Question 3

3a. What additional tests would you want to do?**

3b. What concerns do you have about Joe?**

3a. I would test Joe's Myotomes and Dermatomes? (Carley)

I would perform Hoffman's Reflex test on Joe? (Dani)

I would want to do the upper limb tension tests. (Marleigh K.)

I would refer Joe to have an MRI because I am suspecting he might have MS. (Luke)

I agree with Luke. I would perform a complete UQSE on him but regardless of whether I had any tests come out as positive or not an MRI would be best ASAP based on his symptoms. (Colby)

I agree with Luke that you could refer Joe to have an MRI done. A spinal tap could also be done because this could show abnormalities that are associated with MS. An example is abnormal levels of white blood cells or proteins. (Betsy)
http://www.bing.com/health/article/mayo-MADS00188/Multiple-sclerosis?q=diagnosis+of+multiple+sclerosis&qpvt=diagnosis+of+multiple+sclerosis

I would do Spurling's and Quadrant's test to see if it reproduces any of his symptoms? (Amanda)

I would assess Joe's posture and check to see if he had any tenderness along his spine (Liz)

I would want to refer Joe for a MRI to rule out any type of tumors that might be the cause of the double vision and lack of balance. (Sara G.)

3b. I am concerned about Joe's sensory loss, I would want to rule out Cervical Radiuclopathy and Cervical Myelopathy. (Carley)

I would make sure to rule out Cervical Myelopathy, because of pts. complaints of numbness and tingling. (Dani)

Spurling's and Quadrant test to rule out cervical radiculopathy (Amanda)

I am concerned about Joe's worsening balance and his increased risk of falling, particularily in his home. I would want to know about his house, if he had loose rugs, how many stairs he had, etc. I would then educate him and work with him on ways to decrease the likelyhood of falling. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=900 (Britt)

I would be concerned with Joe's previous history. I would want to make sure that his symptoms are not the same as 3 years ago to rule out a recurring problem. If they were, I would want to make sure he does not have double vision as this could affect his ability to safely work as a bus driver. (Laura)

To add to Laura's comment, I believe his double vision needs to be addressed right away as it affects not only him but other's safety on the road as well. (Betsy)
I would first want to clarify if his symptoms occur while he's driving. Driving might even make all of his symptoms worse. I would be curious to know he comfortable he his driving the bus and if HE feels his symptoms are causing problems. (Amber)

To add to Betsy and Ambers comments, if his double vision/balance issues are causing concern for him in his work as a bus driver, we should also be concerned for his 7-year old daughter. If he is also taking care of her and driving with her in a vehicle, we need to assess if it is safe for him to drive. It may be a good idea to have his partner drive him and his daughter until the double vision is resolved. (Chelsea)

I would refer Joe to an eye doctor for further testing regarding his double vision. Potentially the eye doctor could do further testing that as a PT I would not be specialized in. Using this team effort hopefully we would be able to come to a diagnosis. (Kelly)
I agree that Joe should be referred immediately for the vision problems. As PT's we are supposed to be aware of conditions and also to know when to refer. Due to his job as a bus driver I think this should be addressed for his safety and the safety of the children of the bus. (Denise)
I would refer Joe to a neurologist even to make sure it is not a brain problem due to the poor balance and double vision. (Sara)

QUESTIONS:
Why would you do Hoffman's Reflex test? What does it test? Why would you expect to see a possible positive test?

I would do Hoffman's Reflex test to test if an upper motor neuron lesion on the spinal cord is present. A positive test could show neurological conditions for example an upper motor neuron disease, multiple sclerosis, myelopathy (spinal cord compression), it may also show weak grip strength. (Marleigh)
http://www.articleoutlook.com/hoffmans-sign/

To perform Hoffman's test, you tap the nail on the third or fourth finger. A positive Hoffman's is the involuntary flexing of the end of the thumb and index finger. Normally there would be no reflex at all (Erin)

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