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Re: CASE 1
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Re: CASE 1 - January 10, 2006 5:33:00 PM
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Randy Dixon
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I'd tell the Mom to buy lots of Sesame Street tapes.
Well, that's what stands out, that and sudden onset, which rules out a lot of other things. Heart rate 140, I think that is WNL.
I'd think it was time to look past the UE and look at other things. Maybe ribs or stomachache, though I don't know why sitting resolves pain. Have we seen this kid stand? Would that make any difference? What I have is:
No signs of trauma.
pain relieved either by sitting or attention distraction.
moving arm is painful, but no signs of arm injury. Held to side.
vitals normal
no sign of head or general neurological problems.
I don't know, palpate the abdomen and chest? I'd still be looking at the elbow but once we get past the orthopedic/first aid level I'm pretty much lost.
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Re: CASE 1 - January 11, 2006 12:03:00 AM
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Dr.Wagner
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From: Indianapolis
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I will give the answer and discussion this evening (after work and before LOST)...I can tell you there has been a correct answer stated.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: CASE 1 - January 11, 2006 2:24:00 AM
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SJBird55
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From: Michigan
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I would assume that if you wanted to rule out a spider bite, you'd need some kind of blood work. (Don't ask me what because I am definitely not knowledgeable about labs and LOVE the fact that if patients bring in their lab results the abnormal findings are in bold and the normal range is off to the left. LOL)
What x-rays did you order? What was normal?
I would ask the mom what happened anywhere up to a half hour prior to her "finding" the kid behind the couch crying. If the mom says "nothing," ask her if she picked the kid up by the right arm. If the mom denies, then maybe the kid was trying to climb up the back of the couch and was reaching way up and trying to pull the body up. Are there any older siblings - maybe a sibling picked the kid up by the one arm. Radial head subluxation would be common in kids up to 5 years of age... Ask the mom if the kid likes to climb.
Wags, if this case is just a radial head subluxation, you're slipping. LOL The only reason I wouldn't guess that is because it is common and you always have a twist of some sort...
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Re: CASE 1 - January 11, 2006 3:36:00 AM
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gerry
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From: Montgomery, AL, USA
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I think Randy got it with nursemaids elbow. Had a couple of these at our house when the kids were younger. One spontaneously reduced while taking a bath in warm water. Allowed the child to relax and reach when they were not thinking about it. Another was at night after church, and our pediatrician said to run by her house where she reduced it. The lack of discomfort while just watching TV, pain on movement, and the position of holding the arm next to the body seem to indicate this diagnosis.
I understand reduction happens frequently during x-rays when the tech tries to get the elbow extended for the films. Reduction is by extension/supination, right?
As for the mechanism of injury, could have been from falling off the sofa and trying to hold on with one arm. Or perhaps the mom pulled her up from the floor by her arm, and now feels guilty about causing the pain.
Looking forward to hearing the answer...
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Re: CASE 1 - January 11, 2006 10:52:00 AM
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Jeep
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I'll second nursemaid's elbow.
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Re: CASE 1 - January 11, 2006 10:55:00 AM
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Dr.Wagner
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From: Indianapolis
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Well this is the classic presentation of...
Nursemaid's Elbow .
This requires NO X RAYS.
This is a very very classic case (very true case, just had 3 similar over the weekend), children will hold their arms at their side and cry ONLY when moved, otherwise they are fine.
There is no testing or blood work required (unless unsuccessful after several attempts at relocation)
There are two movements that reduce the joint, Flexion-Supination or Hyperpronation...then allow the child to play undisturbed, the child will move when ready.
There is no splinting or slinging.
The exam usually is completely normal except for the childs lack of movement.
I realize this was relatively basic...but that is the point, some cases are easy some are deceptive. I think we still got a WIDE range of answers, with no clear plan.
As for the Spider bite...if so, there is still NO testing required...but the spider is required for identification. Usually it is only local wound care as needed.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: CASE 1 - January 11, 2006 10:57:00 AM
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FLAOrthoPT
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From: West Palm Beach
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so, it wasn;t an ice block that had melted?
