Clinical Decision Making to Determine Need for Medical Referral

(Vignette Key)
Study participants,
The research team guided by Mike Shoemaker, Wendy
Ginsberg, and Dan Vaughn would like to offer our sincere thanks for
making this survey a success. We greatly appreciate your
participation and were pleased with the amount of responses we
received. We have provided a vignette key to describe our intended
survey response and diagnosis for each vignette included in the
survey.
Thank you!
Crystal Lamb, SPT
Brittany Bilger, SPT
Danielle Hooker, SPT
Michael Shoemaker, DPT, PhD, GCS
Dan Vaughn, PT, PhD

1. A 50 year old male who works as a mechanic and enjoys playing tennis
as a leisure activity complains of insidious onset of left shoulder pain.
His pain is localized to the anterior shoulder but occasionally travels
into the left upper arm. He reports his pain increases with overhead
activities and disturbs his sleep when he lies on his left side. Patient is
left-handed. Upon examination, right upper extremity, left elbow and
left wrist active range of motion (AROM) are within normal limits
without pain. Left shoulder AROM is within normal limits and painful.
Gross upper extremity strength is 5/5 on the right, 4/5 on the left and
painful. Vital signs are normal and patient is in no acute distress. Past
Medical History: HTN controlled with medications.
Correct Survey Response: No Medical Referral Required
Intended Diagnosis: Shoulder Pain/ Impingement Syndrome
Rationale: Clinical presentation of impingement: insidious, pain localized to
anterior shoulder & radiates into arm, pain exacerbated by lying on shoulder
(Koester et al.) Also overhead activities. Left shoulder pain in the context of
this patients PMH could suggest referred pain from cardiovascular causes,
but are unlikely given the patients normal vital signs.
Bigliani L and Levine, WN. Current concepts review: Subacromial
impingement syndrome. J Bone Joint Surg. 1997;79(12):1854-1868.

Koester MC, George MS, Kuhn JE. Shoulder impingement syndrome. Am J

Med. 2005;118:452-455.
2. A 52 year old male who works on an assembly line at a local factory
complains of low back pain which has been treated several times over
the past 10 years. He reports his back pain as a 6/10 currently that has
recently increased after working longer hours at the factory. In the past
couple days, he has experienced numbness and tingling that started in
his buttock region and has since progressed to his legs and feet. He
has also noticed recent bladder changes, with increased difficulty
emptying his bladder, and a feeling of numbness and tingling in his
perianal region. Upon examination, strength assessment of lower
extremities is grossly 3+/5 to 4/5 bilaterally. Assessment of the lumbar
spine shows reduced active range of motion into extension and side
bending, both of which are painful. Reflexes in his left lower extremity
are a 1+ and a 2+ in his right lower extremity. Past Medical History: 30
year history of smoking, Hypertension.
Correct Survey Response: Medical Referral Required Urgent
Intended Diagnosis: Cauda Equina Syndrome
Rationale: This patient demonstrates many classic signs and symptoms of
Cauda Equina syndrome including saddle paresthesia, numbness and tingling
into the lower extremities, and decreased strength of the lower extremities.
The diminished reflexes on the left indicate that the condition is progressing
but has not impacted the right lower extremity reflexes yet. A history of low
back pain suggests that this individual may have had a disc that had started
to herniate and has progressed to a full Cauda Equina syndrome.
Lavy C, James A, Wilson-MacDonald J and Fairbank
J. Cauda Equina Syndrome. BMJ. 2009; 338 (7699): 881-884.
3. A 56 year old female who is unemployed and enjoys working in her
yard reports she experienced a sudden onset of sharp pain while
completing heavy lifting activities 5 days ago. Her pain is localized to
her left posterior thigh and buttock. Symptoms have been gradually
improving, although her pain still makes it difficult to walk and
complete her daily activities. Upon examination, she ambulates with a
guarded, antalgic gait. Passive range of motion of the left hip and knee
are within functional limits. Left knee flexion and hip extension
strength are 3-/5 and painful, all other lower extremity strength tests
are within functional limits. There are no sensory deficits or changes in
deep tendon reflexes. Patient reports marked tenderness and sharp
pain upon palpation of the left proximal hamstring. Past Medical
History: Unremarkable

