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 Red Flags for Potential Serious Conditions in Patients with Thoracic Spine/Rib Problems
Red Flags for the Thoracic Spine and Ribcage RegionConditionRed FlagData obtained duringInterview/HistoryRed FlagData obtained duringPhysical Exam
MyocardialInfarction
1-3
Chest PainPresence of risk factors: Previous history of:coronary artery disease, hypertension,smoking, diabetes, elevated blood serumcholesterol (>240 mg/dl)Men over age 40, women over age 50Pallor, sweating, dyspnea, nausea, palpitationsSymptoms lasting greater than 30 minutes and notrelieved with sublingual nitroglycerinStable AnginaPectoris
4
Chest pain/pressure that occurs with predictablelevels of exertionSymptoms are also predictably alleviated with restor sublingual nitroglycerineUnstable AnginaPectoris
4
Chest pain that occurs outside of a predictablepatternNot responsive to nitroglycerinePericarditis
5
Sharp/stabbing chest pain that may be referred tothe lateral neck or either shoulderIncreased pain with left side lyingRelieved with forward lean while sitting (supportingarms on knees or a table)Spinal Fracture
6
History of fall or motor vehicle crashHistory of osteoporosisProlonged steroid useAge over70Loss of function or mobilityMidline tenderness at level of fractureBrusingLower extremity neurological deficitsEvidence of increased thoracic kyphosisPneumothorax
7
Recent bout of coughing or strenuous exercise ortraumaChest pain - intensified with inspirationDifficult to ventilate/expand ribcageHyperresonance upon percussionDecreased breath soundsPneumonia
5
Pleuritic pain - may be referred to shoulder Fever, chills, headaches, malaise, nauseaProductive coughPleurisy
5
 Severe, sharp “knife-like” pain with inspirationHistory of a recent/co-existing respiratorydisorder (e.g., infection, pneumonia, tumor,tuberculosis)Dyspnea - deceased chest wall excursionPulmonary Embolus
5
Chest, shoulder, or upper abdominal painDyspneaHistory of, or risk factors for developing a deepvein thrombosisDyspneaTachyneaTachycardiaChest Pain withoutcardiac disease
8
Age under 40Type “A” male or “neurotic” femaleHigh perceived level of vital exhaustionRecent uncontrollable and undesirable life eventsReferences:1. Berger JP, Buclin T, Haller E, et al. Right arm involvement and pain extension can help to differentiate coronary diseasesfrom chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain.
 J  Int Med 
. 1990;227:165-72.2. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, et al. Prevalence, clinical characteristics, and mortality among patientswith myocardial infarction presenting without chest pain.
 JAMA.
2000;283:3223-3229.3. Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors.
 Am Heart J 
. 2002;144:1012-7.4. Henderson JM. Ruling out danger: differential diagnosis of thoracic spine.
Physician and Sportsmedicine
. 1992;20:124-31.5. Wiener SL.
 Differential Diagnosis of Acute Pain by Body Region
. New York, McGraw-Hill, 19936. Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging.
 Injury.
2003;34:426-33.7. Misthos P, Kakaris S, Sepsas E, et al.A prospective analysis of occult pneumothorax, delayed pneumothorax and delayedhemothorax after minor blunt thoracic trauma.
 Eur J of Cardio-thoracic Surg
. 2004;25:859-864.8. Roll M, Theorell T. Acute chest pain without obvious organic cause before age 40: personality and recent life events.
 Journal of Psychosomatic Research
. 1987;31:215-221.
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency
 
 
 
THORAX AND RIBCAGE SCREENING QUESTIONNAIRE
 NAME: __________________________________________ DATE: _____________Medical Record #: _________________________Yes No
1. Do you have a history of heart problems?2. Have you recently taken a nitroglycerine tablet?3. Do you have diabetes?4. Do you take medication for hypertension?5. Have you been or are you now a smoker?6. Does your pain ease when you rest in a comfortable position?7. Have you recently had a major trauma, such as a vehicle accident or afall from a height?8. Have you ever had a medical practitioner tell you that you haveosteoporosis?9. Have you had a recent surgery?10. Have you recently been bedridden?11. Have you recently noticed that it is difficult for you to breathe, laugh,sneeze or cough?12. Have you recently had a fever, infection or other illness?13. In the past few weeks, have you notice that when you cough, you easilycough up sputum.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency
 
 
Thoracic Spine Mobility Deficits ICD-9-CM: 847.1 thoracic sprain
 ICF codes
: Activities and Participation Domain code:
d4105
Bending (Tilting the back downward or to the side, at the torso, such as in bowling orreaching down for an object)Body Structure code:
s76001
Thoracic vertebral columnBody Functions code:
b7101
Mobility of several joints
Common Historical Findings
:Symptoms precipitated by a trauma, strain, awkward movement, or prolonged staticposture (bottom line - an identifiable mechanical stress)Pain is usually perceived inferior and lateral to the symptomatic segment
Common Impairment Findings
-
Related to the Reported Activity Limitation or Participation Restrictions:
 Pain increases at end range of the one particular motionPalpable asymmetry of adjacent transverse processes in either thoracic spine flexion orextensionUnilateral posterior-to-anterior (PA) pressures on the involved segment reproduce thereported symptoms
Physical Examination Procedures
:TP Symmetry in Flexion: Upper Thoracic SpineTP Symmetry in Flexion: Mid and Lower Thoracic Spine
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency
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