MU PT 7780 – Differential Diagnosis
Teresa Briedwell PT, DPT
Pulmonary System
Objectives
1. The student will identify common areas of referred pain from pulmonary conditions.
2. The student will recognize and screen for signs and symptoms associated with pulmonary disease.
3. The student will recognize situations requiring immediate medical attention and those that warrant
referral relative to the pulmonary system.
4. The student will report normal respiratory rates for clients from newborn to adult.
5. The student will describe normal pulmonary pain patterns in order to differentiate pulmonary, cardiac,
versus musculoskeletal pain patterns.
6. The student will utilize appropriate respiratory terminology to discuss the patient’s condition.
7. The student will recognize the role of the physical therapist in primary/secondary prevention of
pulmonary disease.
Pulmonary System
• Neck, back or shoulder pain - must consider pulmonary cause
• Most common pulmonary conditions to mimic musculoskeletal pain• Pneumonia
• Pulmonary embolism
• Pleurisy
• Pneumothorax
• Pulmonary artery hypertension
• Evaluate past medical history, risk-factor assessment, and clinical presentation including associated
signs or symptoms
• Previous history of cancer, especially lung or cancers that metastasize to lung (breast, bone) = RED
FLAG
• Lung cancers can produce central nervous system symptoms – muscle weakness, muscle
atrophy, headache, loss of LE sensation, localized or radicular back pain – need physician
evaluation
Medical History
 Smokers
– COPD – leading cause of morbidity/mortality
– Biggest risk factor for development of lung cancer which is leading cause of death from cancer
in men and women
– PHYSICAL THERAPISTS have a role in education – primary prevention
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Asthma
– 15 million people of all ages affected by asthma in US
– 45% increase in mortality related to asthma in last decade
– 61% increase in prevalence in last 15 years
– 12 times more likely to develop COPD
– An acute attack can be life threatening
– Requires modification of our interventions also – adequate hydration, decreased exercise
tolerance
Do not over look exposure to pollutants/toxins as risk factor for disease
– Home remodeling – risk of lead, asbestos, creosote
 Lead poisoning – integumentary changes, musculoskeletal symptoms, neuro signs
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Frequently develop arthralgias and myalgias first followed by chest pain, dyspnea,
cough
Previous history of cancer –
– lung common site for metastasis, often silent until quite advanced
Pulmonary System
Most common sites for referred pain from pulmonary system:
• Chest (anterior, lateral or posterior)
• Ribs
• Upper trap
• Shoulder, medial upper arm (mimics neuromusculoskeletal sources of pain)
• Thoracic spine
Other sites of pulmonary pain include:
• Neck
• Costal margins
• Scapulae
First symptoms often do not appear until stress the pulmonary system with exercise, can induce:
– Pleural pain
– Cough
– Hemoptysis
– Shortness of breath
– Other abnormal breathing patterns
Significant pulmonary disease can lead to heart disease - cor pulmonale, right sided ventricular failure
Pulmonary systems checklist:
• Dyspnea or altered breathing
• Cough
• Hoarseness
• Cyanosis
• Pleural pain
• Sputum/hemoptysis
• Clubbing of nails
• Positive findings on auscultation
• Wheezing/stridor – abnormal respiratory sounds
• Wheezing- high-pitched noise cause by partial obstruction of airway
• Stridor- high-pitched sound associated with obstruction of larynx or trachea
Elderly populations often have atypical presentation – confusion, lethargy, altered sleep patterns, increased
CHF, failure to thrive, shoulder pain
Pulmonary pain patterns:
Pulmonary pain usually increases with inspiratory movements, such as laugh, cough, sneeze, deep breath
• Generally associated signs and symptoms – dyspnea, persistent cough, fever, chills
• Palpation and movements will not reproduce symptoms
• Symptoms often get worse with recumbency, especially at night, supine position may aggravate
shoulder pain due to pressure on diaphragm
•
Two layers of pleura:
• Visceral lines the lung tissue, insensitive to pain
• Parietal pleura lines inside of rib cage, sensitive to pain
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Lung disease must progress until pressure on parietal pleura before experience pain
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Tracheobronchial pain – trachea and large bronchi innervated by vagus trunks, pain referred to sites
