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Re: Help on a complex case-differential diagnosis
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Re: Help on a complex case-differential diagnosis - January 10, 2006 4:11:00 PM
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eam
Posts: 291
Joined: February 5, 2004
From: New York, NY 10028
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Hi gang-
I saw my patient tonight. Cerv. Rotation and Spurlings were +,Distraction and ULTT were -.
She was sore after the IE but over the weekend felt like she was stronger; able to lift her tea kettle and hold it better. A little stronger. Her neck was sore but her peripheral sx's were better.
I have 2 more visits left and a physician who is adamant that she has adhesive capsulitis. I re-checked her shoulder ROM and it was WNL's. Some shoulder pain at the end range of flexion and ER but otherwise normal.
My problem is that I have patient who continues to ask me if my findings confirm the MD diagnosis. And the MD is a VERY GOOD referral source to the practice. Any ideas from a clinical and/or business point of view?
Thanks!
Erica
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Re: Help on a complex case-differential diagnosis - January 10, 2006 6:30:00 PM
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paulpt
Posts: 164
Joined: May 31, 2005
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Erica... here would be my take on things:
obviously this patient has BOTH the cervical radic and the frozen shoulder. Since she has been responding well to your FS Rx, you are focused on her neuro symptoms more. Perhaps since her FS was so significant the other symptoms were less prevalent at the time he saw her initially. Maybe her limited ROM made it difficult for the doc to sense the neuro signs, and maybe that was not the chief complaint at the time of her visit.
The bottom line(s) on this one
It is possible to be respectful to the physician and proud of your dilligent work at the same time.
And tell the patient to get better insurance. Or work out a cash pay program.
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Re: Help on a complex case-differential diagnosis - January 11, 2006 3:36:00 AM
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TLB
Posts: 353
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From: Arizona
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Sorry Paul but adhesive capusulitis doesn't clear in 2 visits especially after onset of 7 days. I would tell the pt. that yes the MD is correct in his/her dx and many times there are multiple issues that can contribute to both neck and shoulder pain. Good luck and don't lose that referral source, now if we had true direct access my answer might be a little different. I would give them some literature on adhesive capusulitis (risk factors, sx and so forth), ask does this sound like you, and explain if it doesn't that if the cervical is left untreated your shoulder problems could advance. Hope this helps.
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Todd
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Re: Help on a complex case-differential diagnosis - January 11, 2006 4:16:00 AM
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TLB
Posts: 353
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From: Arizona
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Erica,
This also could be a great opportunity for you to market that MD by maybe supply lunch and an inservice to the staff on the etiological considerations, pathophysiology, the stages of adhesive capusulitis. You could even make a lamenated cards with this information on it that could be handed to pt's at the MD's office who show signs of AC (of course your name, #, and address would be on the bottom of the card). I would definitely sit down with the MD beforehand and give him some of the research, discuss "what he looks for" and get his ideas on the subject. He just might become your best referral source and every script that comes in the door from him will have your name on it. Good luck.
_____________________________
Todd
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Re: Help on a complex case-differential diagnosis - January 11, 2006 11:54:00 AM
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eam
Posts: 291
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From: New York, NY 10028
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Paul and Todd,
Thanks for the replies. Paul, just to clarify, I was not treating a frozen shoulder, I was treating her neck. And unless she guarded tremendously in her movmement with the MD, then it is highly unlikely that she has the frozen shoulder and it cleared up in 3 days. I will see her on Friday and see how she is.
Erica
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Re: Help on a complex case-differential diagnosis - January 12, 2006 4:47:00 AM
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paulpt
Posts: 164
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Todd. I hope you are aware that I understand that Adehsive caps does not clear up that quickly... and everything else you mentioned is just a better way of saying what I tried to earlier.
But why does this patient only have 4 PT visits?
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Re: Help on a complex case-differential diagnosis - January 14, 2006 5:02:00 AM
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eam
Posts: 291
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From: New York, NY 10028
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Paul and everyone-
The patient is a student on the cheap student insurance (basic type) and is only allowed 4 visits per condition.
I spoke with the MD and he does agree that there is a neck component but still is pretty adamant that the patient has adhesive capsulitis. He told me that he diagnosed it as follows: The patient can lift her arm up in sitting/standing to about 90 degrees in flexion and abduction and then starts to compensate with the upper traps etc. He also states that her ER is somewhat limited in sitting.
Then when he prevents the upper trap compensation with his hand her ROM is more limited. This is despite he never got her on the table to assess the ROM in supine. (which I have, and it is full) I check it every time she comes in. I have seen alot of frozen shoulders and this is not typical of the ones I have seen. I have been treating her neck and she is getting better.
