture and moving about Patients feel better during a headache by remaining in an er