DIFFERENTIAL

DIAGNOSIS LECTURE
1
DR. ANUM ZAFAR
DIFFERENTIAL DIAGNOSIS IN
PHYSICAL THERAPY
WHAT IS A DIAGNOSIS.
• Diagnosis is the process of identifying a specific medical condition or disease in
a patient based on their signs, symptoms, medical history, physical
examinations, and diagnostic tests. It serves as the foundation for developing
treatment plans and providing appropriate healthcare interventions.
WHY WE NEED DIAGNOSIS?

• Identification: Determining the nature and cause of a patient's health issue.

• Data Integration: Combining clinical findings, patient history, and test
results.
• Precision: Providing a precise label for the condition.
• Treatment Guide: Serving as a basis for treatment decisions.
• Outcome: Diagnosis enables healthcare professionals to offer targeted care
and improve patient outcomes.
WHY WE NEED TO DIAGNOSE A MEDICAL
CONDITION IN PHYSICAL THERAPY?
• Accurate Treatment: Diagnosis is the foundation for creating tailored treatment plans in physical
therapy.
• Targeted Interventions: It helps identify the root cause of musculoskeletal or neuromuscular
issues, allowing for precise interventions.
• Safety: Correct diagnosis prevents inappropriate treatments that may exacerbate the condition.
• Optimized Care: Ensures patients receive the most effective and efficient care.
• Progress Tracking: Enables ongoing evaluation and adjustments in treatment based on patient
response.
• Collaboration: Facilitates collaboration with other healthcare professionals for holistic care.
• Outcome: Diagnosis in physical therapy is essential for improving patient outcomes, safety, and
quality of life.
INTRODUCTION TO DIFFERENTIAL
DIAGNOSIS
WHAT IS DIFFERENTIAL DIAGNOSIS??

• Differential Diagnosis is the process of systematically distinguishing

between various potential causes of a patient's symptoms or
conditions.
• It plays a vital role in ensuring accurate diagnosis and tailored
treatment plans."
WHY IS IT IMPORTANT IN PHYSICAL THERAPY?

• Patients often present with musculoskeletal or neuromuscular issues

that can have multiple underlying causes.
• Differential diagnosis helps physical therapists pinpoint the exact
source of the problem, guiding effective treatment.
IMPLEMENTATION IN PHYSICAL THERAPY - STEPS

• Step 1: "Gather Patient History" - Importance of understanding the onset, medical history,
and lifestyle factors.
• Step 2: "Physical Examination" - Highlight the significance of a thorough physical assessment.
• Step 3: "Specialized Testing" - Mention additional tests like X-rays, MRI, or EMG when needed.
• Step 4: "Clinical Reasoning" - Explain the process of analyzing collected information.
• Step 5: "Differential Diagnosis" - Discuss narrowing down potential diagnoses and the role of
clinical findings.
• Step 6: "Treatment Planning" - Emphasize how diagnosis guides personalized treatment
plans.
ONGOING EVALUATION

• Differential diagnosis isn't static; it involves continuous evaluation of

patient progress.
• Allows for necessary adjustments in treatment plans if expected
improvements aren't observed."
COLLABORATION IN DIFFERENTIAL DIAGNOSIS

• Physical therapists often collaborate with other healthcare

professionals to ensure accuracy and holistic care. E.g. Physicians,
orthopedic specialists, radiologists, and more
INTRODUCTION TO
SCREENING FOR REFERRAL IN
PHYSICAL THERAPY
COST-EFFECTIVE CARE

• "To provide cost-effective care, we must:

• "Identify biomechanical or neuromusculoskeletal (NMS) problems.
• "Treat these problems with precision.
• "Screen for medical diseases.
 SYSTEMIC DISEASE SCREENING

• Physical therapists must screen for signs of systemic diseases.

• Because Disease like:
• Peptic ulcers
• Gallbladder disease
• Liver disease
• Myocardial ischemia.

• Can mimic NMS dysfunction.

PATIENT VS. CLIENT DEFINITION
• Understanding patient and client distinctions.
• Definition: "Patients are the population who is sick and receive direct
physical therapy care, while clients are not necessarily sick but may
benefit from consultation, advice, or prevention services."
• Reference: The Guide to Physical Therapist Practice (2003).
EVIDENCE-BASED PRACTICE IN CLINICAL
DECISION MAKING
• Clinical decisions must be based on the best evidence available
• As presented in the Guide to Physical Therapist Practice. Evidence-based
practice (EBP) forms the foundation for diagnosis, prognosis, and
intervention.
• Ensuring valid, reliable, and well-supported clinical decisions.
• Screening for Systemic Disease
• Screening for systemic diseases or vasculogenic causes of NMS symptoms.
• Begins with a comprehensive client history and interview.
• Importance: "Early detection and prevention."
RED-FLAG CHECKLIST

• Using a red-flag checklist based on the history for safe clinical practice
provides:
• Safety: Effective in avoiding the omission of serious disorders.
• Attention to Clues: Emphasizing the importance of thorough attention to
history clues.