Correct Survey Response: No Medical Referral Required

Intended Diagnosis: Muscle strain
Rationale: This is a typical muscle strain presentation; mechanical pain,
known mechanism of injury, muscle tests limited by pain, and symptoms that
are gradually improving demonstrating natural healing. Hamstring strains
can result in difficulty with ambulation due to pain and there is typically
tenderness to palpation over the muscle body and insertion site with a
hamstring strain (Ropiak and Bosco).
Ropiak CR and Bosco JA. Hamstring injuries. Bulletin of the NYU Hospital for
Joint Diseases 2012; 70(1):41-48.
4. A 75 year old sedentary, Caucasian female of small stature complains
of low back and right buttock pain that began 3 weeks ago insidiously.
She notes a significant decrease in her daily activity due to difficulty
with ambulation. Patient does not report any specific trauma or fall
prior to the onset of her back pain. She has 8/10 pain that is elicited
with weight bearing and improves with rest or lying down on her back.
Patient experiences no change in pain with movements of the lumbar
spine. Neurological exam is unremarkable. Past Medical History:
Asthma (treated with corticosteriods via inhaler and frequent episodes
of oral corticosteroids), Left Colles Fracture 4 months ago.
Correct Survey Response: Medical Referral Required NonUrgent
Intended Diagnosis: Sacral Insufficiency/Fracture/Osteoporosis
Rationale: The age of this patient, her Caucasian race, low body weight,
gender and corticosteroid use contributed to increased risk/suspicion of
osteoporosis. The Colles fracture she experienced previously is a common
occurrence in osteoporosis, so this emphasizes this patient as having a
profile for osteoporosis. (Kanis & McCloskey)Sacral insufficiency fractures
occur most often in elderly women and it is often insidious. Prominent clinical
features: low back, pelvic pain; exacerbated by weight bearing activity and
improves with rest. Neurological exam is often unremarkable. (Tsiridis,
Upadhyay, & Giannoudis)
Even if a clinician reading this vignette has never heard of or seen a
sacral insufficiency fracture, the description of a patient with all the risk
factors for osteoporosis (including a past fracture) who had a significant
increase in pain without trauma and significant pain with weight bearing
would indicate at least the possibility of medical referral to rule out a
fracture.

Kanis JA and McCloskey EV. Risk factors in osteoporosis. The European

Menopause Journal.(1998);229-233.
Tsiridis E., Unadhyay N. Giannoudis PV. Sacral insufficiency fractures: current
concepts of management. Osteoporos Int (2006);17:1716-1725
Schindler OS, Watura R, Cobby M. Sacral insufficiency fractures. J Orthop
Surg. (2007);15(3):339-346.
Yoder K, Bartsokas J, Averell K, McBride E, Long C, Cook C. Risk factors
associated with sacral stress fractures: a systematic review. Journal of
Manual and Manpulative Therapy. 2015;23(2): 84-92.
5. A 65 year old retired male who enjoys daily rounds of golf complains of
an insidious onset of back pain that is limiting his ability to golf and
impacts other daily activities. He reports many years of intermittent
episodes of low back pain and had a past (2 years ago) radiograph
image which showed degenerative changes in his lumbar spine. He
describes his current episode as different when compared to his
previous episodes of back pain, as it seems to be rapidly progressing
and is severe. Patient reports his pain has intensified to constant and
throbbing. Upon examination, pain increases during general physical
exertion but not during lumbar motion testing. His range of motion and
muscle strength are within functional limits. Neurological exam is
negative. Past Medical History: Significant Family History of
Cardiovascular Disease, Hypertension, High Cholesterol, Obesity.
Correct Survey Response: Medical Referral Required Urgent
Intended Diagnosis: Abdominal Aortic Aneurysm
Rationale: The case represents possible method of injury and prolonged
history of low back pain. The patient is a male over 50 who is not responding
to conservative treatments which are considered red flags. His pattern of
pain is consistent with an abdominal aortic aneurysm (AAA) as it has been
described as intermittent dull, achy pain to severe constant throbbing pain.
Pain is only worsened by physical exertion and not throughout the
examination including motion, strength, and neurological testing. Patient has
increased risk factors for AAA. This is an urgent referral, throbbing, constant
pain representative of a dissecting AAA and has a high mortality rate. (Cates
1997, Van Wyngarden, Ross, & Hando 2014, Goodman & Synder 2007)
Cates JR. Abdominal aortic aneurysms: clinical diagnosis and management. J
Manipulative Physiol Ther. 1997;20:557-561.
Van Wyngaarden JJ, Ross MD, Hando BR. Abdominal aortic aneurysm in a
patient with low back pain. J Orthop Sports. 2014;44(7):500-507.
Goodman CC, Snyder TEK. Differential diagnosis for physical therapists:
screening for referral. 4th ed. St Louis, MO: Saunders/Elsevier; 2007.

