RED FLAGs Flashcards
Symptom investigation
location of symptoms
The question should start with the patient’s chief presenting complaint, followed up by questions regarding symptom location including:
-Do the chief complaint symptom move or spread up, down?
-Can you rate the symptom intensity on a 0-10 scale at best, worst and an average?
-Do you have symptoms anywhere else?
Noting where the patient does not have symptoms is just as important as documenting where the patient does experience symptoms.
Knowledge of potential pain patterns associated with viscera can guide the PT in selecting the organ systems to screen with questions related to review of systems.
The investigation of symptoms also include the patient’s description of the symptoms.
Certain descriptors are unusual for MSK impairment disorders:
-Vascular disorders: throbbing, pounding, pulsating
-Neurological disorders: sharp, lancinating, shocking, burning
-Visceral disorders: aching, squeezing, gnawing, burning, cramping
Symptom history
The most relevant information for this initial visit is investigating the most recent injury or flare-up.
Impairment-related symptoms typically are associated with traumatic incident, accident, repetitive overuse or sustained postural strains.
Behaviour and pattern of symptoms
The PT should ask questions regarding the following:
- the relationship symptoms have to rest, activities, time of day and positions and postures
- the constancy, frequency and duration of symptoms, including fluctuations in intensity
In addition to insidious onset of symptoms, reports of unexpected or atypical behaviour of symptoms may be the initial clue that raises the suspicion of a serious underlying condition.
LBP (Red Flag)
Tumor
Following questions are asked to increase or decrease the index of suspicion that the patient’s LBP is caused by cancer:
- Do you have history of cancer? If so, what type of cancer?
- Have you recently lost weight?, even though you have not been attempting to eat less or exercise more? if so, how much?
LBP (Red Flag)
Back - related infection
The risk factors for spinal infection are current or recent bacterial infection, intravenous drug use or abuse and immunocompromise
Following questions can be asked:
- Have you recently had a fever?
- Have you recently taken antibiotics or other medicine for an infection?
- Have you been diagnosed with an immunosuppressive disorder?
- Does you pain ease when you rest in a comfortable position?
LBP (Red Flag)
Fracture
Disorders that increase the risk of decreased bone density include hyperparathyrodism, renal failure, chronic gastrointesintal disorders, long-term corticosteroid use
- Have you recently had a major trauma, such as MVA or fall from height
- Have you ever had a medical practitioner tell you that you have osteoporosis or other disorders that could cause weak bones?
LBP (Red Flag)
Cauda equina screening questions
- have you noticed a recent onset of difficulty with training your urine or starting urine flow?
- have you noticed a recent need to urinate more frequently?
- Have you noticed a recent onset of numbness in the area of your bottom where you would sit on a bicycle seat?
- have you recently noticed your legs becoming weak while walking or climbing stairs?
Pelvis, Hip and Thigh (Red Flag)
Colon cancer
Risk factors for colon cancer
- Age older than 50
- History of colon cancer in an immediate family member
- Bowel disturbances
- Unexplained weight loss
- Back or pelvic pain that is unchanged by positions or movements
Pelvis, Hip and Thigh (Red Flag)
Disorders of proximal femur
Pathologic fractures of the femoral neck occur secondary to disease and often in the absence of trauma. These fractures are most common in individuals older than 50 years, who have a history of metabolic bone disease (osteoporosis, paget’s disease). A history of fall from standing position is often reported, along with a feeling of sudden, painful snap in the hip region and a giving way. Acute groin pain is usually reported but pain also may be felt in anteromedial thigh or in the trochanteric region.
Another serious disorder of the proximal hip is AVN of the femoral head. Osteonecrosis of the femoral head is a result of insufficient arterial supply to the region. This ischemic process eventually results in death of the bon tissue of the femoral head.
A similar condition that occurs in children (5-8yo) is Perthe’s disease. This condition results from idiopathic loss of blood supply from the lateral ascending cervical artery to the femoral head. Patients with osteonecrosis and Perthe’s disease report pain in the groin, thigh and knee that worsens with WB activities, resulting in an antalgic gait. Clinical findings include limited IR and AB of the affected hip
A hip disorder that occurs in adolesence is SUFE, which involves progressive displacement of the femoral head relative to the neck through the open growth plate. Patients with SUFE usually experience groin, thigh or knee pain that is described as diffuse and vague. Common clinical findings include antalgic gait, involved extremity positioned in ER and limitation of hip IR.