• However:
• Early Presentation: Some conditions may not be recognizable in early
presentation.
• Outcome: Early recognition may not always impact the treatment or
outcome.
SCREENING AND SURVEILLANCE
 DIFFERENCE BETWEEN SCREENING AND
SURVEILLANCE
• Screening:
• Is A Method For Detecting Disease Or Body Dysfunction Before An Individual
Would Normally Seek Medical Care. Medical Screening Tests Are Usually
Administered To Individuals Who Do Not Have Current Symptoms, But Who
May Be At High Risk For Certain Adverse Health Outcomes.

• Surveillance:
• Is the analysis of health information to look for problems occuring in the
general population, in specific groups, or in the workplace that require
targeted prevention. Surveillance often uses screening results from groups of
individuals to look for abnormal trends in health status.
WHY YOU NEED TO SCREEN PHYSIOTHERAPY PATIENT ??

• The three key factors that create a need for screening are:
• Side effects of medications
• Comorbidities
• Visceral pain mechanisms

• If the medical diagnosis is delayed, then the correct diagnosis is

eventually made when
1. The patient/client does not get better with physical therapy intervention.
2. The patient/client gets better then worse.
3. Other associated signs and symptoms eventually develop.
CLASS DISCUSSION
• Based on your personal experience in clinical settings, what do you
think is the reason for patients to miss screening? How can you
overcome this lacking?
 REASONS FOR MEDICAL SCREENING

• Direct access: Therapist has primary responsibility or first contact.

• Quicker and sicker: patient client base.
• Signed prescription: Clients may obtain a signed prescription for
physical/occupational therapy based on similar past complaints of
musculoskeletal symptoms without direct physician contact.
• Medical specialization: Medical specialists may fail to recognize underlying
systemic disease.
• Disease progression: Early signs and symptoms are difficult to recognize, or
symptoms may not be present at the time of medical examination.
CONTD..
• Patient/client disclosure: Client discloses information previously
unknown or undisclosed to the physician.
• Lack of reporting symptoms: Client does not report symptoms or
concerns to the physician because of forgetfulness, fear, or
embarrassment.
• * Presence of one or more yellow (caution) or red (warning)
flags
 What are the reasons for screening in given
clinical case?

Ref: case example 1-1, 1-2,1-3 from

chapter introduction to the screening
process

Text book: Goodman CC, Snyder TEK.

Differential Diagnostics for Physical
Therapists: Screening for Referral. Saint
CASE EXAMPLE Louis, MO: Saunders: Elsevier
CASE EXAMPLE
What are the reasons for screening in
given clinical case?

Ref: case example 1-1, 1-2,1-3 from

chapter introduction to the screening
process

Text book: Goodman CC, Snyder TEK.

Differential Diagnostics for Physical
Therapists: Screening for Referral. Saint
Louis, MO: Saunders: Elsevier
CASE EXAMPLE
What are the reasons for screening in
given clinical case?

Ref: case example 1-1, 1-2,1-3 from

chapter introduction to the screening
process

Text book: Goodman CC, Snyder TEK.

Differential Diagnostics for Physical
Therapists: Screening for Referral. Saint
Louis, MO: Saunders: Elsevier
PHYSICAL THERAPY DIAGNOSIS
• Class discussion:
• Can there be difference between medical diagnosis and physical therapy
diagnosis of same condition?
• How will you differential between medical and physical therapy diagnosis
DIFFERENCE BETWEEN MEDICAL AND
PHYSICAL THERAPY DIAGNOSIS
• After evaluation of data collected from history, physical examination
and special tests.
• A label given to patients condition that explains their underlying medical
condition at cellular level is a medical diagnosis
• A label given to patient to explain musculoskeletal dysfunction that effect
patients mobility is a physical therapy diagnosis
• E.g.
• Adhesive capsulitis is medical diagnosis of Frozen Shoulder
• Hemiplegia is a physical therapy diagnosis due to multiple medical
conditions like stroke, TIA etc
PHYSIOTHERAPY DIAGNOSIS

APTA's policy mandates physical therapists to establish a diagnosis for each patient/client.
Identifying Impact on Function:
diagnostic labels help identify the impact of a condition on a patient's function.
Level of the Movement System:
• These labels helps a physiotherapist to differentiate between the structure of musculoskeletal
system effected, that gives an in-depth idea about extent and severity of movement
restriction.

