Patient Profile/ Differentials
Unfortunately, my study group did not like idea of patient profiling. So as an alternative, I went in with as many new patients as I could, as a result I managed to have symptoms that patients actually complained of (even though we normally do this). I created differentials and used them as tick box so when my colleagues presented, I would know which ones I had and potentially missed. I would also mention differentials not mentioned by my colleague and tutor, explaining my thought process and justification, to see if it justifiable.
I did find this helpful. A lot of the time when you are observing colleagues it is hard to get your opinions or differentials across as it is not your patient, but talking to tutors they were very helpful and patient in allowing me to talk to them about other differentials. I have definitely broaden my differentials and have broadened my outlook. I feel confident in my differentials now more than ever.
Patient One – 29 year old female police officer
PPW -
LBP – SIJ region, dull pain, constant
RAD – L post thigh and calf, zero below ankle. Pain is shooting in nature.
Agg – walking/standing prolonged periods.
Onset – 3 months ago, rapid turn in response to a car horn.
progression – lower extremity symptoms worsening
Seen GP, referred for imaging, MRI. Test results back which show L5/S1 disc buldge, compressiong on nerve root.
Systemically healthy.
Differentials
Discal herniation L5/S1 – keep it simple and stating the obvious with imaging.
Element of facet involvement compensating for the instability in lower back.
Secondary inflammation of SIJ due to over compensation.
+ associated muscle hypertonicity, gluteals, piriformis, psoas, etc.
Element of facilitation due to on going chronicity.
Tutor response
- impressed by inclusion of facilitation
potentially think about early onset of degenerative changes predisposing a herniation.
Patient Two – 67 year old retired cab driver
PPW -
LBP – L/S region, dull pain, constant, widespread some into buttock.
RAD – zero lower extremity.
Agg – morning pain, sitting
Onset – 10 years ago, intermittent dullness since, zero history of LEX symptoms.
Recently, 2 months prior to consultation.
Systemic health – cystitis
Differentials
Degenerative changes, spondylosis (osteophytic growth), prediposing...
osteoarthritis/spondylarthritis.
+ associated muscular hypertonicity
Viscero-somatic referral (cystits), inferior mesenteric ganglion L2.
Consideration – early onset O/A of hip, affect Lsp mechanics, as symptoms are broad.
Tutor response
overall included most aspects
every basics covered, however a good chance to demonstrate osteopathic knowledge, talk about processes that occur in differentials
O/A hip justified, but less likely, was it worth including?
Patient Three – 48, Information analyst office based
PPW -
- L > R upper Tsp pain, b/w scapula, constant pain
- pain is focal, warm/burning sensation
RAD – zero UEX, some lower Csp dullness
Agg – coughing, deep breath, Rot L
Onset – 2 years ago, NAR, gradual onset
Progression – over last 4/52, worsening, increase notability of pain
History – prescribed 4 weeks ago, noticed a postural change, constant flexion at neck to read.
Gout, 2 years ago, hallux (not sure which), managed and zero problematic.
Systemically healthy.
Differentials
postural mm fatigue causing ischaemic changes in upper thoracic.
Changes due to – rib facet (irritation/inflammation)
C/T, Tsp facet (irritation/inflammation)
resulting facilitation (chronic duration)
3. Psoas/hamstring hypertonicity (prolonged sitting), affecting lower thoracic mechanics
Tutor Response
Very well covered, as expected for a simple enough case
Good justifications
Use correct terminology.
Patient four - 27, female office worker
PPW -
- R sided suprascapular pain, tightness/dullness
- RAD – Csp bilaterally (ache), zero headaches, decreased mobility.
- Agg – prolonged work posture
- LB pain, central , dull but sharp on movements
- RAD – posterior thigh and calf, tightness sensation
- Agg – walking with heels and running
Hxx – RTA – 2008/2009, in a car accident which flipped, torn mm L scapula = depression of scapula.
Ulcerative colitis (medicated and managed)
Differentials
mm imbalance + postural demand at work = ischaemia
rib/Tsp facet
somatic dysfunction resulting facilitation
Lsp facet (psoas shortening due to desk bound nature)
Disc herniation (sensation change in lower extremity)
> associated mm hypertonicity due to 1 or 2
visceral referral – ulcerative colitis (viscero-somatic reflex), potentially psoas spasm due to inflammed bowel.
