在初级保健机构工作的物理治疗师(PT)通常会遇到机械性原因的膝盖疼痛。膝关节疼痛的非机械性原因,比如骨肿瘤,是罕见的,因此,PT通常对险恶病理的怀疑指数较低。本病例报告的目的是描述一名33岁女性的物理治疗师的临床推理过程,该女性表现为膝关节内侧疼痛和随后的转移性黑色素瘤病史。最初,主观和客观测试都指出了膝盖的机械内部紊乱。然而,2次和3次物理治疗之间的症状进展和治疗反应不佳,引起了人们对膝关节疼痛原因的怀疑。这促使骨科转诊和医学成像,显示一个大的骨肿瘤侵入股骨内侧髁,由一个专业的肿瘤团队进一步鉴定为转移性黑色素瘤。进一步的成像显示几个转移皮下,肌肉和脑部病变。这个案例凸显了正在进行的医疗筛查过程的重要性,包括监测症状和治疗反应。
在没有相关解释或损伤的情况下,临床医生应该对先前诊断为癌症且无法解决疼痛的患者有高度怀疑。筛查过程应包括积极监测治疗反应,并在超出假设时间范围或怀疑有险恶病理的情况下,适当转诊平片。对于骨肿瘤,早期专家转诊和随后的肿瘤学团队转诊是必要的,评估转移性疾病并开始治疗。
Physical therapists (PTs) working in primary care settings commonly encounter mechanical causes of knee pain. Non-mechanical causes of knee pain, such as bone tumors, are rare, and therefore, PTs often have a low index of suspicion regarding sinister pathology. The purpose of this
case report is to describe the physical therapist\'s clinical reasoning process for a 33-year-old female presenting with medial knee pain and a subsequent history of metastatic melanoma. Initially, subjective and objective testing pointed to a mechanical internal derangement of the knee. However, symptom progression and poor treatment responses between physical therapy visits 2 and 3 raised suspicions as to the cause of the knee pain. This prompted an orthopedic referral and medical imaging, revealing a large bone tumor invading the medial femoral condyle, which was further characterized as metastatic melanoma by a specialty oncology team. Further imaging revealed several metastatic subcutaneous, intramuscular and cerebral lesions. This
case highlights the importance of the ongoing medical screening process, including the monitoring of symptoms and treatment responses.
Clinicians should have a high index of suspicion in patients with a prior cancer diagnosis and unresolving pain without a relevant explanation or injury.The screening process should include active monitoring of treatment responses and appropriate referral for plain radiographs where hypothesized timeframes are exceeded or sinister pathology is suspected.Early specialist referral and subsequent oncology team referral is imperative for bone tumors, to assess metastatic disease and initiate treatment.