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Re: CASE 1 - January 11, 2006 11:28:00 AM
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karmzack
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From: Hawaii
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LOL Ben, good stuff! The ice block/spider bite scenario is bound to be presented at some point.
Thanks for the case Wags.
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Zack Solomon MPT, OCS, CSCS
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Re: CASE 1 - January 11, 2006 11:48:00 AM
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SJBird55
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From: Michigan
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Do any of you watch CSI Vegas? There was one episode where some dude was sitting in his recliner with an ice block and a fan to cool him. I can't remember the details of the death, but it was electrical in nature - hmm, the combination of the melting ice and electriciy... something about the phone or his foot or something.
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Re: CASE 1 - January 12, 2006 3:28:00 PM
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Sean_Collins
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From: Massachusetts
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perhaps the diagnosis does not require an xray to diagnose - however - are PT's really supposed to be making such differential diagnoses without medical supervision - even with direct access?
_____________________________
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: CASE 1 - January 12, 2006 5:51:00 PM
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Dr.Wagner
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Well of course not, but the idea is to allow for some new thought processes.
Besides, there is an entire forum dedicated to radiology, so I assumed some people were interested.
Furthermore, one must understand the importance of cost control, not to xray everything, and when thinking broadly at differential diagnosis NOT to forget about the physical exam JUST BECAUSE a wide variety of tests may be at hand...which is exactly what was done.
Too many midlevel providers (PA's and NPs) would like to shotgun everything...rather than exam. This thought process needs to be examined and fine tuned.
_____________________________
Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: CASE 1 - January 13, 2006 12:02:00 AM
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Sean_Collins
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From: Massachusetts
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"Well of course not, but the idea is to allow for some new thought processes" - I am assuming you are refering to my question: "are PT's really supposed to be making such differential diagnoses without medical supervision - even with direct access?"
If I am correct - should the new thought processes be geared toward scope of practice of the physical therapist as opposed to physicians? Do such cases and examples for PT's confuse the scope of practice issue, and make it more difficult for therapists to contribute to an understanding of what direct access, autonomy, PT diagnose are within the scope of PT practice?
_____________________________
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: CASE 1 - January 13, 2006 1:00:00 AM
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Sebastian Asselbergs
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Sean, I feel that the more I know of possible pathologies that MAY present themselves in my clinic, the better my management can be. I have direct access, don't need a script (referral) from a physician to eval and treat, and I am after many years, more careful than I have ever been with referring back to medical doctors - despite the fact that I have learned immeasurably more than when I graduated. And not just within my scope: in the fields of psychology, sociology, oncology, carpentry, indian cooking, pharmacology, orthopeadics, radiology etc etc. A case like this one by Doc Wagner - interesting and good to know (Thanks Wags). I can really be trusted to NOT lose sight of our standards of practice or code of ethics - no matter what information and knowledge I decide to obtain. It does not mean I will diagnose and treat this child's elbow - it means I can be aware of the condition and it's presentation - that's all.
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Mundi vult decipi
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Re: CASE 1 - January 13, 2006 1:38:00 AM
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SJBird55
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Sean, have you ever been to Bill Boiss. (can't spell that name) differential diagnosis course? Have you ever been to Robert DuVall's differential diagnosis course? They definitely present issues that we as therapists are not the appropriate personnel to be involved in the issue. It is within the scope of our practice to convey our findings and convey our impression and refer on when appropriate. (The most important thing is to know when to treat and to know when to refer.) I don't believe it is our role to send every single case that we are unsure of to the ER. It's perfectly acceptable to assess and question and attempt to problem solve.
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Re: CASE 1 - January 13, 2006 2:16:00 AM
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Sean_Collins
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From: Massachusetts
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I have not been to the courses - nor does anything presented in those courses represent anything other than 2 individuals opinions of what is necessary in such a course.
