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Re: Case Presentation - June 29, 2006 10:04:00 PM   
Dr.Wagner


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OK, let me make a teaching point:

When someone complains of "dizziness" one of the first questions is "what do you mean by dizzy"
If they do not elaborate more, ask them specifics (ie do they mean vertigo, lightheaded, stroke like, psychotic, weak etc)

This has not yet been defined...


As for Dilantin, 100mg TID is a normal dose.


Now, for the physical exam...tell me how to procede.

Prior to Decision Making, lets get ALL of the information.(ie doing a pelvic exam in this case would be HIGHLY unlikely and would land you in medical review)


PS this is a real case

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Re: Case Presentation - June 29, 2006 10:07:00 PM   
Dr.Wagner


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The Abnormal cells are "early pre cancerous", "they said they would freeze part of them off".

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Post #: 22
Re: Case Presentation - June 29, 2006 10:36:00 PM   
drbuddy

 

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So, what did they mean by dizzy?

If no good info from the answer, I'd start with some neuro tests such as heel to toe walk, Rhomberg's position, finger to nose, check for disdiadochokinesia, heel to shin, etc. I'd also check cranial nerves.

I'll pause to see if that is reasonable...

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Post #: 23
Re: Case Presentation - June 29, 2006 10:56:00 PM   
drbuddy

 

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Oh, and vitals of course...

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Post #: 24
Re: Case Presentation - June 30, 2006 6:50:00 AM   
Sebastian Asselbergs

 

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Before getting into the physical, how about sleeping patterns? Been given any weed by different source? How much is occasional use? If she's doing weed, has she by any chance taken something else recently? How about alcohol? Could be an interesting mix with Dilantin...
How is her response to questions? Slow? Appropriate to the subject? Been under any additional stress - exams, boyfriend, family, job etc?
I really think I'd like to see bloodtests screening for drugs, checking for anemia etc etc. (I'm NOT a doc, so of course I defer to a doc here!). Then - while waiting, check Sharp-Perser, pupils, and as above by Buddy (including pulse, temp etc). Nothing may come from it and this turns out to be wayyyy beyond my scope....LOL

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Post #: 25
Re: Case Presentation - June 30, 2006 7:04:00 AM   
Sean_Collins

 

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Was this patient not referred to therapy by an MD?

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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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Post #: 26
Re: Case Presentation - June 30, 2006 9:30:00 AM   
USAPT

 

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I would discuss with her parents the results of my neuro assessment and answers I received from Sebastians proposed questions.

My next step would be to write a formal evaluation (parents hand deliver to MD) and have the parents take her to their primary care MD for further evaluation.

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Jason, PT
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Post #: 27
Re: Case Presentation - June 30, 2006 11:33:00 AM   
drbuddy

 

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Sounds like a good plan JKral, but no fun for this exercise...

Also, what I happens to me often is the patient says they tried to tell their MD about the problem, but the MD said it was nothing to worry about. Then it's left on me to take care of it. I dont have to diagnose the problem completely, but I need to make a good case so the MD listens (caught a dissecting AAA that way) or figure out which specialist referral should be made and go over the family MDs head. I try not to do the second option unless I have to...

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Post #: 28
Re: Case Presentation - June 30, 2006 2:10:00 PM   
USAPT

 

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Gee, sorry I took the wind out of your sail for a friday. Glad you caught a diff dx case. I'm not hear to toot my own horn. I'm trying to get to the bottom of this case.

As far as going over primary MDs head, I guess that would depend on their insurance (PPO vs HMO)and if you can afford to chance a potential referral source.

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Post #: 29
Re: Case Presentation - June 30, 2006 9:54:00 PM   
Dr.Wagner


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Yes, this is an exercise in which you pretend you are a physician (ie there is no stating "I would refer to ..." no getting off that easy, you don't learn that way...and this is not real life).
When you ask her to define "dizzy" she states..."I'm not walking right...but whatever"
At that point the parents state "yes, she seems to fall to her left or right sometimes...only in the past 2 days"

Neuro exam:
Patient has marked ataxia, cannot safely perform heal to toe. Mild dysmetria, does not improve with repeated testing. no noted abnormalities with alternating supination/pronation of hands.
Cranial nerves 2-12 intact.
Cardiac: HRRR
Lungs: CTA
Abd: soft, non tender, hyperactive bowel sounds
Skin: no rashes, noted small self inflicted laceration about 3 days old on left bicep

On exam, patient seems...well, slow to respond (volitional?) She states she really doesn't smoke pot that often and always gets it from her boyfriend whom she recently broke up with.

When you ask about sleeping she states "I sleep whenever"

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Post #: 30
Re: Case Presentation - July 1, 2006 7:05:00 AM   
Sean_Collins

 

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I am sorry, however I do not understand this pedagogy: learning something for your profession by pretending to be another profession. I wonder if this approach is harmful to the PT profession - as opposed to securing an understanding of how to screen and appropriately refer as part of a common vision/definition(across all health professionals) of what PT direct access is supposed to be.

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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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Post #: 31
Re: Case Presentation - July 1, 2006 10:29:00 AM   
USAPT

 

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My thoughts exactly. The pupose of advancing my education as a PT to include medical diagnostics is knowing certain s/s and knowing when to refer the pt. you, the MD. It is NOT 'getting off easy', it is protecting my license and not going above my scope of practice.

I have learned alot from these discussions and I have always seen it from the point of view as a PT, never an MD.

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Post #: 32
Re: Case Presentation - July 1, 2006 6:01:00 PM   
Synergy

 

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Dr. Wags,

During the physical exam of her integument, does there appear to be a history of 'cutting'? Her relationship with her boyfriend recently ended and she cut her left bicep. Did a bacterial/viral infection show up in the tests? Perhaps this is creating the ataxia.

