Event 2: Differential Diagnosis and Treatment

Test Your Knowledge

What differential diagnosis would you make after Betty's primary care provider visit and exam?

Incorrect. Betty has additional symptoms that are not explained only by muscle spasm. Below are the primary expected symptoms for muscle spasm: History: may or may not have a previous injury. Physical Exam: Scapulohumeral dyskinesia; Muscle guarding/spasm upon palpation Pain: Achy at rest and sharp with movement.
Correct. Below are the primary expected symptoms for frozen shoulder: History: May or may not have previous injury. Physical Exam: Limited in all directions with capsular pattern (external rotation abduction then internal rotation). Pain: Dull, achy, global pain, and stiffness.
Incorrect. Betty has referred pain that is fully not explained only by a nerve injury and Betty has not had a nerve injury. Below are the primary expected symptoms for nerve injury: History: Previous injury or history of degenerative joint disease. Physical Exam: Decreased cervical range of motion: Reflex changes: complaints of numbness, tingling or paresthesia.
Incorrect. Betty does not have a history of fracture or injury. Below are the primary expected symptoms for a history of fracture: History: Previous fracture in the humerus, clavicle and scapula. Physical Exam: Pain upon palpation of the fracture site. Pain: Deep pain, localized to fracture site.
Incorrect. History: Usually in the middle aged adults; pain at night and with rolling onto involved joint. Physical Exam: Muscle and tendon specific discomfort; positive impingement signs. Pain: Pain with specific motions and activities; burning type pain.

Medication Review with Pharmacist

Betty’s primary care provider has prescribed Naproxen to assist Betty in her pain management. The pharmacist is able to come and counsel Betty on Naproxen. The following is the session with Betty and the pharmacist.

Naproxen Risk

What is the potential risk of using naproxen in a 78 year-old woman like Betty?

General risk of NSAIDs are dependent on underlying patient conditions, dose of NSAID used, and length of the treatment. The primary mechanism tied to NSAID toxicity is related to their mechanism of action which is inhibition of prostaglandin synthesis.


Variety of effects including potential for myocardial infarction, strike, or
heart failure especially in those with pre-existing disease.


Elevations in serum transaminases.


NSAIDs can cause inhibition of platelets placing people at higher risk of bleed; combination with other anticoagulants or antiplatelet may increase the risk.


May cause dyspepsia, peptic ulcer disease, and risk for GI bleed.


May cause acute kidney due to vasoconstriction, electrolyte and fluid abnormalities such as hyperkalemia, hyponatremia, and edema; potential worsening of hypertension.

Central Nervous System (CNS)

May be associated with cognitive impairment in older patients, psychosis, and tinnitus. 

Follow-Up Care Order

Which services would be the best for Betty for follow-up care – outpatient physical therapy or home health services?

Incorrect. The primary care provider chose Home Health Services for Betty due to her transportation limitations. She is not able to drive alone and has reported difficulty in steering her car due to her right shoulder pain, resulting in minor bumps and scrapes with her vehicle. Distance of the nearest outpatient physical therapy clinic is 45 minutes away. Her family and friends are not able to transport her to the nearest outpatient at this time.
Correct. Primary care providers order home health because Betty needs to drive in daylight, and the therapy outpatient clinic too far to drive safely along in order to establish homebound status, lives alone, driving difficulty due to right arm pain.

Guidelines for Home Care Eligibility

Home Care Eligibility – Medicare

  • Medicare Eligibility: Part A and /or Part B
  • Patient needs to be under the care of a doctor
  • You must need one or more of the following:
    • Intermittent skilled nursing care
    • Physical therapy, speech-language pathology or occupational therapy services which requires skilled services of a qualified therapist.
    • Must be homebound and doctor certifies you are homebound
  • You may leave home for medical treatment or short, infrequently absences for nonmedical reasons



Outpatient Services

  • Medicare Part B (Medical Insurance) 20% copay for services
    • Nursing outpatient services are not a covered Medicare service
    • Social Services outpatient services are covered when they are provided by a health care provider who accepts assignment.
    • Physical Therapy: Medicare helps pay for medically necessary outpatient physical therapy, speech-language pathology or occupational therapy. There are limits on these services. The therapy cap limits for 2017 are:
      • $1,980 for physical therapy (PT) and speech-language pathology (SLP) services combined
      • $1,980 for occupational therapy (OT) services




Primary Care Provider: Additional Orders

After Betty’s visit, the primary care provider has ordered:

  • Medication: Naproxen. A proton pump inhibitor was not added as the timeframe for the Naproxen is expected to be limited.
  • Home Health Services for Nursing, Social Services and Physical Therapy
  • Follow-up visit with primary care provider.

Test Your Knowledge

Question 1

Which additional orders you feel would be appropriate for Betty at this time?


Question 2

When should you schedule a follow-up visit for Betty with her primary care provider?


 Imaging is not recommended at this time based on the differential diagnosis. Four weeks is the most correct answer in order to see a significant difference in benefit from the anti-inflammatory and additional services ordered.

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