title: Abdominal differential diagnosis in a patient referred to a physical therapy clinic for low back pain.
abstract: METHODS
  Resident's case problem.
  
  
  BACKGROUND
  Acute back pain most often presents as musculoskeletal in nature; however, less frequently it may be the result of an underlying, or coexisting, systemic pathology. When present, the signs and symptoms of systemic pathology can mimic, or be masked by, musculoskeletal back pain, which may pose a diagnostic challenge during the clinical evaluation. The purpose of this resident's case problem is to describe the clinical reasoning process leading to a medical referral for a patient who presented to physical therapy with debilitating low back pain.
  
  
  METHODS
  The patient in this resident's case problem was a 67-year-old male referred to physical therapy with a 2-week history of severe low back pain and muscle spasms. The patient history and physical examination were suggestive of musculoskeletal back pain and physical therapy treatment was initiated. Abdominal pain was elicited during an introductory therapeutic exercise, which was recognized by the therapist as a potential sign of abdominal pathology. The therapist performed an additional review of systems and an abdominal screening examination, which established the necessity of an immediate medical referral. At the emergency department, ominous abdominal pathology was safely ruled out through diagnostic imaging and the patient was treated for secondary gastrointestinal effects of opioid analgesic medications.
  
  
  CONCLUSIONS
  This resident's case problem provides an opportunity to discuss the clinical reasoning process leading to the suspicion of abdominal pathology. Specifically, this case reinforces the importance of recognizing potential signs of systemic pathology, executing an appropriate physical examination, including screening of the involved anatomical region, and providing an appropriate medical referral when indicated.
authors.affiliation: Department Physical Therapy, Franklin Pierce College, Concord, NH 03301, USA. stowellt@fpc.edu
authors.forename: Thomas
authors.initials: T
authors.lastname: Stowell
authors.forename: William
authors.initials: W
authors.lastname: Cioffredi
authors.forename: Ann
authors.initials: A
authors.lastname: Greiner
authors.forename: Joshua
authors.initials: J
authors.lastname: Cleland
mesh_terms: D015746:Abdominal Pain / Q000175:diagnosis*; D000368:Aged; D000701:Analgesics, Opioid / Q000009:adverse effects; D003937:Diagnosis, Differential; D041981:Gastrointestinal Tract / Q000187:drug effects; D006801:Humans; D017116:Low Back Pain; D008297:Male; D026761:Physical Therapy Specialty; D012017:Referral and Consultation; D014481:United States
chemical_list: D000701:Analgesics, Opioid