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Assessing Red Flags

When a patient comes in for consultation we as physiotherapists have a duty to perform a careful history and examination to rule out serious problems and identify the cause of the symptoms. While most patients will have musculoskeletal conditions as an explanation of their symptoms, a small number will have a serious underlying condition of some kind. These people need identifying and referring urgently to a medical specialist for review. The medical community has developed a series of routine enquiries to be performed at consultation and these are referred to as flags in the sense that they should bring immediate attention to the matter.

Red Flags is the term given to the identification of dangerous or potentially dangerous findings in the history or examination. Physicians, physiotherapists and all other medical, para-medical and alternative practitioners should be aware of these warning signs and know where to send the patients next. While it is impossible to spot all serious conditions in patients, going through the list of red flags systematically greatly reduces the risk of missing anything which could be important. There is no substitute for going through a checklist as it is very easy to forget something even though one is familiar with the process.

Bodyweight loss: The reasons for losing weight should always be explored as this can have a serious condition underlying it. Severe, unexpected or sudden weight loss should be discussed to explore potential explanations such as dieting or a loss of appetite secondary to anxiety or depression. Even people who normally work in heavy jobs can lose a lot of muscle bulk if they are unable to work for a few months. A red flag should be suspected if the reason for the weight loss is not clear. 

Losing one's appetite: This can have many causes but if the patient has these signs it is useful to refer to the weight loss remarks above.

Feeling unwell: If you ask people with chronic pain problems if they feel well in themselves they often answer yes. Anyone who complains of persistently feeling unwell, especially with loss of appetite and weight loss, should be regarded with suspicion.

Pain on Rest and at Night: Patients often report they have trouble sleeping with their pains but if the pain is particularly bad lying down or at night it should be recorded as a suspicious finding.

Early Morning Stiffness: Most musculoskeletal injuries or joint problems have some stiffness early in the mornings after they have not been moved for a while. Stiffness lasting for an hour or more could be due to a rheumatoid condition.

Previous Medical History of a Tumour: The examiner should enquire about this as a recurrence could be the presenting cause of the patient's problems.

Bladder and bowel function. Bladder and bowel control is disturbed in many conditions from childbirth to irritable bowel. Any incontinence not previously present or an inability to pass water (retention) is important and should be immediately reported.

Perineal loss of sensibility: The perineal area is between the legs and includes the skin round the genitals and the anus. Certain important medical conditions can change this area, leading to loss of feeling or pins and needles.

Spasticity and hyper-reflexia: On testing, the tone present in the muscles of the limbs should feel normal. Any significant increase in tone, increased reflexes or clonus could indicate a central nervous system problem.

Loss of muscle power: Injuries and damage to structures such as muscles or joints can give weakness but it is usually localised and explained. Weakness which is more generalised is harder to explain on simple anatomical grounds and should be noted.

Age: Most musculoskeletal conditions such as low back pain or neck pain come on between the ages of 20 and 55 years. Anything which comes on earlier or later than these ages may be perfectly straightforward but there is a higher risk of a serious underlying cause.

Thoracic Pain: Most musculoskeletal spinal pains occur in the lumbar, sacral or cervical areas and are benign. Thoracic pain is associated with a higher risk of serious conditions such as tumours and this should be taken into account.

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