National Physical Therapy Examination (NPTE) Quiz: Differential Diagnosis Reasoning

A 45-year-old patient who is an avid swimmer presents with right-sided neck, shoulder, and medial scapular pain, along with paresthesias in the fourth and fifth digits. Symptoms are exacerbated when carrying a heavy bag or performing overhead activities. The physical examination reveals a positive Adson's test and an elevated arm stress test (EAST). There is 4/5 strength in the finger abductors and adductors. Reflexes are normal. The patient has a noted drooping shoulder posture. A chest radiograph was recently performed for an unrelated issue and was reported as unremarkable.

Which of the following conditions is the MOST likely cause of the patient's symptoms?

A 68-year-old female who is 10 days status post right total knee arthroplasty presents to the clinic with an acute onset of severe, diffuse pain and swelling in her right calf that began yesterday. She denies fever or chills. On examination, her right calf is erythematous, warm to the touch, and exquisitely tender to palpation. Calf circumference is 4 cm greater than the left. There is a positive Homan's sign and a palpable, cord-like structure in the popliteal fossa. Her Wells' score is calculated to be 4. She has no history of skin breakdown or prior infection.

Given this clinical picture, which diagnosis requires the MOST immediate medical referral?

A 28-year-old male presents with chronic low back pain and stiffness that has been worsening over the last two years. The stiffness is most severe in the morning, lasting for several hours, and improves with activity but worsens with rest. He has had to start sleeping on his side because lying on his back has become too painful. Examination reveals decreased lumbar spine flexion and extension, tenderness over the sacroiliac joints, and a positive Schober's test. He also mentions a history of intermittent eye pain and redness diagnosed as uveitis.

This patient's clinical presentation is MOST characteristic of which condition?

A 33-year-old female is referred to physical therapy 4 days after being discharged from the hospital. Her hospital course was for a severe gastrointestinal infection. She now presents with rapidly ascending, symmetrical weakness and distal sensory impairments in her hands and feet. She reports her legs feel 'heavy' and she has difficulty climbing stairs. Examination reveals absent deep tendon reflexes in the lower extremities and 1/2+ reflexes in the upper extremities. Cranial nerve examination is unremarkable. Her weakness has progressed since she was discharged.

Which of the following conditions is the MOST likely cause of her current symptoms?

An 80-year-old female presents with recurrent episodes of intense, spinning vertigo lasting for 20-30 seconds. The episodes are consistently triggered when she rolls over to the right in bed or when she tilts her head back to look at a high shelf. Between episodes, she feels perfectly fine, although she is now fearful of moving her head. She denies any hearing loss, tinnitus, or aural fullness. Neurological examination is unremarkable.

Which examination finding would BEST confirm the suspected diagnosis?

A 35-year-old female presents with severe, burning pain in her left hand 8 weeks after a minor crush injury to her index finger, which has since healed. The pain is disproportionate to the initial injury and has spread to involve the entire hand. She describes the hand as being constantly swollen, and the skin appears shiny and is often a blotchy, reddish color. She exhibits extreme sensitivity to light touch (allodynia) and has difficulty moving her fingers due to pain and stiffness. She is very protective of the hand and displays significant emotional distress regarding her symptoms.

This constellation of signs and symptoms is MOST indicative of which of the following conditions?

A 65-year-old male is recovering from a right coronary artery bypass graft (CABG) surgery performed 3 days ago. The physical therapist is seeing him for his first mobilization session. The patient reports new onset of sharp, left-sided chest pain and shortness of breath that started acutely this morning. His vital signs are: heart rate 115 bpm, respiratory rate 24 breaths/min, blood pressure 130/85 mmHg, and SpO2 91% on room air. Auscultation reveals decreased breath sounds at the left lung base. He has a sternal incision and a saphenous vein graft incision on his left leg.

The patient's acute change in status is MOST concerning for which of the following postoperative complications?

A 62-year-old male presents with bilateral buttock and posterior thigh pain that occurs after walking approximately 500 feet. He describes the pain as an 'aching and cramping' sensation. The symptoms are reliably relieved within a few minutes of sitting down or leaning forward on a shopping cart. He denies pain at rest or at night. He has a history of hypertension and hyperlipidemia. Examination reveals diminished pedal pulses bilaterally. Lumbar range of motion is slightly limited in extension, which does not reproduce his leg symptoms. The straight leg raise test is negative. His symptoms are not reproduced with stationary cycling.

Which of the following conditions BEST accounts for the patient's symptom pattern?

A 38-year-old female presents with a 2-month history of right buttock pain. The pain is described as deep and aching, and is worsened by sitting for more than 20 minutes, especially on hard surfaces. The pain sometimes radiates down the posterior thigh but does not go past the knee. She denies low back pain. Physical examination reveals a negative straight leg raise test and negative slump test. There is marked tenderness to palpation in the area of the sciatic notch. The FAIR (flexion, adduction, internal rotation) test is positive, reproducing her buttock pain. Resisted external rotation of the hip is weak and painful.

Based on this clinical presentation, what is the MOST likely diagnosis?

A 19-year-old male presents with right lower quadrant abdominal pain that began 24 hours ago. The pain started as a vague discomfort around his umbilicus and has now localized to the RLQ. He reports nausea and loss of appetite. On examination, he has tenderness at McBurney's point. The therapist performs a maneuver by having the patient lie on his left side and passively extending the patient's right hip. This maneuver elicits sharp right lower quadrant pain. There are no signs of primary hip pathology.

