Case Scenario
Mary, a 29 year old healthy, active female, has just returned from a trip abroad. One week before returning to this country she began noticing some right shoulder and upper thoracic pain. Initially she thought it might be a mild strain since she had been carrying heavy bags throughout the different train stations and airports. Since returning home, the pain increased. She saw her physician for the problem the week after her return. An x-ray of the shoulder was normal. She was given Motrin anti-inflammatory medication and referred to physical therapy.
During the physical therapy evaluation, she reported that she was in good health except for the pain in the right shoulder region. However, she did notice her urine had been noticeable darker since she had initially seen the doctor but reported no pain with urination or back pain.
The objective assessment by the physical therapist was as follows:
• In standing the patient presented with a mild mid-thoracic spinal kyphosis. Thoracic symptoms were not provoked with active trunk movements.
• Passive accessory movements using central and unilateral pressures over the thoracic spine were unremarkable for pain except for some hypomobility between T5-T8.
• On palpation of the mid rhomboids and right upper trapeziums, tenderness was noted.
• Shoulder arm range of motion was restricted in the last 25% of motion in flexion and external rotation.
• Special test for impingement was unremarkable.
• Shoulder strength was normal and distal sensation intact.
Based upon the findings, the physical therapist began treatment of the right shoulder. The patient proceeded with manual therapy and exercise for several visits gaining in right shoulder range of motion and noting a decrease in her shoulder pain.
The beginning of the second week of therapy the patient called in sick and indicated she was not going to make her appointment. She returned on her next scheduled appointment. She reported to the therapist that during the weekend she had right upper abdominal pain and that her urine appeared to be darker and noted a change in bowel habits. In addition she began to note a slight yellowish to the skin as well as a fever from time to time. The physical therapist cancelled the treatment and notified the patient’s physician of the change in status.
1. What do you think is going on with this patient?
2. What history, symptoms, and patient information clued the therapist to refer the patient back to the physician?
3. Why was therapy canceled? Explain your answer.
4. Active and passive mobility test of the thoracic spine failed to provoke any significant symptoms. During the initial assessment, what type of follow-up questions should the therapist have asked to further investigate the pain?
Additional Questions: Respond to these questions using information from your textbook and your clinical practice. Do NOT refer to the scenario above. Each question is worth 2 points.
1. Where does visceral pain occur in the abdominal region? Why is visceral pain considered hard to localize with the abdomen?
2. Define dysphagia. Other than occurring in gastrointestinal disorders, name at least two other conditions where the symptoms of dysphagia can occur.
3. Low back pain may be the only symptom associated with what type of cancer affecting the digestive system?
4. Explain the different ways of bleeding in the GI tract can be manifested and the possible causes.
5. What is the significance of Kehr’s sign?
6. What areas of the body can gastrointestinal (GI) disorders refer pain to?
(1) Mary, a healthy lady, just returned from the trip.The problem with the patient started as pain in right shoulder and upper thoracic region before her return to the country.
As her x-ray report was normal physician suggests her to go for physical therapy and gave her anti-inflammatory drug and her pain was relieved to some extent.
The patient is facing the problem of dark urination from the day beginning of her appointment with the physician, but she is not having any pain.
Dark urination without any burning sensation, in this case, helps to rule out the chance of urinary tract infection. According to van Slambrouck et al., (2013), dark coloration of urine can happen due to dysfunction of liver.Bile is produced at liver and gets accumulated in the gall bladder. Excess bile excretes out through the kidney and makes the color urine darker. In this case as fever is not associated with chill the case of biliary obstruction can be ruled out (Yang 2015).
T5-T8 region is the position where the liver is located. The patient is having the dark urine from the very first day and it is still continuing and additionally, her skin color is changing. Yellow discoloration of skin with fever is a symptom of liver ailment like jaundice. It takes few days to week to develop symptom of jaundice (Barr, 2013).Upper abdominal pain accompanying the other symptoms is also an indicator of jaundice.
As stated by Yabluchansky et al., (2015), change in bowel habits and yellowing of skin with fever is warning symptoms of hepatitis C.
Looking at the above conditions, it can be suggested that the patient is suffering from the liver related problem.
(2) The patient has a history of a recent foreign trip. She also developed symptoms of upper abdominal pain and intermittent fever. A change of skin color to yellow is also reported by the therapist. The patient also informed that there is change in the color of urine and change in bowel habit. This entire series of incidents clued the therapist to refer the patient to the physician.
(3) The therapy was canceled by the therapist as the condition of the patient deteriorated when she developed some other symptoms which may have risen due to some other reason.
Patient has returned from a foreign trip with a history of pain in her upper thoracic and right shoulder region. Later she went through physiotherapy with anti-inflammatory medication as her X-ray report was normal. When the patient was referred to the physiotherapist she had mild thoracic kyphosis and hypo-mobility was observed between T5-T8 regions. Tenderness on palpitation of mid thromboids and upper trapeziums with normal shoulder strength was also observed before she was referred to a physiotherapist. During her second week of appointment to the physiotherapy the patient developed the symptoms of upper abdominal pain and irregular bowel movement. She also reported that dark urination problem was consistent for more than two weeks, and she is also having fever at regular interval.
