When I was in physical therapy school, PTs in the States didn’t have direct access.
I figured I needed to mainly focus on differential diagnosis of musculoskeletal issues and not worry about cancer or visceral referral pattern. However, the States slowly has been adopting direct access for physical therapy and I also learned that regardless of having a referral, physicians don’t always spend enough time with patients to properly rule out other causes.
The purpose of differential diagnosis is not to just identify a specific structure involved, but to also help determine prognosis, other psychosocial factors and to rule out serious pathology and identify conditions not appropriate for physical or massage therapy.
My patient was in her late 20’s and 6 weeks postpartum. She had been having mid-thoracic pain and right scapular pain for almost 12 weeks. Her physician sent her to therapy to receive manual therapy and strengthening.
During the examination, I had difficulty reproducing her pain, but she stated her pain was worse at the end of the day after lifting, carrying and feeding her child all day. She had weakness in her extensors and scapular retractors. Even though I couldn’t reproduce her pain, I gave her some stretching and started some scapular stabilization exercises. I figured her pain was from a sudden increase in lifting and carrying, sitting with her child and a change in her chest size.
Admittedly I treated her for 3 follow-up visits (with little change) before I realized what the problem was.
On the third visit, her husband said: “I just don’t understand why the pain is always so bad late at night.” He was more specific than she had been (end of the day). The pain was late (10 pm) and often caused his wife violent vomiting. That minute the lightbulb went on (and according to my patient I shouldn’t play poker because she knew!). I asked her if she had ever had a White or light stool, she denied it, but her husband said: “don’t you remember the one when you were pregnant?” She had a white bowel movement back when she was about 26 weeks pregnant! She had denied pain anywhere else, but the minute I palpated her upper right abdominal quadrant she jumped off the table and reported radiation to her back/scapular area.
There it was….GALLBLADDER!
She was admitted to the hospital an hour later and was in surgery 4 hours later. The surgeon said she was days away from a rupture.
Quite honestly, I felt like an ass.
I had seen her for 4 visits total before the husband had said the words that made gallbladder click in my head. I realize she had seen both her Obstetrician and her Primary Care physicians prior to coming to see me, but that did little to make me feel much better at the time. I had just started treating pregnancy and postpartum and couldn’t believe I almost missed something so important! I went back and reviewed all my red flags and visceral referral patterns after this incident.
I also share this story with every obstetrics in therapy class I teach.
Also, women and men often present differently with visceral referral patterns. For gallbladder, women tend to have more vomiting than men. Also, during pregnancy, the increase in estrogen leads to an increase in cholesterol in the bile and estrogen reduces gallbladder contractions. The decrease in contractions leads to less bile leaving and an increased risk for gallbladder stones. This can lead to severe pain and potential for infection.
Summary of Gallbladder symptoms:
- Chills and/or low-grade fever
- Dark colored urine
- Jaundiced appearance
- Light-colored stools
- Nausea and vomiting (especially at night)
- Stomach pain particularly after a high-fat meal
- Right shoulder/scapular, mid back pain
We are never going to be perfect, but the goal is to learn from past patients and pick up on patterns faster the next time. It also helps to share our experiences. So keep these risk factors and symptoms in the back of your mind the next time your patient’s mid thoracic pain isn’t making sense!