Differential Diagnosis (DD) Answer Key || Chapter 06

1. Pursed-lip breathing in the sitting position while leaning forward on the arms relieves symptoms of dyspnea for the client with:

a. Orthopnea
b. Emphysema
c. CHF
d. a and c

2. Briefly describe the difference between myocardial ischemia, angina pectoris, and MI.

Myocardial ischemia is a deficiency of blood supply to the heart muscle that is usuallycaused by narrowing of the coronary arteries. Angina pectoris is the chest pain that occurs when the heart is not receiving an adequate supply of blood, and therefore, has insufficient quantities of oxygen for the workload. Myocardial infarction is death of the heart tissue when blood supply to that area is interrupted.

3. What should you do if a client complains of throbbing pain at the base of the neck that radiates into the interscapular areas and increases with exertion?

Monitor vital signs, and palpate pulses. Evaluate past and current medical history for the presence of coronary artery disease. Any suspicion of thoracic aneurysm must be reported to the physician immediately. It is beyond the scope of a physical therapist’s practice to suggest the possibility of an aneurysm. Rather, clinical observations should be documented and submitted to the physician. A summary comment can be made such as,

“This clinical presentation is not consistent with a musculoskeletal problem. Please evaluate.”

4. What are the 3Ps? What is the signifcance of each one?

The three Ps include:

• Pleuritic pain (exacerbated by respiratory movement involving the diaphragm, such as sighing, deep breathing, coughing, sneezing, laughing, or the hiccups; this may be cardiac with pericarditis, or it may be pulmonary); have the client hold his or her breath, and reassess symptoms—any reduction or elimination of symptoms with breath holding or the Valsalva maneuver suggests a pulmonary or cardiac source of symptoms.

• Pain on palpation (musculoskeletal origin)

• Pain with changes in position (musculoskeletal or pulmonary origin; pain that is worse when lying down and that improves when sitting up or leaning forward is often pleuritic in origin).

5. When are palpitations clinically signifcant?

Palpitations may be considered physiologic (i.e., “within normal limits”) when they occur at a rate of less than six per minute. Palpitations lasting for hours or occurring in association with pain, shortness of breath, fainting, or severe lightheadedness require medical evaluation. Palpitations in any person with a history of unexplained sudden death in the family require medical referral. Palpitations can also occur as an adverse effect of some medications, through the use of drugs such as cocaine, as the result of an overactive thyroid, or because of caffeine sensitivity. Palpitations as a recurring symptom (even if less than six/minute) should always be reported to the physician.

6. A 48-year-old woman with TMJ syndrome has been referred to you by her dentist. How do you screen for the possibility of medical (specifcally cardiac) disease?

Past medical history/risk factors—Personal or family history of coronary arterydisease, heart disease, angina, myocardial infarction, or risk factors associated with these (see Table 6-3). Assess menstrual history: A menopausal or postmenopausal woman with a high risk for heart disease may develop symptomatic coronary artery disease.

Clinical presentation—Objective findings from the clinical evaluation do not seemconsistent with temporomandibular dysfunction; assess the effect of using a stationary bicycle or treadmill (stairs or walking will also work) without upper extremity exertion on jaw pain. Increased pain or symptoms with increased lower body exertion may be a sign of cardiac involvement and should be reported to the referring dentist.

Associated signs and symptoms—Assess for coincident nausea, diaphoresis, pallor, ordyspnea during painful or symptomatic periods. Look for recent history (last 6 weeks to 6 months in onset) of shortness of breath at night, extreme fatigue, lethargy, and weakness. Ask about the presence of other body aches and pains (be alert for “heartburn” unrelieved by antacids, isolated right biceps muscle aching, and breast or chest pain). Measure vital signs for any unusual findings, and assess changes in vital signs with changes in workload during exercise.

7. A 55-year-old male grocery store manager reports that he becomes extremely weak and breathless when he is stocking groceries on overhead shelves. What is the possible signifcance of this complaint?

The onset of myocardial infarction can be precipitated by working with the arms extended over the head. Ischemia or infarction may be the cause of this client’s symptoms. Assess for history of heart disease and the presence of known hypertension, angina, past episodes of heart attack, or congestive heart failure. Assess vital signs and changes in vital signs with increased workload and assess the effect of increasing the workload of the lower extremities only.

Evaluate for thoracic outlet syndrome (TOS), especially with a cardiovascular component (see Table 17-5). Evaluate for and treat trigger points of the chest, upper abdomen, and upper extremity.

This client should be evaluated by his physician; the therapist’s information gathered from the assessment will be helpful in the medical differential diagnosis.

8. You are seeing an 83-year-old woman for a home health evaluation after a motor vehicle accident (MVA) that required a long hospitalization followed by transition care in an intermediate care nursing facility and now home health care. She is ambulating short distances with a wheeled walker, but she becomes short of breath quickly and requires lengthy rest periods. At each visit the client is wearing her slippers and housecoat, so you suggest that she start dressing each day as if she intended to go out. She replies that she can no longer ft into her loosest slacks and she cannot tie her shoes. Is there any signifcance to this client’s comments, or is this consistent with her age and obvious deconditioning? Briefly explain your answer.

Examine this client for the presence of cyanosis, orthopnea, and tachycardia; for changes in renal function (decreased urination during the day but frequent urination at night); and for a spasmodic cough triggered by lying down or at night. These may be indicators of congestive heart failure and must be reported to the physician. Take note of whether this client is taking NSAIDs and digitalis together; this combination of medications can cause ankle swelling—a symptom that must also be reported to the physician.

9. Peripheral vascular diseases include:

a. Arterial and occlusive diseases
b. Arterial and venous disorders
c. Acute and chronic arterial diseases
d. All of the above
e. None of the above

10. Which statement is the most accurate?

a. Arterial disease is characterized by intermittent claudication, pain relieved by elevating the extremity, and history of smoking.
b. Arterial disease is characterized by loss of hair on the lower extremities and throbbing pain in the calf muscles that goes away by using heat and elevation.
c. Arterial disease is characterized by painful throbbing of the feet at night that goes away by dangling the feet over the bed.
d. Arterial disease is characterized by loss of hair on the toes, intermittent claudication, and redness or warmth of the legs that is accompanied by a burning sensation.

11. What are the primary signs and symptoms of CHF?

a. Fatigue, dyspnea, edema, nocturia
b. Fatigue, dyspnea, varicose veins
c. Fatigue, dyspnea, tinnitus, nocturia
d. Fatigue, dyspnea, headache, night sweats

 12. When would you advise a client in physical therapy to take his/ her nitroglycerin?

a. 45 minutes before exercise
b. When symptoms of chest pain do not subside with 10 to
15 minutes of rest
c. As soon as chest pain begins
d. None of the above
e. All of the above