6. A 64 year old male, who is a retired police officer, is self-referred for

decreased strength and endurance. He reports no pain but has
shortness of breath while working in his vegetable garden and climbing
stairs. He attributes shortness of breath partly to his diagnosis of
COPD and reports that his COPD symptoms have been stable for the
past 6 months. He reports increased difficulty with tasks such as
lifting, squatting and walking long distances. Upon examination, gross
upper extremity strength is 4/5 bilaterally and gross lower extremity
strength is 3+/5 to 4/5 bilaterally. Resting vitals are as follows: Heart
Rate 89, Blood Pressure 135/87, SpO2 94% on room air, Respiratory
Rate 24, RPE 7/20. Patient ambulates a distance of 367 meters (1,200
feet) during the 6-minute walk test with one standing rest break. Posttest vitals are as follows: Heart Rate 123, Blood Pressure 152/87, SpO2
92% on room air, Respiratory Rate 36, RPE 14/20. He denies
exertional chest pain or lower extremity cramping. Past Medical
History: COPD, 30 pack-year history of smoking.
Correct Survey Response: No Medical Referral Required
Intended Diagnosis: Stable COPD/Deconditioning
Rationale: The patient describes difficulty with daily activities, shortness of
breath and strength is decreased overall suggesting the patient is
deconditioned. Resting vitals are slightly elevated and initial SpO2 is slightly
low, but patient is stable. The patients vital sign response to exercise is
appropriate given his deconditioned state and COPD and the distance for his
6 minute walk test also suggests deconditioning overall. He has risk factors
for cardiovascular disease but does not demonstrate signs suggestive of a
symptomatic disease state.
Reid WD, Chung F and Hill K. Stable Chronic Obstructive Pulmonary Disease.
Cardiopulmonary Physical Therapy: Management and Case Studies.
2nd ed. Thorofare, NJ: SLACK Incorporated; 2014: 354-358.
7. A 59 year old female elementary school teacher complains of intense
back pain that began a couple of days ago. The patient does not
believe that she has done anything to cause her back to hurt. She
rates her pain at a constant 8/10 and describes it as feeling deep. The
patient complains that she cannot get into the right position to
lessen her pain. Upon examination, pain is localized to T7-T9 area and
wraps around her right side to her xiphoid process. She experiences
mild tenderness with palpation to her right subcostal margin. Her lower
rib spring testing is restricted and painful but did not reproduce her
chief complaint. Range of motion of the lumbar spine and gross
strength is within functional limits. Neurological exam is unremarkable.
Past Medical History: Unremarkable.