Holistic approach:
• Physical therapy diagnosis is crucial in providing a label of whole body and not just a system.
Based on EBP that requires considering individual as a whole and not just the disease system.
PRESENCE OF CONSTITUTIONAL
SYMPTOMS;
CLEAR INDICATOR OF SYSTEMIC CONSTITUTIONAL SYMPTOMS
DISEASE Fever
• Refer to constellation of signs and Diaphoresis (unexplained
symptoms present whenever the perspiration)
Night sweats (can occur during the
patient/client is experiencing a day)
systemic illness . Nausea

• No matter what system is Vomiting

involved, these core signs and Diarrhea

symptoms are often present. Pallor

Dizziness/syncope (fainting)

Fatigue

Weight loss
 YELLOW AND RED FLAG
• Red flags are warning signs of serious conditions or complications that
demand immediate attention.
• Yellow flags indicate potential psychosocial factors that may influence a
patient's diagnosis, prognosis, or response to treatment.
• Both red and yellow flags help healthcare professionals provide more
comprehensive and patient-centered care by addressing not only the
physical aspects of a condition but also the broader context in which it
occurs.
 Red Flag

Red flags are clinical indicators or warning signs that

Definition: suggest the presence of serious or potentially life-
threatening conditions or complications.
In diagnosis, red flags alert healthcare providers to the
Role in possibility of severe underlying issues that require
immediate attention. They prompt thorough evaluation,
Diagnosis: additional testing, or referral to specialists.
Treatment Red flags can influence treatment decisions by indicating
the need to address the underlying serious condition first.
Consideratio Treatment may involve urgent medical intervention or
ns: stabilization.

In screening, red flags help identify individuals who should

Screening: be referred for further evaluation or diagnostic testing due
to the suspicion of a severe health problem.
 Yellow Flag
• Yellow flags refer to clinical, psychosocial, or behavioral
Definition: factors that may complicate the diagnosis, prognosis, or
management of a patient's condition.

• In diagnosis, yellow flags signal the presence of potential

Role in obstacles or challenges in a patient's response to
treatment. These factors may include psychological
Diagnosis: distress, fear, anxiety, or social factors.
• Yellow flags prompt healthcare providers to consider the
Treatment patient's psychosocial well-being and may lead to the
inclusion of psychological interventions or counseling as
Considerations: part of the treatment plan.
• Yellow flags in screening may highlight individuals who
require a more comprehensive assessment to
Screening: understand how psychosocial factors might impact their
condition or treatment outcomes.
IDENTIFICATION OF RED AND YELLOW FLAG IN PATIENT
HISTORY

• Thorough Assessment
• Comprehensive history-taking helps identify red and yellow flags, guiding
further assessment and personalized treatment planning.

• Patient-Centered Care
• Utilizing these flags ensures patient-centered care that addresses individual
needs and risks.
 Identification of Red Flags in History

Symptom Onset:
• Inquire about the sudden or severe onset of symptoms, especially if they are acute and
unusual.
Previous Medical History:
• Ask about significant past medical conditions, surgeries, or hospitalizations that may be related
to current symptoms.
Family History:
• Explore any family history of serious medical conditions, such as cancer or cardiovascular
disease.
Medication Use:
• Learn about current medications, recent changes, or new prescriptions, as some medications
may have adverse effects.
Trauma or Injury:
• Identify any recent trauma, falls, accidents, or injuries, as they may indicate potential
musculoskeletal issues.
Alarming Symptoms:
• Look for specific alarming symptoms like unexplained weight loss, severe pain, sudden vision
changes, or neurological deficits.
Pregnancy or Recent Childbirth
• For female patients, consider pregnancy or recent childbirth, which may have implications for
maternal or fetal health
 Identification of Yellow Flags in History

Psychological History
• Inquire about any history of anxiety, depression, or other mental health conditions that
may impact treatment.
Social Factors
• Discuss living situation, social support, work-related stressors, or financial issues that
may affect recovery.
Beliefs and Expectations
• Explore the patient's beliefs and expectations regarding their condition and treatment.

Previous Treatment History

• Ask about past healthcare or therapy experiences to assess treatment adherence and
patient satisfaction.
Coping Mechanisms
• Learn about the patient's strategies for managing pain or symptoms, especially if
maladaptive coping mechanisms are present.
Patient's Goals
• Understand the patient's goals and concerns to identify any unrealistic expectations or
incongruence with recommended treatments
ANY QUESTIONS??
Brief review:
Define red and yellow flag. Why do we need to assess them as a physiotherapist?
CLASS ASSIGNMENT

• Read and understand: BOX 1-2 i.e. Red Flags of chapter; introduction to
the screening process And identify red flags in case example; 1-4
• Reference: Goodman CC, Snyder TEK. Differential Diagnostics for
Physical Therapists: Screening for Referral. Saint Louis, MO: Saunders
Elisevier