Red Flags

Question 1

Cancer red flags:

Answer 1

Persistent pain at night
Constant pain anywhere in the body
Unexplained weight loss
Loss of appetite
Unusual bumps or growths
Unwarranted fatigue

Question 2

Cardiovascular Red Flags

Answer 2

Shortness of breath
Dizziness
Pain or a feeling of heaviness in the chest
Pulsating pain anywhere in the body
Constant and severe pain in lower leg (calf) or arm
Discolored or painful feet
Swelling (no history of injury)

Question 3

Gastrointestinal/genitourinary

Answer 3

Frequent or severe abdominal pain
Frequent heartburn or indigestion
Frequent nausea or vomiting
Change in or problems with bladder function
Unusual menstrual irregularities

Question 4

Miscellaneous

Answer 4

Fever or night sweats
Recent severe emotion disturbances
Swelling or redness of any joint without history of injury
Pregnancy

Question 5

Neurological

Answer 5

Changes in hearing
Frequent or severe headaches without history of injury
Problem with swallowing or changes in speech
Changes in vision (blurriness or loss of sight)
Problem with balance, coordination, or falling
Fainting spells (drop attacks)
Sudden weakness

Question 6

Back-related tumor

Answer 6

Age over 50 years
History of cancer
Unexplained weight loss
Failure of conservative therapy

Question 7

Back-related infection (spinal osteomyelitis)

Answer 7

Recent infection (urinary tract or skin infection)
Intravenous drug user/abuser
Concurrent immunosuppressive disorder

Question 8

Back-related infection findings:

Answer 8

Deep constant pain, increases with weight bearing
Fever, malaise, and swelling
Spine rigidity, accessory mobility may be limited

Question 9

Back related tumor findings:

Answer 9

Constant pain not affected by position or activity

Worse at night

Question 10

Cauda equina syndrome

Answer 10

History of spinal stenosis or degenerative disk disease
Urine retention or incontinence
Fecal incontinence
Saddle anesthesia
Global or progressive weakness in the lower extremities
Sensory deficits in the feet (L4, L5, S1 areas
Ankle dorsiflexion, toe extension, and ankle plantarflexion weakness

Question 11

Spinal Fracture

Answer 11

History of trauma (including minor falls or heavy lifts for individuals with osteoporosis or elderly individuals)
Prolonged use of steroids
Age over 70 years

Question 12

Physical exam spinal fracture findings:

Answer 12

Exquisitely tender with palpation over fracture site
Increased pain with weight bearing
Edema in local area

Question 13

Abdominal Aneurysm

Answer 13

Back, abdominal or groin pain
Presence of peripheral vascular disease or coronary artery disease and associated risk factors (age >50, smoker, HTN, DM
Symptoms not related to movement stresses associated with somatic LBP

Question 14

Abdominal Aneurysm physical exam findings:

Answer 14

Abnormal width of aortic or iliac arterial pulses

Presence of a bruit in the central epigastric region upon auscultation

Question 15

Colon Cancer

Answer 15

Age of 50 years
Bowel disturbances (rectal bleeding or black stools)
Unexplained weight loss
History of colon cancer in the immediate family
Pain unchanged by positions or movement

Question 16

Physical Exam findings for colon cancer

Answer 16

Possible tenderness to palpation of abdomen in area of cancer
May have ascites
May have hypoactive or hyperactive bowel sounds in the later stages

Question 17

Pathological fractures of the femoral neck

Answer 17

Older women (>70 years) with hip, groin, or thigh pain
History of a fall from a standing position

Question 18

Physical Exam findings for pathological fractures of femoral neck

Answer 18

Severe, constant pain that is worse with movement

A shortened and externally rotated lower extremity

Question 19

Osteonecrosis of the femoral head (avascular necrosis)

Answer 19

History of long-term corticosteroid use (patients with rheumatoid arthritis, systemic lupus erythematosus, or asthma)
History of avascular necrosis of the contralateral hip
Trauma

Question 20

Physical Exam findings for Osteonecrosis of the femoral head (avascular necrosis)