Correct Survey Response: Medical Referral Required Urgent

Intended Diagnosis: Visceral Referred Pain

Rationale: This case represents a referred pain location for the gallbladder.
The pain is described as deep and intense which often a descriptor of
visceral pain. Intense pain with insidious onset is reason for concern. She is
unable to relieve her pain with movement or positional changes. Restricted
and painful rib springing result could be due to muscle guarding. Other
examination findings were unremarkable. (Goodman & Synder 2007)
Goodman CC, Snyder TEK. Differential diagnosis for physical therapists:
screening for referral. 4th ed. St Louis, MO: Saunders/Elsevier; 2007.
8. An 82 year old female who lives with her husband in a ranch style
home complains of decreased balance. She reports several falls since
discharge from inpatient rehabilitation 4 months ago following a right
middle cerebral artery CVA. In particular, she experiences frequent
loss of balance and numerous near falls while dressing and preparing
meals. Patient demonstrates moderate right-sided weakness with
strength grossly 3/5 to 3+/5. Left-sided strength is within functional
limits. Patient ambulates with small based quad cane for 200 feet with
decreased gait velocity, decreased right foot clearance and decreased
weight bearing on right lower extremity. Berg Balance Test scores are
20/56 indicating a high fall risk. All deficits are similar to those
documented during her inpatient rehabilitation stay. Vital signs
including orthostatic measurements are normal and patient denies
syncope/pre-syncope as a cause of her falls. Past Medical History: Left
Middle Cerebral Artery CVA, Left THA 15 years prior, Mild Vascular
Dementia.
Correct Survey Response: No Medical Referral Required
Intended Diagnosis: Balance/Stroke
Rationale: Falls and loss of balance are common post stroke, especially in
the patients home (Batchelor et al). The patient has a high number of falls
post discharge often during daily activities and her Berg Balance score
suggests she is at a high fall risk. It does not appear that any additional
medical conditions are contributing to her condition except for residual
effects of her MCA stroke. The falls since discharge and persistently reduced
function in her upper extremity are likely due to weaknesses, decreased use,
and lack of continued progress since she stopped having regular therapy
visits.
Berg Balance Scale. http://www.aahf.info/pdf/Berg_Balance_Scale.pdf.
Retrieved on May 20,2015.

Batchelor FA, Mackintosh SF, Said CM, Hill KD. Fall after stroke. International
Journal of Stroke. 2012; 7:482-490.
9. A 58 year old female who is a former competitive runner complains of
left knee pain that increases with activities including stair climbing and
walking long distances. She reports significant morning stiffness and
swelling in her left knee that lasts well over 30 minutes after getting
out of bed. Over the past three months, patient has noticed occasional
swelling and pain in her wrist and hands that preceded the onset of her
knee pain. Upon examination, left knee active range of motion is
restricted at end ranges and all ligamentous tests of the knee are
negative. The left knee is warm to touch and mildly swollen.
Additionally, the patients wrist and metacarpophalangeal (MCP) joints
are red and mildly swollen. Past Medical History: Unremarkable.
Correct Survey Response: Medical Referral Required NonUrgent
Intended Diagnosis: Rheumatoid Arthritis/Inflammatory
Condition
Rationale: With OA there is typically pain with activity including stair
climbing and walking long distances, and associated morning stiffness that
lasts less than 30 minutes. (Felson 2006). The former athletic participation
could also contribute to the occurrence of OA.
American Rheumatism Association criteria for RA includes morning stiffness,
arthritis of 3 or more joints, arthritis of hand joints, and symmetric arthritis
for at least 6 weeks which are all potentially represented in this case (Arnett
et al, Mooney & Mcgee). Onset of RA is often associated with weight loss and
anorexia (Glazier 1996)
Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, Healey
LA, Kaplan SR, Liang MH, Luthra HS, et al. The American Rheumatism
Association 1987. Revised criteria for the classification of rheumatoid
arthritis. Arthritis Rheum. 1988; Mar;31(3):315-24. PubMed PMID:
3358796.
Mooney J and Mcgee M. Early recognition of rheumatoid arthritis. Nurs
Residential Care. 2012;14(7):344-347.
Glazier R. Managing early presentation of rheumatoid arthritis. Can Fam
Physician. 1996;42:913-922.
Felson DT. Osteoarthritis of the knee.N Engl J Med. 2006;354:841-848.
10. A 38 year old male who works as a construction site manager complains of

low back pain that has been present over the past week. He reports no known
mechanism of injury but may have overdone it at work. He rates his pain
as 6/10 that worsens when he stands and walks. He is unable to sleep due to
being uncomfortable in his preferred position (lying on his stomach). While

resting in his recliner chair his symptoms are relieved. Upon examination,
range of motion is restricted in both lumbar flexion and extension. Patient
reports pain during range of motion testing and demonstrates increased
muscle guarding of bilateral lumbar musculature upon palpation. Neurological
exam is without deficits. Past Medical History: Unremarkable.

