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Patient seen in 2020
A 35 year old female presented for her 3rd PT visit. Her chief compliant had been SIJ pain with some pain in the groin region. So far manual treatment and exercise had reduced pain slightly. She was also educated to wear an SIJ belt due to this being her 3rd bout of SIJ pain since her last pregnancy in 2011.
When she presented to the clinic today, she looked bloated and reported new symptoms.
She reported that three days prior she began to have numbness in the groin region and some pain with urination. She went to her OBGYN the next day and at the visit she expressed concern of fullness. The MD catharized her and was able to extract 12 urine sample containers full of urine. They told her to follow up with her PCP and sent her home.I will tell you what happened after everyone responds
(article attached on red flag management)
QUESTIONS:
What are you going to do on this visit today?
What is your concern for this patient?
Where would you recommend referring them to?
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For this visit, I would inquire further about these new onset of symptoms – when they started, if they remain; has the pt been able to urinate without pain and without lingering feelings of fullness? Has she had any instances of incontinence? I would also inquire about strength, dropping of items and walking ability/balance. For objective testing, I would do a neuro screen including: UE/LE reflexes, UE/LE myotomes, LE dermatome testing (UE if indicated from questions). I would also check UMN signs including inverted supinator, babinski, clonus and ataxia. I would be concerned about possible cauda equina syndrome with this pt or possible issues related to the kidneys(although this would not explain the groin numbness). I would refer this pt to neuro for MRI imaging of the low back to be performed in order to rule out compression of the spinal cord.
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I agree with what both Clare and Emily stated in regards to further subjective questioning and objective procedures. Given the objective neuro findings and onset of new symptoms at this visit, my level of concern would be high due to the potential that this presentation, if not immediately treated, could cause long-term, life altering changes.
Therefore, I would hold therapy for that day and immediately refer the patient to the ER.
I agree with Emily that if the concern was for CES, I would anticipate more LMN s/s, but given the (+) Hoffman’s, my concern is higher for a space occupying lesion or spinal cord compression higher than the level of L1, which further emphasizes the need for an immediate emergency referral.
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I would also ask further questions about her symptoms-if they have been worsening, is the pain spreading and referring further down the leg now? does she have any UE symptoms? are the symptoms bilateral? Has she noticed loss in strength or difficulty walking? Or are the symptoms mostly in her SIJ and groin region and is reproduction of symptoms consistent with different movement patterns to determine if it is more mechanical in nature. I would look at UE and LE reflexes as well, including UMN signs (babinski, clonus, hoffman’s). To me this sounds like it could possibly be cauda equina, and if symptoms were not improving and the pt reported that they were worsening I would have her go straight to the ER to be seen. If symptoms were stable and not worsening, then I would have her follow up with her PCP and want her to be seen by a neurologist to get imaging done. I would also reach out to her PCP to update them on her symptoms and talk about POC moving forward.
For cauda equina though, I would expect hyporeflexia and more flaccidity with testing. So if she does have positive UMN signs, then I would be concerned of spinal cord compression further up. I would follow the same plan as stated above based on findings.
Similar to what Clare said, with relation to where her symptoms are, I would be concerned for possible kidney involvement and would examine tenderness at her costovertebral angle on both sides, and ask about N/V or fever for potential kidney infection and refer her back to her PCP if she has positive findings for this.
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