Less likely, however Ankylosing Spondylitis
Tutor response
Done very well, good demonstration of osteopathic knowledge
kept it simple yet explained and justified very well.
Very good to mention ankylosing spondylitis, able to describe pathology and process.
Slightly rusty in terms of testing for rheumatological testing of ankylosing spondylitis
Patient five – 31, works in charity, desk bound and travelling long distances
PPW -
- LB pain central, broadly into the buttocks, can be dull or sharp in nature, related to movement, flexion in particular
- RAD – zero LEX symptoms
Onset – 4/52, lifting kettle bells, heavy weight, flexion to extension, pain felt post exercise
Progression – stable/relieving
Hxx – similar pain 5-6 years prior, with neurological symptoms (shooting pain post thigh), resolved after 3 months with zero treatment
Systemically Healthy
Differentials
Disc – annular strain, less like herniation as no LEX symptoms
Facet – capsular strain due to the peak of loading was on full flexion
Recovering muscular spasm
less likely, but if poor technique and due to site of pain, sacroilliitis
Tutor response
did well to present, good linking of case history to differentials
BIG MISTAKE – missing the obvious, potential herniation 5 or 6 years ago, include potential early spondolytic changes, creates a better picture of the patient.
Patient six – 34, free lance photographer
PPW – R shoulder pain, some lower Csp pain, pain is sharp, intermittent
- RAD – Lateral arm, forearm, and thumb and first finger numbness.
- random onset of numbness, no pattern noticed, no loss of grip
Onset – 6 months ago, gradual onset
Progression – worsening, increased frequency and onset of numbness.
Agg – working posture, taking photos, right shoulder hunched whilst right arm holds top of camera, left shoulder depressed holding the bottom of the camera.
Hxx – zero
Systemic health – asthma, medicated (ventillin)
Differentials
first rib (+ other ribs) – fixed inspiration due to work posture and asthma, upper rib breathing mechanics increasing stress on accessory, some inflammation of facet, leading to neuro-vascular thoracic outlet picture,
cervical disc, c5/c6 herniation
+ associated muscle hypertenocity
Supraspinatus/biceps tendonitis
Tutor response
Good linking of asthma with the effects it has on biomechanics
be able to distinguish specifically between disc and thoracic outlet, for examiners sake.
Good knowledge of dermatomes and peripheral pathway
Keep it simple, no digging a hole for yourself.
Many thanks to the patients for allowing me to make this all happen.
I did find this helpful. A lot of the time when you are observing colleagues it is hard to get your opinions or differentials across as it is not your patient, but talking to tutors they were very helpful and patient in allowing me to talk to them about other differentials. I have definitely broaden my differentials and have broadened my outlook. I feel confident in my differentials now more than ever.
Patient One – 29 year old female police officer
PPW -
LBP – SIJ region, dull pain, constant
RAD – L post thigh and calf, zero below ankle. Pain is shooting in nature.
Agg – walking/standing prolonged periods.
Onset – 3 months ago, rapid turn in response to a car horn.
progression – lower extremity symptoms worsening
Seen GP, referred for imaging, MRI. Test results back which show L5/S1 disc buldge, compressiong on nerve root.
Systemically healthy.
Differentials
Discal herniation L5/S1 – keep it simple and stating the obvious with imaging.
Element of facet involvement compensating for the instability in lower back.
Secondary inflammation of SIJ due to over compensation.
+ associated muscle hypertonicity, gluteals, piriformis, psoas, etc.
Element of facilitation due to on going chronicity.
Tutor response
- impressed by inclusion of facilitation
potentially think about early onset of degenerative changes predisposing a herniation.
Patient Two – 67 year old retired cab driver
PPW -
LBP – L/S region, dull pain, constant, widespread some into buttock.
RAD – zero lower extremity.
Agg – morning pain, sitting
Onset – 10 years ago, intermittent dullness since, zero history of LEX symptoms.
Recently, 2 months prior to consultation.
Systemic health – cystitis
Differentials
Degenerative changes, spondylosis (osteophytic growth), prediposing...
osteoarthritis/spondylarthritis.
+ associated muscular hypertonicity
Viscero-somatic referral (cystits), inferior mesenteric ganglion L2.
Consideration – early onset O/A of hip, affect Lsp mechanics, as symptoms are broad.
Tutor response
overall included most aspects
every basics covered, however a good chance to demonstrate osteopathic knowledge, talk about processes that occur in differentials
O/A hip justified, but less likely, was it worth including?