(4) A physiotherapist must evaluate and examine all the probable causes of the patient’s symptoms. A visit to the therapist for a number of times the patient was able to gain right shoulder range of motion and a decrease in shoulder pain. In this case, it was thought that the patient’s symptoms were due to pain in shoulder.
Therapist should have asked the questions –
When is the pain beginning?
How long is the pain sustaining?
Is there any activity which is increasing the pain?
Whether the pain is radiating or localized?
Is there any previous injury?
(1) Abdominal cavity being the largest body cavity contains the following organs liver, adrenal glands, gallbladder, spleen, pancreas, small intestine kidneys, and large intestine. Abdominal visceral pain arises from visceral peritoneum.
Visceral pain is hazy, crampy, tedious which is hard to describe. Visceral pain abdomen is hard to locate also (Børglum & Jensen, 2012). As visceral organs are connected with spinal cords and send afferent stimuli to spinal cord. A number of nerve endings in the visceral organs of abdomen are comparatively less than other organs like skin. This is also due to widespread deviation of visceral input within the CNS
(2) Dysphagia: Dysphagia is a medical term used to indicate difficulty in swallowing. This also refers to condition in which a sensation of stacking some thing in the tract from mouth to stomach.
According to Tsuzuki et al., (2012) dysphagia can happen due to conditions other than gastrointestinal disorders. Lung cancer and lymphoma in can create similar type of symptoms as dysphagia. Infectious disease such as tuberculosis may also develop dysphagia like symptoms. Cardiovascular diseases like dilated auricles can also cause esophageal dysphagia.
(3) Pancreatic cancer is associated with only symptoms of lower back pain.
(4) Bleeding may occur in GI in different ways.
Vomiting red blood or heatemesis is bleeding from upper gastrointestinal tract. Black blood vomiting is an indication of upper gastrointestinal tract bleeding. The color of vomitus becomes dark due to exposure to gastric acid of heme molecule of red blood cells. Peptic ulcer is considered to be the cause of black blood vomiting.
Blood in stool is the excretion of fresh blood in or with stool. This kind of bleeding pattern is associated with lower GI tract due to due to hemorrhoids, colorectal cancer, ulcerative colitis, inflammatory bowel disease, etc.
Black stool or melena is associated with peptic ulcer or bleeding from upper GI tract.
(5) Kehr’s sign is a kind of referred pain. This indicates a violent pain in the shoulder (Intravia & DeBerardino, 2013). This happens due the presence of blood in the peritoneal cavity. When the pain is in the left shoulder, then it is an indication of ruptured spleen. Often this discovery is endorsed with German surgeon Hans Kher.
(6) Pain can be felt at different region of body, but it can have its origin in gastro intestinal tract. Pain in upper right abdomen and right shoulder area may be due to dysfunctional gallbladder. Mild to moderate pain in right shoulder may be due to hepatitis. Manifestation of esophageal pain is heart burn or chest pain. Acute pancreatitis or pancreatic pain injury refers to the left shoulder. Gastric ulcer pain passes on to substernal region while perforated ulcer pain refers to one or both the shoulders. (Huang & Azagury, 2016).
References:
Barr, D. A. (2013). Jaundice and liver injury: 5 case reports. Reactions,1453, 25.
Børglum, J., & Jensen, K. (2012). Abdominal surgery: advances in the use of ultrasound-guided truncal blocks for perioperative pain management. INTECH Open Access Publisher.
Huang, L. C., & Azagury, D. E. (2016). His Upper GI Tract. In Men’s Health(pp. 51-67). Springer New York.
Intravia, J. M., & DeBerardino, T. M. (2013). Evaluation of blunt abdominal trauma. Clinics in sports medicine, 32(2), 211-218.
Tsuzuki, A., Kagaya, H., Takahashi, H., Watanabe, T., Shioya, T., Sakakibara, H., … & Saitoh, E. (2012). Dysphagia causes exacerbations in individuals with chronic obstructive pulmonary disease. Journal of the American Geriatrics Society, 60(8), 1580-1582.
van Slambrouck, C. M., Salem, F., Meehan, S. M., & Chang, A. (2013). Bile cast nephropathy is a common pathologic finding for kidney injury associated with severe liver dysfunction. Kidney international, 84(1), 192-197.
Yabluchansky, M., Bogun, L., Martymianova, L., Bychkova, O., Lysenko, N., & Makienko, N. (2015). Approach to the Patient with Disease of the Hepatobiliary Tract and Pancreas.
Yang, D. (2015). Abnormal Liver Function. Handbook of Medicine in Psychiatry.
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