Differential Diagnosis I Thomas Souza, DC, DACBSP
Differential Diagnosis Rule out referable conditions Determine further diagnostic needs Determine treatment needs Avoid mis-diagnosis
Approach to Differential Diagnosis Common disorders occur commonly Although a disorder may have many symptoms, know the most common presenting symptom No disease is rare to the person that has it Your patient can have more than one disorder
Self-Study Approach • Be able to explain the cause of a presenting complaint anatomically and/or physiologically • Be able to compose a short, classic case presentation of a named disorder • Be able to construct an algorithm for evaluation/Tx of a presenting complaint • Be able to prioritize the relevance of a list of signs/symptoms • Be able to take a list of 3-4 symptoms and discuss them with different variables such as age, sex, past Hx, etc..
Patient Presentation The rare but dangerous Specific red flags What the patient knows What the patient doesn’t know (but thinks they know) What’s most common
General Strategy Understand the possible anatomical and physiological basis for the patient’s complaint Translate the patient's complaints into strategies for provocation or relief Gather functional information and use for outcome measure
Case Presentation A 65 year old female presents with a complaint of a headache The headache is temporal in location (side of head) What are the “alarms”? What are the common life-style considerations? What are the common named conditions?
Level of Concern Temporal Location New Headache Senior Patient
Serious Headache Only about 2% of patients in-office and 4% of patients in an emergency room setting will be diagnosed with a headache indicating serious pathology (e.g. tumor, AVM, aneurysm, etc.) Bigal ME, Bordini GA, Specialia JG. Etiology and distribution of headaches in two Brazilian primary care units. Headache 2000;40:241-247.
Sequence of Red-Flag Check-List Trauma Nuchal rigidity Vision loss Neurological signs/symptoms New Headache (especially in an older patient)
Ischemic or Hemorrhagic Several Days <24 hrs Ischemic (nor Hemorrhagic)
Where in the brain? Which side? Other discriminators • Weakness and sensory findings on opposite of lesion below the neck • Aphasia usually indicates the left cortex • Anterior Circulation • Motor or sensory findings • Language/Speech • Memory • Posterior Circulation • Coma • Drop attacks • Vertigo • Nausea • Ataxia
Subdural Hematomas More common in seniors Due to trauma which shifts the brain tearing the bridging cortical veins (low pressure) Symptoms are often immediate but may take days to months to develop (chronic subdural hematoma) Hemiparesis when present is almost always contralateral, whereas, pupillary dilation is ipsilateral
Epidural Hematoma Due to head trauma usually associated with a skull fracture tearing the middle meningeal artery and vein There may be a lucid period of a few hours before lapsing into coma
Key distinguishing factor? HEAD TRAUMA
Increased Intracranial Pressure Three components confined by the skull: • The Brain • Blood • Cerebrospinal Fluid
In general, tumorsare slow-growing so that symptoms are slow in onset, whereas, edema/hemorrhage (either spontaneous or trauma induced) cause a more acute onset of symptoms
Stroke: How common? The third leading cause of death in the U.S.
Stroke: What’s Different? Thromboembolic (Ischemic) Stroke Hemorrhagic Stroke OR
Temporal Arteritis • Older individual (>50 y/o) • Temporal tenderness in half of cases • Possible associated polymyalgiarheumatica • Elevation of ESR or C-Reactive protein • Loss of vision is the risk without Tx • Tx is with a limited use of corticosteroids • Listed as possible yellow-flag for possible VBA risk
What do likelihood ratios mean? LR>10 = strong positive test result LR=1 No diagnostic value LR<0.1 = strong negative test result
The Temporal Artery of a Patient with Giant-Cell Arteritis Salvarani C et al. N Engl J Med 2002;347:261-271
Sequence of Life-Style Checklist Stress Known Allergies Food/nutrition –specific food triggers Dehydration, hypoglycemia, sleep disturbances Eyestrain, sinus congestion, postural strain Medications – including OTCs, caffeine, and alcohol
Case Presentation 21 y/o female with a 3 year history of chronic headaches Unilateral; changes sides some times Some nausea If she takes 1,000 mg of aspirin the HA goes away in a couple of hours Calls them “bad” but does seem to be able to do her administrative assistant work
Level of Concern Young Patient Chronic Headaches Responds to Meds
Classic Presentations of Most Common Headaches Cervicogenic Tension-like Migraine Cluster
Cluster Headaches • Primarily male, middle-aged, often heavy drinker or smoker • Facial/orbital pain • Lacrimation, rhinorrhea • Severe pain (10/10) • Lasts average of 30-45 min. (as much as 2 hours)
Migraine Headaches Classic (with aura) • Primarily female • Familial Hx • Aura • Last hours- 1 day • Incapacitating • Nausea/vomiting common Common (without aura) • Primarily female • No aura • Last days • Not incapacitating • Nausea/vomiting possible
History Findings for Migraine 85% report a pulsatile HA 75% report associated neck pain 75% report associated photophobia,phonophobia,and nausea 50% report at least one of the following triggers: Change in weather Stress Lack of sleep/fatigue Alcohol food triggers Commonly associated with other disorders including psychological, MS, Raynaud’s, and Meniere’s
Migraine in Children About 20% of children with migraines report visual aura. The distinction may be that spots, colors, dots, or lights are more often reported. The aura is generally short-lived being 30 minutes or less. The description of pounding or pulsating is less common as are reports of phonophobia and photophobia. Finally, headaches are generally shorter lasting on average less than 2 hours. They may be more frequent in children. Family Hx may be important with a 70% chance of migraine if both parents have migraines.
Chiropractic and Headaches Cranial nerve V related to blood vessels in head and sensation to face and other structures Relationship between cervical spine and cranial nerve V
The Aura Spreading Cortical Depression It is believed that a spreading wave of cortical depression is the cause of the aura seen with migraine headache
The Aura Found in 15-30% of migraine sufferers Reports of stars, flashes, sparks, lightening bolds first This is followed by scotomas (blind spots) These visual phenomena are likely reflective of hyerpexcitability followed by neural depression