Patient Three – 48, Information analyst office based
PPW -
- L > R upper Tsp pain, b/w scapula, constant pain
- pain is focal, warm/burning sensation
RAD – zero UEX, some lower Csp dullness
Agg – coughing, deep breath, Rot L
Onset – 2 years ago, NAR, gradual onset
Progression – over last 4/52, worsening, increase notability of pain
History – prescribed 4 weeks ago, noticed a postural change, constant flexion at neck to read.
Gout, 2 years ago, hallux (not sure which), managed and zero problematic.
Systemically healthy.
Differentials
postural mm fatigue causing ischaemic changes in upper thoracic.
Changes due to – rib facet (irritation/inflammation)
C/T, Tsp facet (irritation/inflammation)
resulting facilitation (chronic duration)
3. Psoas/hamstring hypertonicity (prolonged sitting), affecting lower thoracic mechanics
Tutor Response
Very well covered, as expected for a simple enough case
Good justifications
Use correct terminology.
Patient four - 27, female office worker
PPW -
- R sided suprascapular pain, tightness/dullness
- RAD – Csp bilaterally (ache), zero headaches, decreased mobility.
- Agg – prolonged work posture
- LB pain, central , dull but sharp on movements
- RAD – posterior thigh and calf, tightness sensation
- Agg – walking with heels and running
Hxx – RTA – 2008/2009, in a car accident which flipped, torn mm L scapula = depression of scapula.
Ulcerative colitis (medicated and managed)
Differentials
mm imbalance + postural demand at work = ischaemia
rib/Tsp facet
somatic dysfunction resulting facilitation
Lsp facet (psoas shortening due to desk bound nature)
Disc herniation (sensation change in lower extremity)
> associated mm hypertonicity due to 1 or 2
visceral referral – ulcerative colitis (viscero-somatic reflex), potentially psoas spasm due to inflammed bowel.
Less likely, however Ankylosing Spondylitis
Tutor response
Done very well, good demonstration of osteopathic knowledge
kept it simple yet explained and justified very well.
Very good to mention ankylosing spondylitis, able to describe pathology and process.
Slightly rusty in terms of testing for rheumatological testing of ankylosing spondylitis
Patient five – 31, works in charity, desk bound and travelling long distances
PPW -
- LB pain central, broadly into the buttocks, can be dull or sharp in nature, related to movement, flexion in particular
- RAD – zero LEX symptoms
Onset – 4/52, lifting kettle bells, heavy weight, flexion to extension, pain felt post exercise
Progression – stable/relieving
Hxx – similar pain 5-6 years prior, with neurological symptoms (shooting pain post thigh), resolved after 3 months with zero treatment
Systemically Healthy
Differentials
Disc – annular strain, less like herniation as no LEX symptoms
Facet – capsular strain due to the peak of loading was on full flexion
Recovering muscular spasm
less likely, but if poor technique and due to site of pain, sacroilliitis
Tutor response
did well to present, good linking of case history to differentials
BIG MISTAKE – missing the obvious, potential herniation 5 or 6 years ago, include potential early spondolytic changes, creates a better picture of the patient.
Patient six – 34, free lance photographer
PPW – R shoulder pain, some lower Csp pain, pain is sharp, intermittent
- RAD – Lateral arm, forearm, and thumb and first finger numbness.
- random onset of numbness, no pattern noticed, no loss of grip
Onset – 6 months ago, gradual onset
Progression – worsening, increased frequency and onset of numbness.
Agg – working posture, taking photos, right shoulder hunched whilst right arm holds top of camera, left shoulder depressed holding the bottom of the camera.
Hxx – zero
Systemic health – asthma, medicated (ventillin)
Differentials
first rib (+ other ribs) – fixed inspiration due to work posture and asthma, upper rib breathing mechanics increasing stress on accessory, some inflammation of facet, leading to neuro-vascular thoracic outlet picture,
cervical disc, c5/c6 herniation
+ associated muscle hypertenocity
Supraspinatus/biceps tendonitis
Tutor response
Good linking of asthma with the effects it has on biomechanics
be able to distinguish specifically between disc and thoracic outlet, for examiners sake.
Good knowledge of dermatomes and peripheral pathway
Keep it simple, no digging a hole for yourself.
Many thanks to the patients for allowing me to make this all happen.