Answer 20

Gradual onset of pain; may refer to groin, thigh, or medial knee that is worse with weightbearing
Stiff hip joint; restrictions primarily in IR and flexion

Question 21

Legg-Calve-Perthes disease

Answer 21

Boys age 5 to 8 with groin or hip pain
Antalgic gait
Pain complaints aggravated with hip movement, especially hip flexion and internal rotation

Question 22

Slipped capital femoral epiphysis

Answer 22

Overweight adolescents
History of a recent growth spurt or trauma
Groin aching exacerbated with weight bearing
Involved leg held in external rotation
Range of motion limitations of hip internal rotation

Question 23

Peripheral arterial occlusive disease

Answer 23

Age > 60 yrs
History of type 2 diabetes
History of ischemic heart disease
Smoking history
Sedentary lifestyle
Concurrent intermittent claudication

Question 24

Physical Exam findings for Peripheral arterial occlusive disease

Answer 24

Unilaterally cool extremity (bilateral if aorta is involved)
Prolonged capillary refill time (>2 sec)
Decreased pulses in arteries below level of the occlusion
Prolonged vascular filling time

Question 25

Deep vein thrombosis

Answer 25

Recent surgery, malignancy, pregnancy, trauma or leg immobilization Calf pain, edema, tenderness, warmth Calf pain that is intensified with standing or walking and relieved by rest and elevation Possible pallor and loss of dorsalis pedis pulse

Question 26

Compartment syndrome

Answer 26

History of blunt trauma, crush injury, or unaccustomed exercise Severe, persistent leg pain that is intensified with stretch applied to involved muscles Swelling, exquisite tenderness and palpable tension/hardness of involved compartment Paresthesia, paresis, pallor, pulselessness

Question 27

Septic Arthritis

Answer 27

History of recent infection, surgery, or injection Coexisting immunosuppressive disorder Constant aching or throbbing pain, joint swelling, tenderness, warmth May have elevated body temperature

Question 28

Cellulitis

Answer 28

History of recent skin ulceration or abrasion, venous insufficiency, congestive heart failure, or cirrhosis Pain; skin swelling; warmth; advancing, irregular margin of erythema/reddish streaks Fever, chills, malaise, and weakness

Question 29

Myocardial infarction

Answer 29

Presence of risk factors: previous history of coronary artery disease, HTN, smoking, DM, elevated cholesterol Men over age 40 years; women over age 50 years

Question 30

Physical Exam findings for MI:

Answer 30

Chest pain Pallor, sweating, dyspnea, nausea, palpatations Symptoms lasting > 30 mins and not relieved with sublingual nitroglycerin

Question 31

Unstable angina pectoris

Answer 31

History of coronary artery disease Physical exam findings Chest pain that occurs outside of a predictable pattern Not responsive to nitrogylcerin

Question 32

Stable angina pectoris

Answer 32

Common in people > 65 years More common in men History of coronary artery disease Chest pain/pressure that occurs with predictable levels of exertion Symptoms predictably alleviated with rest of nitroglycerin

Question 33

Pericarditis

Answer 33

Often associated with autoimmune diseases (systemic lupus erythematosus, RA) History of MI History of renal failure, open heart surgery, or radiation therapy

Question 34

Exam findings for Pericarditis

Answer 34

Sharp/stabbing chest pain that may be referred to the lateral neck or either shoulder Increased pain with left sidelying Relieved with forward leaning while sitting (supporting arms on knees or a table.

Question 35

Pulmonary embolus

Answer 35

History of, or risk factors for developing, deep vein thrombosis Immobility Trauma Cancer

Question 36

Physical Exam findings for PE

Answer 36

Chest, shoulder, or upper abdominal pain Dyspnea Tachypnea Tachycardia

Question 37

Pleurisy

Answer 37

History of a recent or concurrent respiratory disorder (infection, pneumonia, tumor, TB) Physical exam findings Severe, sharp, knifelike pain with inspiration Dyspnea, decreased chest wall expansion

