Differential Diagnosis in a Patient Presenting With Both Systemic and Neuromusculoskeletal Pathology: Resident's Case Problem

Abstract

Study Design Resident's case problem. Background Patients presenting with multiple symptomatic areas pose a diagnostic challenge for the physical therapist. Though musculoskeletal and nonmusculoskeletal symptoms typically present separately, they can occur simultaneously and mimic each other. Consequently, the ability to differentiate between musculoskeletal and nonmusculoskeletal symptoms is an important skill for physical therapists. The purpose of this resident's case problem was to describe the clinical-reasoning process leading to medical and physical therapy management of a patient presenting with upper and lower back pain, bilateral radiating arm and leg pain, and abdominal pain. Diagnosis The patient was a 30-year-old woman referred to physical therapy for upper and lower back pain. A detailed history and thorough examination revealed that the patient had signs and symptoms consistent with a possible abdominal aortic aneurysm. She was referred for medical management and was diagnosed with symptomatic cholelithiasis. She subsequently had a cholecystectomy, which ultimately resolved her abdominal pain and reduced her pain in other areas significantly. Although many of her symptoms resolved postoperatively, her pain in other areas remained and was potentially musculoskeletal in origin. Following re-evaluation and 3 physical therapy treatments over a 2-month period, she was relatively symptom free at discharge and had achieved all functional rehabilitation goals. Discussion This resident's case problem provides an opportunity to discuss the differential diagnosis, clinical reasoning, and outcome of a patient who presented with both systemic and neuromusculoskeletal pathology. Level of Evidence Differential diagnosis, level 5. J Orthop Sports Phys Ther 2018;48(6):496-503. Epub 6 Feb 2018. doi:10.2519/jospt.2018.7652.

Extravertebral low back pain: a scoping review

“…The RCT compared two treatment strategies for managing gallstone disease and reported baseline symptoms encompassing pain radiating to the back. Among the case reports, one focussed on cholecystitis [ 373 ], while the other delved into symptomatic cholecystolithiasis [ 374 ], both involving female patients. LBP can present both acutely (particularly with inflammation) [ 373 ] as well as chronically (with symptomatic cholecystolithiasis without inflammation) [ 374 ].…”

“…Among the case reports, one focussed on cholecystitis [ 373 ], while the other delved into symptomatic cholecystolithiasis [ 374 ], both involving female patients. LBP can present both acutely (particularly with inflammation) [ 373 ] as well as chronically (with symptomatic cholecystolithiasis without inflammation) [ 374 ]. Accompanying symptoms often comprise abdominal pain [ 373 , 374 ], predominantly localised in the right upper quadrant or epigastric region [ 375 ].…”

“…LBP can present both acutely (particularly with inflammation) [ 373 ] as well as chronically (with symptomatic cholecystolithiasis without inflammation) [ 374 ]. Accompanying symptoms often comprise abdominal pain [ 373 , 374 ], predominantly localised in the right upper quadrant or epigastric region [ 375 ]. Other symptoms include gastrointestinal symptoms such as fat intolerance, nausea and vomiting, diarrhoea, and difficulty in defecation [ 375 ].…”

“…Many case reports lack details regarding the clinical setting, but it is reasonable to assume that they predominantly originate from specialist clinics or hospitals, as these comprise the majority of reports. Unfortunately, only a limited number of reports indicated whether patients were referred from primary care and the specific reasons for their referral [ 54 , 137 , 211 , 229 , 263 , 274 , 279 , 297 , 374 ]. It has been suggested that non-mechanical back pain may indicate the possibility of extravertebral LBP [ 3 , 464 ].…”