Clinical Diagnosis in Physical Medicine & Rehabilitation E-Book

Case by Case

Dr Subhadra Nori, Michelle Stern, Se Won Lee

• Publisher: Elsevier
• Year: 2020
• ISBN:
  9780323722520
• Topic: Medicine
• Subtopic: Physiotherapy, Physical Medicine & Rehabilitation

Offering a strong focus oninvestigative methods and action strategiesfor diagnosis of musculoskeletal issues, Clinical Diagnosis in Physical Medicine & Rehabilitation: Case by Caseis a must-have resource forquick reference during daily rounds, as well as a handy study and review tool for oral boards. This portable reference covers what approaches to take when a patient presents with specific musculoskeletal issues (including differential diagnoses possibilities), what tests are appropriate to order, how to determine the relevance of results, and what treatment options to consider. Practical and easy to use, it helps youapply foundational knowledge to everyday clinical situations.

• Provides comprehensive, interdisciplinary guidance forclinical diagnosis and problem solvingof musculoskeletal issues that are commonly encountered in an office or clinic setting.
  
  

• Offers acase-by-case analysisorganized by chief complaint, body part, or condition, allowing for optimal on-the-spot reference.
  
  

• Helps physiatrists and residentsthink through every aspect of clinical diagnosis, clearly organizing essential information and focusing on a quick and accurate thought process required by limited time with each patient.
  
  

• Covers neck pain, back pain, total body pain (fibromyalgia), lymphedema, tingling and numbness, gait difficulty, and much more.
  
  

Chapter 1: Neck Pain

Dr. Subhadra Nori, MD

Case History

A 57-year-old woman presents to the Physical Medicine and Rehabilitation (PM&R) clinic with a history of neck pain. She describes her pain as constant. She experiences pain on movement of the neck. This pain has been present for about 4 to 5 months and is progressively worsening. She takes an occasional Tylenol which seems to help but temporarily. There is numbness of the upper left arm; she is unable to sleep because of this pain. She has not seen any other physician nor had any workup.

• Past medical history: She has history of hypertension (HTN) for which she is on Losartan, 25 mg. O.D. for the past 10 years. She is postmenopausal.
• Social history: She works as a school teacher, lives with family in an apartment with elevator on the fourth floor. She has two children aged 18 and 16 years.
• Past surgical history: None
• Allergies: Dust
• Medications: Losartan, 25 mg O.D., occasional Tylenol
• BP: 140/70 mmHg, RR: 14/min, PR: 75 pm, Temp: 97° F, Ht: 5’5, Wt: 130 lbs, BMI: 22 kg/m²

Physical Examination

• Well-developed (WD), well-nourished (WN) lady in moderate distress.
• Head, ears, eyes, nose and throat (HEENT): Extraocular movement (EOM)’s full, no ptosis.
• General: She is alert, oriented and in mild to moderate distress because of L sided neck pain.
• Extremities: No edema, no skin rashes, no surgical scars, no fasciculations seen
• Musculoskeletal examination: Range of motion (ROM) of neck—complete in all directions.

Motor Examination

• Right upper extremity (RUE) all groups 5/5 left upper extremity (LUE) 3/5 deltoid, biceps, and brachioradialis.
• All other muscles were 5/5.
• There was some wasting of deltoid and biceps muscles.
• Deep tendon reflex (DTR)-1+ in biceps, brachioradialis on L 2 and + on R
• Sensory examination: Dull to light touch in lateral forearm on the LUE intact in all dermatomes on the RUE.
• Gait was within normal limits (WNL) without any deviations.
• Tone was normal.
• Labs: White blood cell (WBC) 7000, cell/mL; hemoglobin 12.0 g/dL.

General Discussion

General approach to neck pain. The approach to a patient with subacute onset neck pain is uniquely different from that of acute pain. The initial focus should be to differentiate neurologic disorders from musculoskeletal conditions. The points to focus in the physical examination are muscle wasting of deltoid and biceps. Weakness of muscle supplied by the C5‒C6 roots and depressed reflexes in the C5‒C6 distribution. Sensory loss also conforms to this distribution.

Differential diagnosis should include:

• 1. Discogenic pain—acute disc herniation at cervical spine intervertebral joints can lead to nerve root compression.
• • Symptoms depend upon the level of compression. A herniated nucleus pulposus (HNP) at C4‒C5 will be compressing C5 root causing arm pain, tingling, and root burning that may radiate to fingertips. Muscles supplied (diagram C spine, nerves by root) C5 nerve, that is, deltoid. Therefore a patient with HNP at C4‒C5 will have neurologic symptoms affecting C5 nerve root. Biceps, brachioradialis, and coracobrachialis will be affected (Fig. 1.1).
• 2. Compression fracture—history of trauma usually precedes. Examination reveals pain and tenderness at spine level worsening with flexion. Compression fracture can be caused by traumatic or nontraumatic causes.
• 3. Strains and strains—diffuse neck pain following a motor accident vehicle usually referred to as “whiplash.” Examination is positive for neck tenderness diffusely, usually no neurologic symptoms exist.
• 4. Osteoarthritis/spondylosis—refer to generalized osteoarthritis (OA) in an elderly patient, usually pain is worse with activity. Flexion may cause more pain than extension. Neurologic symptoms are seen in the distribution of nerve root that is compromised.
• 5. Connective tissue disease—multiple joint arthralgia, fever, weight loss, fatigue and other systemic symptoms are seen. Examination reveals spinous process tenderness and other joint tenderness.
• 6. Inflammatory spondylarthropathies—present as neck pain with intermittent pain, morning stiffness worsening with activity.
• 7. Malignancy—constant pain, worsen in supine position. Systemic manifestation, such as weight loss, may accompany.
• 8. Vertebral discitis—constant pain, often no fever, normal blood count but C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are frequently elevated.

• 

  Fig. 1.1 Nomenclature of spinal nerves, posterior view.
  From R.L. Drake, W. Vogl, A.W.M. Mitchell. Gray’s Anatomy for Students, 4e. Elsevier, Philadelphia, 2020, Fig. 1.25.

• 9. Cervical myelopathy—present in 90% of individuals by the seventh decade and is the most common form of spinal cord dysfunction in people over 55 years of age. Upper motor neuron signs and symptoms.
• • Referred pain: lung cancer—both small cell and adenocarcinoma can metastasize to cervical spine and cause epidural or extradural metastasis, likewise breast cancer can metastasize to cervical spine.
• 10. Cervical myeloradiculopathy—believed to occur because of spondylosis and repetitive compression damage to C-spinal cord and roots. ¹ Anterior spondylitic spurs, posterior longitudinal ligament in folding can also cause compression. Acute flexion extension injuries can initiate compression of an already compromised C-spine because of spurs, osteophytes, and thickening of ligaments.
• • Signs and symptoms are characterized by weakness in lower extremities, gait disturbances. Spasticity and upper motor n...