Question 38

Pneumothorax

Answer 38

Recent bout of coughing or strenuous exercise or trauma Chest pain, intensified with inspiration Difficulty ventilating or expanding rib cage Hyperresonance on percussion Decreased breath sounds

Question 39

Pneumonia

Answer 39

History of bactierial, viral, fungal, or mycoplasmal infection Often follows influenza History of inhalation of toxic or caustic chemicals, smoke, dusts, or gases (smoking)

Question 40

Exam findings for Pneumonia:

Answer 40

Pleuritic pain, may be referred to the shoulder Fever, chills, headaches, malaise, nausea Productive cough

Question 41

Cholecystitis

Answer 41

Most common in middle age (particularly in women) | WBC count may be elevated (12,000-15,000/mL)

Question 42

Exam findings for cholecystitis

Answer 42

Colicky pain in right upper quadrant with accompaning right scapular pain Symptoms may worsen with ingestion of fatty foods Symptoms not increased by activity or relieved by rest

Question 43

Peptic ulcer

Answer 43

Dull or gnawing pain or burning sensation in the epigastrium, mid-back, or supraclavicular regions Symptoms relieved with food History of infection (H. pylori) History of multiple stressors, poor coping skills, persistent anxiety, and depression

Question 44

Exam findings for peptic ulcer

Answer 44

Localized tenderness at right epigastrim | Constipation, bleeding, vomiting, tarry-colored stools, coffee-ground emesis

Question 45

Pyelonephritis (kidney infection)

Answer 45

More common in women Recent or coexisting UTI Kidney stone or past episode of kidney stone

Question 46

Physical Exam findings for Pyelonephritis (kidney infection)

Answer 46

Fever, chills, malaise, headache, flank pain Enlarged prostate Tenderness over the costovertebral angle (Murphy’s sign)

Question 47

Nephrolithiasis (kidney stones)

Answer 47

``` Reside in hot and humid environment Past episodes of kidney stones Sudden, severe back or flank pain Chills, fever, nausea, or vomiting Renal colic Symptoms of UTI ```

Question 48

Spinal Fracture

Answer 48

``` History of fall or motor vehicle crash History of osteoporosis Prolonged use of steroids Age over 70 years Loss of function of mobility ```

Question 49

Physical exam findings for spinal fracture:

Answer 49

``` Midline tenderness at level of fracture Most common levels are T11-L1 Bruising Lower extremity neurologic deficits Evidence of increased thoracic kyphosis ```

Question 50

Cervical ligamentous instabilities

Answer 50

Major trauma such as MVA or fall from a height History of RA or ankylosing spondylitis Oral contraceptive use Long tract neurologic signs especially present in more than one extremity; dizziness; nystagmus; vertigo with head/neck movements/positions; clonus; positive Babinski’s sign

Question 51

Cervical central cord lesion

Answer 51

Older age or post trauma Incontinence Gait disturbances due to hyperreflexic lower extremities Upper extremity (especially hand) atrophy and paresis

Question 52

Cervical and shoulder girdle peripheral entrapment neuropathies

Answer 52

Paresthesias Pain present at rest and possibly with a retrograde distribution Muscles innervated can be tender to palpate Muscles and sensory distribution follow specific nerve pattern

Question 53

Spinal accessory nerve injury

Answer 53

History of a penetrating injury, such as stab or GSW Direct blow or stretching of the nerve during a fall or MVA Surgical history of radical neck dissection for tumor or cervical lymph node biopsy

Question 54

Spinal accessory nerve injury exam findings:

Answer 54

Assymmetry of the neck line and drooping of the shoulder Inability to shrug Lack of scapular stabilization Weakness of shoulder abduction

Question 55

Axillary nerve injury

Answer 55

Patients > 40 with shoulder dislocation History of traction force or blunt trauma to the shoulder History of brachial neuritis or quadrilateral space syndrome Weakness of shoulder abduction and flexion Lack of sensation of lateral aspect of the upper arms

Question 56

Long thoracic nerve injury

Answer 56

Identified in players of many sports, including tennis, volleyball, archery, golf, fymnastics, bowling, weight lifting, soccer, hockey, and rifle shooting Recent chest surgery or trauma to the thoracic cage Serratus anterior weakness with scapular winging Loss of scapulohumeral rhythm

Question 57

Suprascapular nerve injury

Answer 57

Deep, poorly localized pain History of fracture of the scapula with involvement of the notch and blade of the scapula Traction injury mechanism

Question 58

Suprascapular nerve injury physical exam findings:

Answer 58

Similar presentation to rotator cuff tear because of wasting of the supraspinatus and/or infraspinatus muscles Loss of strength in abduction and external rotation of the shoulder

Question 59

Pancoast Tumor

Answer 59

Men over age 50 years with history of cigarette smoking Nagging-type pain in the shoulder and along the vertebral border of the scapula Pain that progressed from nagging to burning in nature, often extending down the arm and into the ulnar nerve distribution

Question 60

Vertebrobasilar artery insufficiency

Answer 60