I agree that it is within our scope of practice to examine and evaluate to convey our impression if we have to refer. And that it is important to know when to treat and when to refer - this is the entire point of the direct access movement. I also agree that it is not our role to send all cases to the ER - but in cases you are unsure of based on the history, and can possibly be dangerous to perform examinations on until certain (worst case scenario) diagnoses are ruled out should be sent to the ER for medical evaluation.
For example - if there is the potential that my patient has coronary artery disease and stable angina - do I continue to evaluate the shoulder pain and maybe even differentially diagnose the stable angina by putting them on the treadmill to assess the angina to increased exertion? No, I send them to the ER to rule out the angina.
In this case - I saw a potential for a worst case scenario of a fracture - maybe not even a normal one - maybe pathological (again worst case scenario). I have seen 2 cases of children doing routine things (just playing as children play) and they end up having fractures - its only a few - and epidemiologically or from a cost effective approach using "decision analysis" perhaps an xray was not the first thing that shoudl have been done, but how much pain, suffering and damage is risked by mobilizing for the sake of examination before ruling out the worst case scenario - especially with the history that was presented?
Sabastian - I am not saying that I cannot trust YOU NOT to lose sight - I am saying that as a profession our dialogue needs to keep in mind the full spectrum of issues, and not merely enter in routine discussion of issues that are beyond our scope without even pointing out the fact that they might be beyond our scope - for fear that those discussions might become so routine that we lose sight, or that others who over hear our conversations might take them out of context. As individual professionals we are responsible for ourselves, but also collectively for the profession. With this responsibility for the profession we need to be aware of how our individual actions influence the entire body realizing that we do not have individual control over every part of the profession. We cannot determine how this conversation might impact a student or new clinician - we cannot determine whether it would lead them to examine a case that should really be sent to the ER because they feel that they need to have something to say - other than - I want to rule out the worst case scenario first -
This is different than identifying that altered menstrual periods might be associated with the back pain of a young female patient post miscarriage - this sort of differential diagnosis does not carry with it risk to the patient when examining the back pain - But rather leads to a medical referral when the back pain does not fit into any regular pattern associated with MSD and the patient has this history of gynecological issues.
Is the difference between these clear? Please do not interpret anything I am saying as restricting to the professional decision making of physical therapists - just trying to keep several aspects of the discussion in the open.
I do greatly appreciate the case by Dr. Wagner - and the tremendous amount of response from members. I merely want to point out that sending them to the ER is one course of action, and it is not, nor should it be, in my opinion be considered a decision that goes against direct access, or autonomy of the physical therapist within their practice.
_____________________________
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: CASE 1 - January 13, 2006 2:25:00 AM
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Sean_Collins
Posts: 74
Joined: October 20, 2005
From: Massachusetts
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I need to make a correction to my last post: I said:
"I have not been to the courses - nor does anything presented in those courses represent anything other than 2 individuals opinions of what is necessary in such a course"
I should have said: "I have not been to the courses - nor does anything presented in those courses NECESSARILY represent anything other than 2 individuals opinions of what is necessary in such a course"
_____________________________
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: CASE 1 - January 13, 2006 2:59:00 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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Thank you for your thoughtful reply, Sean.
I agree that these types of cases should not be interpreted as within our scope - by students ot newbies to the profession. But that is surely the task of their professors and teachers? Is learning the standards and scope of practice not an essential part of their core curriculum? And if a discussion of cases outside our scope would be used by a lurking student as a guideline to apllu in practice, - well, that student has failed to grasp the lessons of scope of practice. And then this online discussion would not really be the core issue - rather the lack of understanding the standards of practice. And that does not bode well for his or her future practice.
I have been involved in clinical supervision of PT students and have been on university faculty - standards of practice here are so well-defined, that we can send a student into an OR to observe and we can rest assured that s/he will NOT perform this type of action in practice (tongue-in-cheek!).
I do not want to hi-jack this thread, but I believe we should expect MORE from our PT students and their level of applicable knowledge - not less.
i'll shut up now....