of neck and anterior chest at level of lesion, such irritation result of inflammatory lesions, irritating
foreign materials, or cancerous tumors
•
Pleural pain – must be in contact with parietal pleura, sharp, localized pain aggravated by respiratory
movements, pain may be relieved by sidelying on affected side which diminishes the movement
(autosplinting)
• Exact cause of pain not known
• Often present with pleurisy, pneumonia, pulmonary infarct, tumor, pneumothorax
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Diaphragmatic pleural pain – dual innervation through phrenic and intercostal nerves, damage to
phrenic causes paralysis of corresponding half of diaphragm, phrenic nerve supplies sensory and
motor to both surfaces of diaphragm
• Stimulation of peripheral diaphragmatic pleura – sharp pain along costal margins, can be
referred to lumbar region by lower thoracic somatic nerves
• Stimulation of central portion of diaphragmatic pleura – sharp pain referred to upper trap
and shoulder on ipsilateral side
• Diaphragmatic pleurisy often associated with pneumonia, sharp pain along costal margins
or upper trap, aggravated by diaphragmatic motion (cough, laugh, deep breathing), can
be tenderness along costal margins, change in position of trunk should not reproduce
symptoms
(however forceful, repeated coughing associated with pneumonia can cause true intercostal
lesion making differentiation impossible – need medical referral for further diagnostic testing)
CHECKLIST
Dyspnea: breathlessness or shortness of breath
• Can be cardiac or pulmonary in origin
• Severity of dyspnea is related to extent of disease
• Dyspnea relieved by specific breathing (pursed-lip breathing) or by specific body position
(leaning forward on arms) generally related to pulmonary disease rather than cardiac
•
Pursed-lip breathing in emphysema provides resistance to outflow and improves the
mixing of gases in lung
Altered breathing patterns:
• Look for excessive use of accessory muscles (scalenes, intercostals)
• Rapid breathing
• Prolonged expiration
• Asymmetrical chest expansion/excursion
• Pursed-lip breathing
• Hunched over body postures
• Nostrils flaring
• Shallow breathing patterns
Normal Resting Respiratory Rates
• Monitor rise and fall of chest to assess resting respiration rate
• Normal tidal volume – adult 500 mL
• Expiration twice as long as inspiration
Age
Breaths/min
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Neonate
30-40
1 year
20-40
2 year
25-32
4 year
23-40
6 year
21-26
8-10 year
20-26
12-14 year
18-22
16 year
16-20
18 year
12-20
Adult
10-20
Boissonnault WG. Primary Care for the Physical Therapist: Examination and Triage. St. Louis: Saunders-Elsevier, 2005.
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Respiratory Terminology:
Apnea – absence of breathing
Tachypnea – rate more than 20 breaths/min in an adult
Bradypnea – rate of less than 12 breaths/min in an adult
Hyperpnea – normal rate but increased volume
Hypopnea – normal rate but decreased volume
Hyperventilation – increased rate and volume
Hypoventilation – decreased rate and volume
•Cheyne-Stokes – hyperventilation followed by hypoventilation then apnea, with cycle
repeatingOrthopnea – difficulty breathing while patient is horizontal, with ease of breathing with more
vertical positioning
Dyspnea – labored or difficult breathing
Normal respiratory response to activity
• Increased rate and volume to supply oxygen and remove carbon
• More strenuous the activity, the greater demand for oxygen
• Once exceed anaerobic threshold, hyperventilation will begin,
of labored breathing
• With deconditioning anaerobic threshold decreased
dioxide
difficulty speaking because
Oxygen saturation (pulse oximetry) (SaO2) useful measure of adequacy of ventilation, reveals the saturation
of oxygen on hemoglobin contained in RBCs, normal values – 90-100%, only a partial
picture of
oxygen delivery
• no known lung pathology, stop exercise/activity if drops below 90%
• Known lung pathology, stop exercise/activity if decrease SaO2 by 5% below resting value or if
lower than 88% in persons with right sided heart failure
• Be very careful about just increasing oxygen flow rate during activity
Cough:
• Generally pulmonary cause although can be related to cardiac disease, especially if nocturnal (night)
• Considered chronic if duration 3 weeks or longer
• Often associated with smoking, allergies or post-nasal drip
• Cough often productive
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Dry, hacking cough associated with onset of pneumothorax