``` Dizziness Vertigo that lasts for minutes Headaches Visual disturbances Nausea Loss of consciousness Apprehension with end range neck movements ```

Question 61

Meningitis

Answer 61

``` History of recent bacterial or viral infection (influenza) History of skull fracture Positive slump sign Headache Fever GI signs of vomiting and symptoms of nausea Photophobia Confusion Seizures Sleepiness ```

Question 62

Primary brain tumor

Answer 62

``` age 20-64 Ataxia Speech deficits Sensory abnormalities Headache GI signs of vomiting and symptoms of nausea Visual changes Altered mental status Seizures ```

Question 63

Subarachnoid hemorrage

Answer 63

History of smoking, HTN, and alcohol abuse Headache of sudden onset (worse HA of life) Brief loss of consiousness Brain tumor signs (neurologic dysfunction, nausea and vomiting) Meningeal irritation (nuchal rigidity, fever, photophobia, nausea and vomiting)

Question 64

Fractures

Answer 64

Recent fall or trauma History of osteoporosis Extended use of steroids (e.g. respiratory problems) Pathologies with improper bone remodeling Pain, tenderness, swelling, ecchymosis

Question 65

Radial head fracture

Answer 65

Fall onto an outstretched arm that is supinate (FOOSH injury) Anterolateral pain and tenderness at the elbow Inability to supinate and pronate the forearm Elbow held against the side with 70 degrees of flexion and slightly supinated

Question 66

Distal radius (Colles’) fracture

Answer 66

``` Fall onto an outstretched arm with forceful wrist extension Age > 40 Women affected more than men History of osteoporosis Wrist held in neutral resting position Wrist swelling Movements into extension are painful ```

Question 67

Scaphoid fracture

Answer 67

Wrist swelling Wrist held in neutral position Pain in the “anatomic snuff box” FOOSH

Question 68

Triangular fibrocartilaginous complex tear

Answer 68

Traumatic fall on outstretched hand with forearm pronated Commonly associated with Colles’ fractures Ulnar-sided wrist pain Tenderness and clicking with passive ulnar deviation Weakness with grip strength Dorsal ulnar head subluxation

Question 69

Space Infection of the Hand

Answer 69

Recent puncture of skin Recent insect bite Presence of an abscess Purulent tenosynovitis of tendons that go through that space

Question 70

Physical Exam findings Space Infection of the Hand:

Answer 70

Typical signs of inflammation: swelling in palm, dorsum of hand, or fingertips Pain, tenderness, warmth, erythema Signs of long-standing infection: high fever, chills, weakness, malaise

Question 71

Raynaud’s phenomenon/disease

Answer 71

Paist medical history of RA, occlusive vascular disease, smoking, or use of beta blockers Hands or feet that blanch, go cyanotic and then red with exposed to cold or emotional stress Pain and tingling in hands or feet when they turn red

Question 72

Complex regional pain syndrome (CRPS) – formerly RSD – reflex sympathetic dystrophy)

Answer 72

Trauma including fracture, dislocation, or surgery Pain does not respond to typical analgesics Severe aching, stinging, cutting, or boring pain that is not typical of injury; hypersensitivity Area swollen (pitting edema), warm, and erythematous