Correct Survey Response: No Medical Referral Required

Intended Diagnosis: Non-Specific Low Back Pain

Rationale: This case represents a male under the age of 50. His pain is
mechanical as it worsens with standing, walking, lumbar motion testing.
Directional preference is not completely clear as patient reports pain with
flexion but could be due to the injury being acute. Although no known
mechanism of injury, non-specific mechanical cause is possible. Unable to
sleep is due to difficulty finding a comfortable position because of symptoms
versus waking due to pain. Typical benign low back pain presentation
including worse with movement, improved with rest, and negative
neurological findings. (Della-Giustina, Atlas & Deyo)
Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the
primary care setting. J Gen Intern Med. 2001;36:120-131.
David Della-Giustina. Acute back pain. Primary Care Reports 1 Oct. 2008.
Health Reference Center Academic. Web. 22 Feb. 2015.
Goodman CC, Snyder TEK. Differential diagnosis for physical therapists:
screening for referral. 4th ed. St Louis, MO: Saunders/Elsevier; 2007.
11.
A 56 year old male commercial driver presents with decreased
endurance and 4/10 cramping leg pain bilaterally after walking several
minutes. He reports that his symptoms have gradually developed over
the past 6 months. Patients pain is relieved by rest in sitting or in
standing. Upon examination, lumbar range of motion is slightly
restricted in flexion and extension but does not reproduce his leg pain,
as he claims it feels good. Manual muscle testing of lower extremities
are within functional limits with the exception of decreased strength in
gross bilateral hip musculature, 4-/5. No lower extremity edema is
noted. Neurological exam is unremarkable. Past Medical History:
Hypertension, Coronary Artery Disease, Diabetes Mellitus.

Correct Survey Response: Medical Referral Required NonUrgent

Intended Diagnosis: Claudication/Pulmonary Artery Disease

Rationale: This case represents a typical presentation of vascular

claudication. Pain is described as cramping and induced by
exercise/activity. Pain subsides immediately afterwards with rest. Slight
lumbar range of motion restriction and decreased hip strength could be due
to decreased activity. Past medical history of coronary artery disease is
common with peripheral vascular disease. (Schemieder & Comerota)
Schmieder FA, Comerota AJ. Intermittent claudication: magnitude of the
problem, patient evaluation, and therapeutic strategies. Am J Cardiol.
2001;87:3D-13D.
12.
A 75 year old retired business man with a complicated medical
history is seeking physical therapy intervention due to his wifes
concern for his decreased balance and endurance. His wife reports a
decline in function since hospitalization 3 weeks ago for an
exacerbation of heart failure. Patient was ambulating without an
assistive device and had no functional limitations prior to his hospital
stay. Patient experiences episodes of dizziness and muscle cramping
since his discharge. Upon examination, strength tests are within
functional limits, with a grade of 4/5 or greater. He demonstrates
impaired static and dynamic standing balance. He ambulates with a
front wheeled walker and a slowed gait velocity. Throughout the
examination the patient is lethargic and appears confused. Vitals signs
during examination are stable with the exception of a slightly elevated
blood pressure (135/88). Past Medical History: Diabetes Mellitus,
Chronic Heart Failure, Coronary Artery Disease, Hypertension,
Extensive medication list that includes insulin, Lasix (furosemide),
Zestril (lisinopril).

