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"Dizzy" case presentation 2
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"Dizzy" case presentation 2 - July 4, 2006 7:17:00 AM
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Dr.Wagner
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A 45 year old female presents with the primary complaint of being "dizzy"...
Go
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Dr. Wagner DO
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Re: "Dizzy" case presentation 2 - July 4, 2006 8:35:00 AM
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jma
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1. When did this begin? Is this the first time this has happened? If not, how many times has she experienced her "dizziness".
2. When does/did this occur? Did it happen in the morning/afternoon/evening? Did/does it occur after performing certain activities or did/does it arise even at rest?
3. What is her current health status? Is she taking any medications? Did she ever notice the "dizziness" while taking the medications, if any?
4. Are there certain body positions that bring on the dizziness? Are there certain positions that alleviate the dizziness when it does occur?
5. When the dizziness occurs, does she feel like she will lose her balance? Does she feel like she is spinning or the room spinning?
JMA
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Re: "Dizzy" case presentation 2 - July 5, 2006 3:35:00 AM
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USAPT
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What does she mean by "dizzy"?(pt., please be more specific)
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Jason, PT
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Re: "Dizzy" case presentation 2 - July 5, 2006 4:24:00 PM
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Dr.Wagner
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The patient looks at you (you notice she has one eye patched), she states "I feel off balance, sometimes the room spins, other times I do"
Most recently this happened 2 days ago...but I had this happen to me once before, about a year ago."
"Nothing changes the sensation, I just feel better when I am not walking around"
When you ask her about past medical history and meds she states "I sometimes get headaches, but I don't take any medications...I am on birth control, I have had my gall bladder taken out and my appendix taken out"
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Dr. Wagner DO
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Re: "Dizzy" case presentation 2 - July 5, 2006 4:42:00 PM
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Sean_Collins
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As a PT, if a patient came to me with a prescription (or referral) for PT with the diagnosis of "dizzy" I would first have to know what was done by the physician to come up with that diagnosis. So, first - did she see a physician for this symptom? What was done? Any tests? Are they ruling out anything? Or did she just walk into PT one day?
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Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: "Dizzy" case presentation 2 - July 5, 2006 5:04:00 PM
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drbuddy
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What is the reason for the eye patch?
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Re: "Dizzy" case presentation 2 - July 6, 2006 3:19:00 AM
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Shill
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I think she's a pirate. Hang on to your wallet. Does she have a peg leg? ARGH.
Or, she may have diplopia, and the patch "fixes" this for her. Where she got the patch (and of course why she wears it) would be a good question to ask. Visual changes in a pt at this age who is on birth control and a smoker may mean that TIA should be ruled out.
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Steve Hill PT
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Re: "Dizzy" case presentation 2 - July 6, 2006 5:12:00 AM
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Dr.Wagner
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You ask her about the eye patch and she states...
"Well, I AM a pirate, but that isn't why I wear the patch...I have double vision, this clears it up"
As for the referral, the physician didn't order anything yet, is currently out of the office.
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Dr. Wagner DO
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Re: "Dizzy" case presentation 2 - July 6, 2006 5:19:00 AM
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Sean_Collins
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So why is she in the Physical Therapist's office?
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Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: "Dizzy" case presentation 2 - July 6, 2006 7:11:00 AM
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Dr.Wagner
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I must restate.
She says "I have had a CAT scan a year ago, it didn't say anything"
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Dr. Wagner DO
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Re: "Dizzy" case presentation 2 - July 6, 2006 7:19:00 AM
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Sean_Collins
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This just does not sound like a patient that would wander into a PT clinic. Perhaps an ER, or a physicians office, but not your ordinary PT clinic. Is the point that IF it did happen the PT needs to know what to do - besides sending them to a physician?
Also - a CT scan a year ago - from patient report - does this say much at all about what is going on now?