Hoarseness:
• May be associated with tumor - vocal cord paralysis or
• Can be associated with bronchitis – acute or chronic
• Pressure on trachea
entrapment/compression of laryngeal nerve
Cyanosis:
• Bluish discoloration of lips, and nail beds of fingers and toes
• Suggests inadequate blood oxygen levels, reduced hemoglobin levels
• Can be associated with cardiac or pulmonary disease (pulmonary disease usually linked to central
cyanosis – oxygen levels reduced in the arterial blood)
Pleural Pain:
• Must extend to parietal pleura before produces pain
• Generally sudden onset and aggravated by breathing, coughing, laughing, deep inspiration
• Vary from discomfort to sharp, knife-like, or stabbing sensation in chest
• May be relieved with autosplinting – lying on involved side
Sputum/Hemoptysis:
• Productive cough
• Coughing up blood
Specific Pathology Notes
 Pneumonia: often presents with generalized aches, myalgias in thighs/calves, can have painful/swollen
knees, fatigue is very common – respiratory signs and symptoms often later
 Tuberculosis: increasing number of drug-resistant strains because people fail to complete course of
antibacterials, may be able to help educate these patients and their families about the importance of the
treatment
– Adopted children from high-risk countries are at greater risk of TB due to health environment in
that country
– Generally affects the lungs but can be extrapulmonary and attack other organs or joints –
avascular necrosis of hip, spinal involvement (Pott’s disease)
 Certain types of emphysema can lead to spontaneous pnemothorax which is a medical emergency
 Pulmonary Emboli (high mortality rate)
– Generally secondary to a DVT (proximal)
– NEED TO PREVENT DVT – Physical Therapists have a role in the prevention especially in
acute care, home health, SNF, long term care
– Dyspnea, report sudden onset of pleuritic pain aggravated by breathing, chest pain, cough, may
see hemoptysis, apprehension tachypnea and fever
– Severe obstruction of 60-70% of pulmonary circulation, can lead to cor pulmonale, serious
cardiac emergency
 Pancoast Tumor – apex of lung
– One of the most frequently missed diagnoses
– Looks like shoulder or neck problem with involvement of C8, T1-2 dermatomes
– Can develop Horner’s syndrome – enophthalmos, ptosis, and miosis
– Generally report sharp pain in shoulder, maybe pain in axilla/subscapular area
– Can radiate to neck, head and chest, down medial aspect of arm (ulnar nerve)
– May see atrophy of muscles and weakness in hands
– Pulmonary symptoms are often very delayed, but should be considered a red flag when
accompanying neck, shoulder or arm pain
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– Looks similar to trigger points of serratus anterior muscle
Auscultation of Lungs:
Listen for normal breath sounds associated with turbulence of air flow in the appropriate anatomic locations
• Vesicular
• Bronchial
• Bronchovesicular
Can hear normal breath sounds in the wrong areas which can be a sign of pulmonary disease
Listen for ‘adventitious’ (abnormal) breath sounds
• Crackles
• Wheezes
• Pleural friction rub
Other assessment tools:
 Respiratory rate
 Breathing patterns – excursion, symmetry, accessory muscle use
 Tactile fremitus
 Nail bed changes/cyanosis
 Symmetry of chest/thorax – AP dimensions
 Palpation
 Trigger point examination
 Use of Dyspnea Scale
Notes about Interventions
 Exercise does not improve pulmonary function – maintains cardiovascular fitness and trains skeletal
muscle to function more efficiently
 Use of oxygen during activity/exercise with pulmonary patients to keep O2 saturation adequate at or
about 90%
– Patients with emphysema depend on arterial oxygen saturation levels as trigger for respiratory
system, if increase O2 delivery can depress the respiratory drive in these patients
Guidelines for Immediate Medical Attention:
• Abrupt onset of dyspnea accompanied by weak or rapid pulse and fall in blood pressure
especially following MVA, chest injury or other traumatic event
• Chest, rib, or shoulder pain with neurologic symptoms following recent scuba diving
• Client with symptoms of inadequate ventilation or carbon dioxide retention
• Any red flag signs and symptoms in a client with previous history of cancer, especially lung
cancer
Guidelines for Physician Referral:
• Shoulder pain aggravated by respiratory movements; have client hold breath and reassess
symptoms; any reduction or elimination of symptoms with breath holding or Valsalva manuever
suggests