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Mundi vult decipi
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Re: CASE 1 - January 13, 2006 3:05:00 AM
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SJBird55
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From: Michigan
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Or Sean, another decision could be to assess the situtation and then phone the primary care physician and communicate that you have one of his/her patients in your clinic right now and that the kid may have nursemaid's elbow. What would the physician prefer be done - a) patient head to physician office right now for care or b) patient head to the ER? In the above case, it wasn't life and death - the kid wasn't crying when the mom first walked in.
I don't know about you, but where I practice, I get a lot of "arm pain," "leg pain," "low back pain." I think you get the idea - combined with "evaluate and treat." We really do diagnose. It gets into semantics whether it is a medical diagnosis or not and we may not document exactly what we may think, but we are treating based on some diagnosis that isn't so broadly general as whatever body part pain. So, my point is, that even in a situation in which we are not practicing direct access, we still need to be as diligent in our assessment skills and in our critical thinking processes to ensure we are treating and referring on appropriately.
Both Bill and Robert do a great job in their courses. The courses are evidence-based, improve critical thinking ability and bring awareness to conditions that mimic orthopaedic conditions. It may be their "opinion," but they definitely have the experience practicing with quite a bit of autonomy such that their "opinion" and their experience does matter. I could be wrong, but I'm pretty sure that they have functioned like physician extenders and have been the first in line for neuromusculoskeletal complaints.
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Re: CASE 1 - January 13, 2006 3:51:00 AM
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Sean_Collins
Posts: 74
Joined: October 20, 2005
From: Massachusetts
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Hi SJ - I do not deny that they likely do a great job with their courses, and I know what you mean about the referrals for arm, leg, back pain that we are left to diagnose. But, these are referrals from the MD - if there was a cause from an MD regarding the suspicion of a fracture that would have already been dealt with in those cases.
I do agree with your other option - assess (without doing anything risky with the possibly worse case scenario) and call the primary care physician.
Sebastian: "But that is surely the task of their professors and teachers? Is learning the standards and scope of practice not an essential part of their core curriculum? " Yes it is, however students leave academics and become ever more influenced by their peers - academics can do its best to invoke a solid foundation - but what these students see in practice has a very strong influence over them. In most cases this is positive - however, I specialize where there is more and more evidence that the tides of the professional/social climate have a tremendous influence on students - this is in the area of vital sign and cardiovascular/pulmonary examination. I train my students and evaluate their skills and decision making. In a two year survey of 65 students on 3 affiliations each, I have data to suggest that what they learn in the class is only applied a fraction (20-30% of the time) - many of the clinicians they work with are previous graduates! The students that graduate have a tendency (not all but many) to tip toward the norm - and the norm is usually lacking in cardiopulmonary areas.
Sorry for the sidebar - thanks for the discussion!
_____________________________
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: CASE 1 - January 13, 2006 5:17:00 AM
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SJBird55
Posts: 2362
Joined: May 10, 2004
From: Michigan
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Nah, Sean, what we are led to believe is that an MD would screen appropriately. If that were always the case and a true assumption, then the patient that was referred to me for treatment from a general surgeon for "shoulder pain" after being tossed from his tractor into the road because a car ran into his tractor wouldn't have taken 2 phone calls from me to the referral with my recommendation that based on my assessment the patient actually had a cervical spine issue and that he needed to be re-assessed. Low and behold he had a cervical fracture - the dude had been to the ER, seen some general surgeon, been to his primary care physician... to this day, I'm still not sure how the heck a cervical fracture got missed by all of them, but it was my "squeakiness" and my final refusal to treat him until that darn cervical spine was ruled out as the factor for all his complaints.
Things like the situation I got into shouldn't happen, but they do. I don't know about anyone else, but just because a physician writes something on a piece of paper doesn't mean that I don't treat the situation as direct access. I always pretend that I don't have that piece of paper and I put on my thinking cap. Direct access or not, our assessment skills and our decision-making process should be the same. We have a decent amount of knowledge as a profession to not have to hide behind a physician's signature.
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