MS Emergencies and Red flags

Question 1

what makes a specific condition an emergency?

Answer 1

1. the potential for permanent injury
2. potential for life-threatening complications
3. potential for litigation if a “borderline situation” become a declining situation that should have been predicted and prevented

Question 2

Osteomyelitis

Answer 2

10-15% of patients with osteomyelitis develop neurological lesion or frank
spinal cord compressio

Question 3

Atlanoaxial subluxation and instability:

Answer 3

excessive mobility between C1 and C2 leaves the
spinal cord vulnerable to compressive injury when C1 translates anteriorly on C2 during
cervical flexion. This may progress to neurological compromise including paralysis.

Question 4

Cauda equina syndrome

Answer 4

compression of the sacral nerve roots due to lumbar disc
herniation. Urinary retention, urinary and bowel incontinence, sphincter dysfunction and
lower extremity neurological deficits are common. Emergency surgical decompression is
mandatory.

Question 5

Myelopathy, Myelitis

Answer 5

spinal cord compression, inflammation or other lesion. May be due
to infection, edema, tumor, spinal fracture, stenosis or inflammatory disease.

Question 6

Acute non-traumatic monoarthritis

Answer 6

must determine if from sepsis or infection.
Considered to be infectious until proven otherwise. Emergency referral for aspiration and
synovial joint fluid culture.

Question 7

Supracondylar fracture of the mid/distal humerus

Answer 7

puts the brachial artery (and branches)
as well as radial, ulnar and median nerves at risk for lesion and subsequent paralysis or
hemorrhage respectively.

Question 8

Acute compartment syndrome

Answer 8

potentially irreversible muscle and/or nerve compression
injury due to inflammation, swelling, or bleeding within a fascial compartment. Usually
lower leg, but also forearm. May occur following trauma, fracture or overuse (strenuous
exercise)

Question 9

Giant cell arteritis, Temporal arteritis:

Answer 9

may rapidly progress to blindness.

Question 10

Acute red eye, including acute iritis and scleritis

Answer 10

may be rheumatoid arthritis, reactive

arthritis, ankylosing spondylitis, sarcoidosis which may result in blindness.

Question 11

Transverse myelitis

Answer 11

segmental spinal cord infection. Emergency referral.

Question 12

Septic arthritis

Answer 12

intra-articular bacterial infection that results in articular destruction and death in 5-10% of patients. Emergent referral for joint aspiration.

Question 13

Neuropsychiatric lupus

Answer 13

neuropsychiatric manifestations in a patient with lupus.

Question 14

Red flags for cancer

Answer 14

• Older than 50
• Hx of CA
• unexpected weight loss over 3 mos
• No relief with bed rest- No response to Tx in 1 month
• pain duration > 1month

Question 15

red flags for low back in Hx

Answer 15

• under 20y.o
• constitutional s/sx
• increased risks

Question 16

what to consider w/ hx of corticosteroid use?

Answer 16

fracture

osteoporosis

Question 17

what to consider with hx of diabetes

Answer 17

avascular necrosis of the hip and spinal cord or a spinal infection

Question 18

red flag for low back pain from PE

Answer 18

1.Neurological deficits in older patients: Malignancy must be considered.
2. The “alarm sign”: If a patient with sciatica points to a specific location in the leg or
pelvis as being aggravated during a SLR test, consider a local mass.
3. Pain with spinal percussion: If
exquisitely painful, and the pain lingers, then consider possible cancer or spinal infection.

4. Hip pain with contracture: Consider infection.
5. Pronounced loss of hip flexor strength can suggest a tumor affecting the spinal cord.
6. Palpable mass: Consider a tumor or abscess.
7. Significant bony tenderness: Palpatory bony tenderness, especially of more superficial
   bones, such as the tibia and sternum, can be associated with bone disease such as
   multiple myeloma.
8. Vascular deficits (e.g., loss of pulse): Indications of poor blood supply in the foot may
   be linked to peripheral arterial disease and deep vein thrombosis contributing to a
   patient’s leg symptoms, and have a weak link with abdominal aortic aneurysms.
9. Deformity: Kyphosis can reflect vertebral collapse. Scoliosis that is painful, acute or focal
   may suggest an underlying disease process.
10. Abdominal mass or bruit: Abdominal Aortic Aneurysm

Question 19

low back pain red fags with ancillary studies

Answer 19

1. elevated ESR or CRP: CA, Infec, A.I
2. elevated serum calcium and or alk/phos: linked to bone metastatic disease
3. anemiacould be due to chronic diseases
4. back pain with pathological imagin

Question 20

red flags for shoulder pain possible malignancy

Answer 20

1. Shoulder pain that cannot be reproduced or aggravated by physical examination
   maneuvers
2. Past history of cancer
3. Unrelenting pain, especially at night
4. History of smoking
5. Over 50 years old
6. Fatigue or general feeling of ill health
7. Localized edema

Question 21

RED FLAGS INDICATING POSSIBLE INFECTION

Answer 21

1. Acute non-traumatic monoarthritis is an emergent referral to rule out infection via
   aspiration.
2. Current fever
3. Recent history of infection (e.g., throat, lung, or tuberculosis)
4. Recent dental work, surgeries, or other invasive procedures
5. Recent open wound
6. Positive tuning fork test
7. Presence of localized edema

Question 22

RED FLAGS INDICATING POSSIBLE MYOCARDIAL INFARCTION OR OTHER HEART CONDITIONS

Answer 22

1. Visceral referred pain to left (or right) shoulder, jaw, or chest
2. Sharp, clinching, or crushing chest pain radiating to left shoulder and jaw
3. Patient demonstrates classic Le-vine’s sign over chest
4. History of cardiovascular disease
5. Diaphoresis or shortness of breath

Question 23

RED FLAGS INDICATING POSSIBLE GALLBLADDER DISEASE

Answer 23

1. Visceral referred pain to the right shoulder and scapula 2. Poorly defined pain that cannot be reproduced upon examining shoulder 3. Pain with percussion in upper right quadrant of the abdomen

Question 24

RED FLAGS FOR INFLAMMATORY ARTHROPATHIES

Answer 24

1. Symptoms are bilateral 2. Symptoms are episodic 3. Other joints are involved 4. Acute non-traumatic monoarthritis is an emergent referral to rule out infection via
   aspiration.

Question 25

RED FLAGS FOR REFERRED PAIN FROM THE NECK

Answer 25

1. Patient also complains of neck pain 2. Motion of the neck causes shoulder pain