The positive result of the maneuver performed by the therapist increases the suspicion of which condition?

A 32-year-old woman from Connecticut presents in late summer with a 3-week history of migratory arthralgia affecting her knees and elbows, profound fatigue, and intermittent headaches. She recalls having a circular red rash on her thigh about a month ago after a hiking trip, which resolved on its own. She denies significant morning stiffness. Examination shows mild swelling and tenderness in the right knee but is otherwise unremarkable. She has no significant past medical history.

This patient's constellation of symptoms is MOST suggestive of which of the following conditions?

A 40-year-old male presents with sharp, retrosternal chest pain that began 2 days ago. He reports the pain is worse when he is lying flat and during deep inspiration. He finds some relief by sitting up and leaning forward. He denies any radiation of pain to his arm or jaw. On auscultation, a friction rub is heard over the left sternal border. His vital signs are stable, and an ECG shows diffuse ST-segment elevation without reciprocal changes. Cardiac enzymes are slightly elevated.

The patient's signs and symptoms are MOST consistent with which of the following conditions?

A 52-year-old female presents with complaints of fatigue and a 'heavy feeling' in her eyelids, which worsens as the day progresses. She works as a teacher and finds her voice becomes hoarse and her speech slurs by the end of the school day. She also notes difficulty chewing tough foods and has experienced double vision when watching television in the evening. Symptoms are noticeably better in the morning after a night of rest. A neurological exam is normal except for the development of bilateral ptosis after 30 seconds of sustained upward gaze.

The patient's pattern of fluctuating, activity-induced weakness is MOST characteristic of which neuromuscular disorder?

A 45-year-old male presents with a sudden onset of severe low back pain that began this morning after he bent down to pick up a box. The pain radiates bilaterally down the posterior aspect of both legs to his feet. He reports a 'saddle-like' numbness in his groin and perineal area. He also states that he has felt an increasing urge to urinate but has been unable to void for the past few hours. Examination reveals absent Achilles reflexes bilaterally, 3/5 strength in ankle plantarflexion, and decreased sensation to pinprick in the S2-S4 dermatomes.

Which of the following conditions is the MOST critical diagnosis to identify?

A 72-year-old female presents with bilateral shoulder pain and marked morning stiffness lasting over 90 minutes for the past month. She reports significant difficulty with overhead activities such as combing her hair. She also complains of generalized malaise, fatigue, and a low-grade fever. Physical examination reveals limited active and passive shoulder abduction and flexion bilaterally due to pain and stiffness. There is tenderness over the subacromial spaces but no significant weakness on manual muscle testing of the rotator cuff. Laboratory results show a markedly elevated erythrocyte sedimentation rate (ESR) of 85 mm/hr.

Given this patient's presentation and lab findings, what is the MOST likely diagnosis?

A 58-year-old male presents with a 6-month history of insidious onset of neck stiffness, bilateral hand clumsiness, and a feeling of unsteadiness when walking. He reports dropping objects more frequently and has difficulty with buttoning his shirt. His symptoms are slowly progressive. Examination reveals a positive Hoffman's sign bilaterally, a positive inverted supinator sign, hyperreflexia in the quadriceps and Achilles tendons, and a positive Babinski sign. Strength testing is 4/5 in the intrinsic hand muscles and 5/5 elsewhere. Sensation is intact to light touch and pinprick, but he reports vague, non-dermatomal paresthesias in his hands and feet. There is no facial weakness, dysarthria, or dysphagia.

Based on the patient's clinical presentation, which of the following conditions is the MOST likely diagnosis?

A 48-year-old female marathon runner reports a 4-month history of worsening right lateral hip pain. The pain is located over the greater trochanter and can radiate down the lateral thigh. It is aggravated by running, lying on her right side at night, and prolonged sitting. Examination reveals significant point tenderness over the greater trochanter. The hip flexion, adduction, and internal rotation (FADIR) test is negative. However, resisted hip abduction is weak and painful, and she demonstrates a positive single-leg stance test (Trendelenburg sign) for 30 seconds with reproduction of her lateral hip pain.

Which diagnosis BEST explains this patient's clinical presentation?

A 22-year-old collegiate soccer player sustained a blow to the left upper abdomen and lower rib cage during a game 2 hours ago. He was initially able to continue playing but was later removed due to increasing abdominal discomfort. He is now in the training room and complains of intense, sharp pain in his left shoulder. There is no history of shoulder injury, and the athletic trainer's examination of the shoulder joint itself is negative for any local tenderness, instability, or painful arc of motion.

The patient's left shoulder pain is MOST likely an example of referred pain from an injury to which organ?

A 66-year-old male with a history of coronary artery disease and atrial fibrillation is brought to the emergency department with sudden onset of vertigo, dizziness, diplopia, and dysarthria. During the physical therapy screen, the patient demonstrates ataxia of the right upper and lower extremities. A cranial nerve exam reveals nystagmus, dysphagia, and hoarseness. He also has loss of pain and temperature sensation on the right side of his face and the left side of his body. Motor strength is grossly intact.

This specific combination of neurological signs is MOST consistent with an occlusion of which artery?