Knee, lower leg, ankle and foot pain (Red Flag)
Peripheral arterial occulsive disease
Peripheral vascular disease is the manifestation of atherosclerosis below the bifurcation of the abdominal aorta. This disease is common because the risk factors for heart disease are widespread in our society (type 2 DM, smoking, sedentary lifestyle). Individuals who have a history of ischemic heart disease should be assumed to have peripheral arterial occlusive disease until proved otherwise. A primary clinical feature of this disease in intermittent claudication. A pateitn with intermittent claudication often complains of aching in the buttocks, thigh and calf pain that is precipitated by walking, intensifies with walking and disappears with rest. In addition, the patient may complain of the distal extremities feeling cold.
The physical examination findings that suggest peripheral occlusive arterial disease include decreased pedal pulse (posterior tibialis and dorsalis pedis arteries), unilateral cool extremity and wounds and sores on the toes and feet.
Knee, lower leg, ankle and foot pain (Red Flag)
DVT
DVT is spontaneous obstruction of the popliteal vein of the calf and may manifest as a gradual or sudden onset of calf pain, typically intensified with standing or walking and reduced with rest and elevation. 50% of patients with DVT do not experience the calf pain. Physical examination findings that increase the suspicion of a DVT are localised calf tenderness, swelling and edema and skin warmth.
The potential that the blood clot may travel proximally toward or into the pulmonary vessels is the risk that makes a DVT a serious condition.
Knee, lower leg, ankle and foot pain (Red Flag)
Compartment Syndrome
The inflammatory phase of healing that accompanies the trauma or overuse strains to the legs can lead to an abnormal increase in pressure in one of the fascial compartments of the leg. This abnormal increase in pressure resulting from acute swelling inside a fascial connective tissue compartment is called a compartment syndrome. The vascular occlusion and nerve entrapments that are possible sequalae of a compartment syndrome makes this condition a medical emergency. The patient often reports severe, persistent leg pain that is intensified when stretch is applied to the involved muscles. The physical examination reveals swelling, exquisite tenderness and palpable tension of the involved compartment.
Knee, lower leg, ankle and foot pain (Red Flag)
Infections
Septic arthritis is an inflammation in a joint caused by a bacterial infection and cellulitis is an infection in the skin and underlying tissues after bacterial contamination of a wound. Patients who have septic arthritis complain of a constant aching or throbbing pain and swelling in a joint. The involved joint is usually tender and warm when palpated. patients who develop septic arthritis often are immunocompromised or have pre-existing joint disease. This immunosuppression may be a result of corticosteroid use, alcohol abuse, renal failure, malignancy, DM, IV drug use, collagen vascular disease, organ transplantation and AIDS
Shoulder and Cervical pain
Ligamentous injury
The PT should rule out a ligamentous injury after trauma, such as MVA or a fall. Also patients with RA, down syndrome and women who use oral contraceptive should be screened for ligamentous instability of the neck. The alar and transverse ligaments maintain the proper relationship between C1 and C2 whereas the ligamentus flavum, anterior and posterior longitudinal ligaments and interspinous and intertransverse ligaments help maintain the proper alignment through the entire cervical region. resultant instability can lead to significant neurological and cardiovascular consequences.
Typical neurological symptoms include tingling, numbness, weakness or burning pain. Possible spinal cord compromise is suspected when patients present with these symptoms in more than one extremity. In addition, dizziness, vertigo or nystagmus associated with head or neck movements should alert the PT. Other potential signs to note during physical examination are clonus and a positive babinski sign.
Shoulder and Cervical pain
Brachial plexus neuropathies
Can occur secondary to repetitive overuse, postural syndromes and trauma.
If a patient presents with weakness of shoulder abduction and cannot shrug a shoulder, the PT should suspect a nerve entrapment of the spinal accessory nerve. The patient typically has dull pain, weakness and drooping of the shoulder. The patient has paralysis of the trapezius muscle, and wining of the scapula is usually present.
Weakness of shoulder abduction and flexion should raise the suspicion of a possible axillary nerve entrapment or injury. The axillary nerve arises from the posterior cord of the brachial plexus and has fibres from the C5,6 roots. The axillary nerve innervates deltoid and teres minor muscles, while supplying the sensation of the lateral aspect of the upper arm.
Scapular winging may be due to trapezius involvement related to serratus anterior paralysis. the SA is innervated by the long thoracic nerve after it branches from the roots of C5,6,7. The nerve passes down the posterolateral aspect of the chest wall and its superficial course makes it susceptible to injury.
Poorly localised shoulder pain also may be related to RC tear or to suprascapular nerve entrapment. The suprascapular nerve, similar to the long thoracic nerve, is a motor nerve and pain resulting from its irritation is deep and poorly localised. The suprascapular nerve derives from the upper trunk of the brachial plexus, formed from the roots of C5 &6.
