October- Red Flag management

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    • #8792
      Kyle Feldman

      This was a patient I saw in July 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.

      Questions for thought

      What are you going to do on this visit today?

      What is your concern for this patient?

      Where do you send them?

      I will tell you what happened after everyone responds

    • #8800
      Steven Lagasse

      The focus of this visit should be to screen for additional red flags and other plausible explanations. The most glaring would be cauda equina syndrome. I believe urinary retention yields the highest positive likelihood ratio, followed by saddle paresthesia – it appears this patient has both. Screening for bilateral leg pain, multi-segmental weakness, sensory loss, hyporeflexia, and/or subjective sexual dysfunction are all warranted (per the VOMPTI slides).

      Post-screening, I would educate this patient on the matter and strongly recommend she seek care immediately (assuming nothing else added up). I would also attempt to call her PCP with the patient in the room. Hopefully, this would expedite her receiving care and/or shed light on the situation regarding other plausible reasons for these symptoms.

      I find it perplexing that the patient’s OBGYN did not feel this was more urgent and send her to the emergency room. I understand frightening a patient is not always beneficial. However, if there is a time to scare someone, this may be that time. After all, I wouldn’t want to be the clinician who misses a more sinister pathology and leaves a patient with potential permanent deficits in urogenital function.

    • #8802
      Kyle Feldman

      your right Steven

      During this visit I had a spine specialist and neurologist on the phone. They could not believe the OBGYN situation either.

    • #8803

      Agreed with Steven that the gist of this visit should be red flag screening and also doing a neuro exam. It is definitely concerning that she is experiencing these new symptoms. Cauda equina and pelvic organ prolapse are my biggest concerns.

      I would for sure call her PCP and let them know the urgency of the situation, and discuss with them the need for her to be seen by a specialist or go to the emergency room if unable to get in with them within a reasonable time. If I had the connections, then calling the specialist directly is another route, which seems like what you did Kyle.

    • #8804
      Kyle Feldman

      We only heard from Steven and Anna but I will still tell you what happened.

      She was sent to the ER for concerns of cauda equina. Imaging was negative and she was sent home with a self catheter. Due to the lack of answers she was sent to Reston for further work up.

      Imaging showed no cauda equina but did show an unexplained mass.
      She was seen by her oncologist and a metastasis of her colon cancer from 2014 was found along her sacrum.

      She is currently being treated for the cancer and pain reduction with PT

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