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Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: "Dizzy" case presentation 2 - July 6, 2006 7:27:00 AM
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Dr.Wagner
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Sean please, this is a case of differential diagnosis. A chance to actively work out a problem with a patient with a vague "medically complex" presentation.
I am not asking for treatment.
I am asking for a way to systematically work through a problem of differential diagnosis.
Please, if you do not wish to participate, please do not ruin this discussion with others.
Thank you.
If there is anyone left, plese lets continue this case.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: "Dizzy" case presentation 2 - July 6, 2006 7:36:00 AM
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Sean_Collins
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I understand the concept of differential diagnosis, however, I also understand when a patient does not belong in a PT clinic being worked up by a PT when there has not been a ruling out of other medical conditions. You are presenting cases that come from the ER to Physical Therapists - last I checked PT's do not work in the ER. I really do not understand the benefit of cases like this to the development of differential diagnosis for a physical therapist. Perhaps asking therapists that work in outpatient clinics suggest cases from their actual case loads, and then you, as an ER physician can assist them in their differential diagnosis?
I am not trying to be disruptive, I merely desire an appropriate direction to this activity, and cannot just sit aside while this happens without providing my opinion.
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Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: "Dizzy" case presentation 2 - July 6, 2006 8:04:00 AM
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drbuddy
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Why did she have the CAT scan done?
I'd also ask her if she had any other doc's examine her for her vision problems. If so, ask what they came up with or ask to see her medical records.
I agree with Sean to a point. I'm not so sure this would walk into a PT's office, and if it did, no one would expect the PT to manage it. But, this exercise could be helpful nonetheless. I think it's important to understand the clinical reasoning behind ddx. If you do, you might pick up on things the physician misses. Beleieve it or not, MDs and DOs can be way off the mark at times.
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Re: "Dizzy" case presentation 2 - July 6, 2006 8:10:00 AM
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Sean_Collins
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I agree that ddx is critical, and even if the physician provider was off the mark with this case - there would at least be a mark, so the PT would know what they had done, were thinking, etc.
I will not interupt again, unless I have somethind to add to the case.
Best
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Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: "Dizzy" case presentation 2 - July 6, 2006 12:20:00 PM
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USAPT
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what are her vitals? anything out of ordinary to correlate with her other complaints?
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Jason, PT
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Re: "Dizzy" case presentation 2 - July 6, 2006 3:45:00 PM
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jma
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From: NY
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Did an opthalmologist examine her in the past? What was the cause of her diplopia? Was there a reason it could not be corrected and that she has to use a patch instead?
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Re: "Dizzy" case presentation 2 - July 6, 2006 4:27:00 PM
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FLAOrthoPT
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sean this is way more common of a scenario than you may realize, and even if it is not the primary reason you are seeing her, you may be the one to help figure something out a doctor misses, you spend WAY more time on a clinical eval than ANY other medical professional, so you must be ont he lookout, even if all she came in was for trap strain, but started telling you some of this, you better catch something like this...
ps, test her cranial nerves. get more details about her headaches. keep going I love these things...
Ben Galin, PT, DPT, OCS
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Re: "Dizzy" case presentation 2 - July 6, 2006 7:43:00 PM
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Dr.Wagner
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From: Indianapolis
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Sean, I post based upon ALOT of positive feedback in the past. I post because I enjoy it.
I post because I doubt many physicians would.
I post because perhaps much of this can bring pieces of pathology together for people...these cases have REAL answers...
Back to the patient.
"well, I had a CAT scan because there was this time I had blindness in my right eye for a day...that went away"
You check the vitals
HR 90, BP 110/70, RR 18, o2 sat 98%
You check cranial nerves
You remove "the patch"
There appears to be a dysfunction of CN III and VI
All other cranial nerves are intact
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: "Dizzy" case presentation 2 - July 7, 2006 12:13:00 AM
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Sean_Collins
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From: Massachusetts
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Understood - please accept my apologies, ignore my previous posts, and enjoy the rest of the case.
Regards -
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Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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