I would want additional tests for drugs, CSF, & systemic infection (hx of trichomonas). Is this girl anorexic or depressed ("I sleep whenever")?

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Chris Adams, PT, MPT

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Post #: 33
Re: Case Presentation - July 1, 2006 10:37:00 PM   
Dr.Wagner


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Relax guys...there is no one from the licensing board here, I won't tell. There is an entire section on reading radiographs correct...just play along.

I want you to just theorize. Put together a reasonable hypothesis to WHY. I am not holding you to it. I mean, why learn pharmacology? Did you just learn the NAMEs or did you learn a tad bit about what they do? Yes.

Put it together...

THis patient presents with "cutting"
This patient is ataxic with other signs of cerebellar problems.
This patient had a recent "breakup"
This is a new and rapid occurance.
This is a teenage female.
This patient is on medications.


What is wrong.

What needs to be checked?

What is the diagnosis.

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Dr. Wagner DO
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Post #: 34
Re: Case Presentation - July 2, 2006 2:03:00 AM   
Randy Dixon

 

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I would still guess she is on drugs. Maybe downers, maybe just alcohol. I'd discount whatever she tells me about her drug use, she's 17.

I don't know how to differentiate drug use if there are no obvious signs and the blood/urinalysis don't pick them up.

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Post #: 35
Re: Case Presentation - July 2, 2006 6:41:00 AM   
Sean_Collins

 

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"Relax guys...there is no one from the licensing board here, I won't tell. There is an entire section on reading radiographs correct...just play along."

I am not concerned about you telling, I am only calling to question the method. PT is not a "I wanted to be a doctor but I couldnt" profession. It is not whether we can make medical diagnoses or not because of the licensing board, it is whether or not such an activity helps train a PT, or just leads to role confusion.

"I want you to just theorize. Put together a reasonable hypothesis to WHY. I am not holding you to it. I mean, why learn pharmacology? Did you just learn the NAMEs or did you learn a tad bit about what they do? Yes."

I am not asking to be held to anything. I just think this leads to more confusion than necessary on a site like this, regardless of whether a licensing board is reading.
I learned enough pharmacology to know when medications would result in changes in physiological response that I should be aware of during PT examinations and interventions, NOT so i could prescribe them.

Please do not feel the need to tell me about theorizing and the benefits of hypthesis generation. But these should be done within a framework of PT practice. Unless we want to start theorizing about practice in an attempt to firmly identify the boudnaries from which we are hypothesizing. If we do not want boundaries, why have any boundaries, and why prevent a change in this discussion to philosophical metaphysics (not occult metaphysics).

_____________________________

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 &

(in reply to Dr.Wagner)
Post #: 36
Re: Case Presentation - July 2, 2006 12:19:00 PM   
Dr.Wagner


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Yes, it is correct to begin to doubt her character and to suspect she is NOT telling you the truth, Randy.

Most toxicology cases present with a series of predictable physical findings and a "story" that does NOT quite JIVE.

Just like the malingerer who seems to be holding on to that bit of back pain or shoulder impingement for a bit too long...the story doesn't jive.

In this case she (the patient) is a young female brought by her parents.

She is under significant stressors lately and has an ACUTE onset of motor problems.

At the same time you get the feeling she has "experimented" with some limited drug use.

The presents itself as a Toxicology case.

Early DILANTIN became a concern. Yes, as stated previously 100mg TID is a normal dose...but she never took the PRESCRIBED DOSE.
THIS WAS A HESITANT SUICIDE ATTEMPT>>>>DILANTIN OVERDOSE (most females, forgive the term, hesitate and are more likely to have suicidal gestureing with overdoses...males are more reactionary and shoot,hang,big overdose,car accident type suicides)

DILANTIN TOXICITY presents with ataxia...very clear ataxia...also with a generalized weakness, plus minus nystagmus...lethargy.


Everyone did great.

The general approach to the "DIZZY" patient starts with clarifying the definition of DIZZY in the patients "own words".
DIZZY means something different to everyone. In this case it was a sense of a walking disorder...and she was just not herself.
Once "DIZZY" is defined, get a clear past medical history, social history and medication list.
Followed by a review of systems (usually contained within the subjective history when patients describe the event)

Then a physical exam, well focused.

Then put it together.

Clearly alot of people were suspicious, but held back.

Diagnostics (while not always helpfull, they can be nice); a CT of the head, urine, and tox level (suspicious of drug use)...and of course the Dilantin level. A few people hinted at this but did not commit.

In real life, this patient was diagnosed and treated...but she is only one example of perhaps 5 "DIZZY" patients I see daily. They each have seperate causes...but always the same initial complaint...DIZZY.


Thanks Guys, you did great.
I hope we can continue the dialogue!!

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Dr. Wagner DO
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Post #: 37
Re: Case Presentation - July 3, 2006 8:11:00 AM   
USAPT

 

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Another good case. Thanks Doc.

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Post #: 38
Re: Case Presentation - July 3, 2006 10:43:00 PM   
drbuddy

 

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I agree, keep up the good work. These cases are much appreciated.

Healthcare professionals with direct access should be able to follow the thought process you outlined above. Even if it is to refer out, you need to have some kind of idea what is going on with the patient.

In this case above, everyone said refer out to a physician, but unless you dig just a little bit deeper, how do you know when and where to refer? Maybe you do a few cerebellar tests and find that she is having stroke symptoms, then it's a 911 call. Maybe most of the tests are normal and it's just a call to set up an appt with their physician at their earliest convenience.

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Post #: 39
Re: Case Presentation - July 4, 2006 3:50:00 AM   
nari

 

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Buddy,

True. Red flags are essential for any PT to know, and even if one is not sure, we should have enough knowledge to know our limits and refer on.

Nari

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