Am I crazy to assume that he is off on his method of diagnosis with this? (I have half a mind to do grade 1 mobs to the shoulder -like a little placebo, sort of, just to placate the patient and the MD and see how she does!)
Erica
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Re: Help on a complex case-differential diagnosis - January 14, 2006 7:54:00 AM
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nari
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From: Australia
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Erica
i think he is off on his method, but many MDs are a bit fixated on the adhesive capsulitis theme. If you have to follow what he says, why don't you do what you have half a mind to do? Continue with the neck Mx and 'modulate' the shoulder? Might work very well....
Nari
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Re: Help on a complex case-differential diagnosis - January 14, 2006 4:00:00 PM
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eam
Posts: 291
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From: New York, NY 10028
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Nari-
I agree. I think what bothers me more is that patients view physical therapists as extensions of the MD script and not a separate clinical entity of our own. (I know that is a different topic altogether). So, hopefully, my little shoulder modulation will work. Thanks!
Erica
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Re: Help on a complex case-differential diagnosis - January 14, 2006 7:43:00 PM
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nari
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Erica
I appreciate your quandary about patients in the USA expecting PTs to follow a script.
You'll have to get sneaky...a sort of compromise, as you say.
Good luck!
Nari
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Re: Help on a complex case-differential diagnosis - January 15, 2006 10:50:00 AM
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Rwantz
Posts: 84
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From: Middletown, PA
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Hold on, how can a PT not follow a physician's script if they practice under the guidance of a physician. If the physician wants something, then why would the PT not provide it as the physician has prescribed. Would a pharmacist offer a patient a different medication because the pharmacist feels that the doctor could have ordered something stronger or more appropriate? If the physician orders something, at least consider it. If you feel that the physician is totally off base, how about if you call them and use your persuasiveness to have the physician reconsider or reevaluate. Sounds like common sense to me.
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Re: Help on a complex case-differential diagnosis - January 15, 2006 11:08:00 AM
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nari
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From: Australia
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Rwantz
Why are they practising under the guidance of a physician in the first place?
There is no problem with what you say, otherwise.
Nari
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Re: Help on a complex case-differential diagnosis - January 15, 2006 3:20:00 PM
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eam
Posts: 291
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From: New York, NY 10028
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Rwantz-
I do not practice under the guidance of a physician. I am not a Physicians Assistant; I am a Physical Therapist. Unfortunately I do not live in a direct access state and need the Rx for legal purposes. With this particular case, I felt the diagnosis was off base and this poor girl only had a limited amount of visits and as a practicing clinician that I am, I felt duty bound to talk the physician re: the diagnosis as the patient constantly asked me.
I am seeing her on Tuesday so we will see how she is.
Erica
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Re: Help on a complex case-differential diagnosis - January 16, 2006 5:21:00 AM
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Dr.Wagner
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From: Indianapolis
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I agree with the musculoskeletal thoughts...I think it is bizarre that the patient decided to take TB meds, based solely on a positive TB test...simply wierd
By the way...Isoniazid (TB med) is has a 10-20% chance of causing a PERHIPHERAL NEUROPATHY.
Feel free to post such cases in the Medical Complexity forum...that is why I am here!!
_____________________________
Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Help on a complex case-differential diagnosis - January 16, 2006 5:38:00 AM
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jma
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From: NY
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I'm curious, now that you mentioned the medication. Eam, was the individual still on or off the medication during the PT treats?
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Re: Help on a complex case-differential diagnosis - January 18, 2006 9:37:00 AM
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eam
Posts: 291
Joined: February 5, 2004
From: New York, NY 10028
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Interesting about the TB meds-I mentioned that to the MD after the evaluation but he said he would not affect anything. It seemed a little too coincidental-as it was the only thing that changed in her life since her problem started.
Dr.Wagner, I will look to the case study section in the future, great format to learn and grow.
JMA-she is still on the tb meds. She just started taking them.
I saw her yesterday and she was better. Able to lift her arm up better and increased cervical rotation. Will continue to post on her as she is an interesting case.
Erica
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Re: Help on a complex case-differential diagnosis - January 25, 2006 4:46:00 PM
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eam
Posts: 291
Joined: February 5, 2004
From: New York, NY 10028
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Hi everybody-
I promised an update on this patient. Saw her this past Tuesday and she reported good improvement, able to lift her arm better. Still had some neck soreness. I have been treating her neck and added some T4 mobs in sitting with shoulder abduction.
The treatment before I did add some grade 1 shoulder mobs just to satisfy her and the MD. Objectively, she can lift her arm up with no compensation at this point. Thanks again for the replies.
Erica
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