Clinical reasoning for a patient with neck and upper extremity symptoms: a case requiring referral.

The purpose of this case report is to describe a 56-year old female patient with a bizarre pattern of cervicobrachial symptoms. The patient was managed according to the McKenzie "Mechanical Diagnosis and Therapy" principles and the physical examination alongside the movement testing showed inconsistent findings. Due to the patient's cancer-related medical history, presence of night pain, general weakness and the non-response to treatment, a referral to a medical specialist was immediately made. Imaging studies revealed metastases to the axial skeleton in multiple sites and a metastatic lesion was established as a medical diagnosis. With many physical therapists becoming first-entry providers it is likely that encounters with cases other than the purely musculoskeletal will increase. Serious pathologies can mimic musculoskeletal disorders, confusing even the most experienced therapist and as a result, pernicious and possibly life-threatening disease might easily be missed. This would be crucial especially in cases when the patient should immediately be referred to a medical specialist. Physical therapists should hone their clinical skills not only in treatment aspects but also in screening procedures in order to prompt a referral when it is required.