pulmonary or cardiac source of symptoms
• Shoulder pain aggravated by supine positioning; pain that is worse when lying down and
improves when sitting up or leaning forward is often pleuritic pain; abdominal contents push up
into diaphragm
and into parietal pleura
• Shoulder or chest (thorax) pain that subsides with autosplinting (lying on painful side)
• Signs of asthma or bronchial activity with exercise
• Weak or rapid pulse accompanied by fall in blood pressure (pneumothorax)
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Presence of associated signs or symptoms, such as persistent cough, dyspnea (rest or exertional),
or constitutional symptoms
Clues for Screening for Pulmonary Disease:
• Age over 40 years
• History of cigarette smoking for several years
• •Past medical history of breast, prostate, kidney, pancreas, colon, or uterine cancer
• Recent history of upper respiratory infection, especially when followed by noninflammatory joint pain
of unknown cause
• Musculoskeletal pain aggravated by respiratory movements (breathing, coughing, laughing)
• Respiratory movements are diminished or absent on one side (pneumothorax)
• Dyspnea (unexplained or out of proportion) especially when accompanied by unexplained weight loss
• Unable to localize pain with palpation
• Pain does not change with spinal movements (no change in symptoms with side bending, rotation,
flexion or extension), (exceptionintercostal tear in association with forceful coughing or pleural
pain may be reproduced with trunk movement, but will not be able to
localize that with palpation)
• Pain does not change with alterations in position (possible exceptions-sitting upright is preferred with
pneumothorax, symptoms may be worse at night with recumbency, sitting upright eases or relieves
symptoms)
• Symptoms are increased with recumbency (lying supine shifts contents of abdominal cavity in upward
direction, thereby placing pressure on the diaphragm and the lungs, referring pain from a lower
pathologic condition)
• Presence of associated signs and symptoms, especially persistent cough, hemoptysis, dyspnea, and
constitutional symptoms (sore throat, fever, chills)
• Autosplinting decreases pain
• Elimination of trigger points resolves symptoms confirms a musculoskeletal condition or conversely
trigger point therapy does not resolve symptoms raising a RED FLAG
• Anytime an older person has shoulder pain and confusion at presentation, consider the possibility of
diaphragmatic impingement by underlying lung pathology, especially
pneumonia
Case Study:
55 year-old male presented with shoulder pain radiating down the arm present for the last three months. His job as a
mechanic requied many hours with the arms raised overhead, which is what he thought was causing the problem.
He was diagnosed with cervical radiculopathy after cervical x-rays showed moderate osteoarthritic changes at the C6-7-8
levels. EMG studies confirmed the diagnosis and he was sent to physical therapy.
The client gave a history as a nonsmoker but mentioned his parents were chain-smokers and his wife of 35 years smokes
heavily. There was no other significant social or personal history. The client was adopted and did not know his family
history.
The therapist conducted a physical screening examination and noted slight drooping of the left eyelid, which the client
attributed to fatigue and changes with middle age. Vital signs were unremarkable. Muscle atrophy and weakness were
present in the left hand consistent with C7-8 neurologic impairment. There were changes in the thumbs and index fingers
on both sides that looked like digital clubbing. The nail beds were spongy with a definite change in shape of the distal
phalanx.
When asked if there were any other symptoms of any kind anywhere else in the body the client mentioned a change in the
way he inspires. He noticed his left face and armpit do not perspire the same as the right side. He could not remember
when the change began but knew it had not been like that his whole life.
What are the Red flags?
What other screening tests might be appropriate?
Refer, treat and refer, treat only?
If you treat, any contraindications for interventions? What is our back-up red flag?
References:
1. Goodman CC., Snyder TE. Differential Diagnosis for Physical Therapists: Screening for Referral (4th ed.). St. Louis: Saunders-Elsevier, 2007.
2. Boissonnault WG. Primary Care for the Physical Therapist: Examination and Triage. St. Louis: Saunders-Elsevier, 2005.
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