Correct Survey Response: Medical Referral Required Urgent

Intended Diagnosis: Medication complication/Stable Chronic

Heart Failure

Rationale: Given that patients are living longer and with more medical
complications due to medical advancements, physical therapists will
encounter more complex patients with many factors contributing to their
illness and recovery (Fulton 2005). Issues such as polypharmacy and poor
health literacy can lead to medication complications and increase patient risk
for falls, subsequently increasing the health care burden and lowering
patient health status (Ferrer 2012, Boye 2012). In this vignette we include
symptoms that suggest hypokalemia which can be caused by Lasix in hopes
that physical therapists would take note of the adverse reaction to this
medication and the need for medical referral.

Fulton MM and Allen ER. Polypharmacy in the elderly: A literature review.

Journal of the American Academy of Nurse Practitioners. 2005; 17(4):
123-132.
Lasix Side Effects Center. http://www.rxlist.com/lasix-side-effects-drugcenter.htm. Retrieved on May 20, 2015.
Desai, AS, Stevenson, LW. Rehospitalization for heart failure. Circulation.
2012;126:501-506.

13.
A 22 year old male college student who recreationally plays
basketball reports injuring his right ankle 4 weeks ago during a game.
He self-treated his ankle sprain with an over-the-counter ankle
immobilizer and has been ambulating with the assistance of a knee
scooter he received from his sister. He reports having significant calf
pain that has increased over the last few days. Upon examination, the
patients ankle ROM and strength are decreased and there is
moderate, unilateral right lower leg swelling. During examination, the
patient notes difficulty with breathing that began in the last 24 hours.
Past Medical History: Tonsillectomy at 8 years old.
Correct Survey Response: Medical Referral Required Urgent
Intended Diagnosis: Pulmonary Embolism

Rationale: Immobilization and unilateral swelling are associated with a

positive test for PE (Courtney et al, Kostantinides) Pain with breathing is a
clinical sign of PE. This is a likely presentation to an outpatient physical
therapy clinic in a direct access setting.
Courtney DM, Kline JA, Kabrhel C, et al. Clinical features from the history and
examination that predict the presence of absence of pulmonary
embolism in symptomatic emergency department patients: Results of
a prospective, multicenter study. Ann Intern Med. 2010;55(4):307-315.
Kostantinides S. Acute pulmonary embolism. N Engl J Med. 2008;359:28042813.
14.
A 46 year old female who works as an accountant complains of
neck pain that is making daily activities difficult and is worse at the
end of the day. Patient reports being involved in a low-speed car
accident seven months prior but was not sent to the hospital for any
imaging after the accident. She notes some numbness and tingling in
her hands bilaterally but reports this as a recurrent, intermittent
symptom for the past few years and is unchanged since the accident.
Upon examination, patients posture in sitting and standing is
significant for moderate forward head and rounded shoulders. Patient
demonstrates decreased cervical range of motion with flexion and
extension limited to 45 degrees in each direction, rotation to 60
degrees bilaterally, and lateral flexion to 40 degrees bilaterally with
increased pain at end ranges. There is tenderness with palpation along
bilateral cervical and shoulder musculature. Upper limb nerve tension
tests reproduce numbness and tingling to hands during the elbow
extension component. Strength and deep tendon reflexes of all
extremities are normal. Ligamentous tests of the upper cervical spine
are negative for instability. Past Medical History: Unremarkable.

Correct Survey Response: No Medical Referral Required

Intended Diagnosis: Neck Pain

Rationale: This case incorporated a few of the Canadian C-Spine Rules but
the patient was outside of the parameters indicated by those predictors. The
described patient is at a high risk for an overuse injury due to employment
and poor posturing.
Stiell IG et al. The Candian C-Spine Rule versus the NEXUS Low-Risk Criteria
in patients with trauma. N Engl J Med 2003;349:2510-8.
http://www.nlm.nih.gov/medlineplus/ency/article/003025.htm
Canadian C-spine Rules.
http://www.health.vic.gov.au/vscc/downloads/canadianc-spinerule.pdf.
Accessed May 20,2015.
15.
A 16 year old high school athlete, who is in the middle of his
basketball season, complains of right knee pain that has been
increasing during the last week of practices. He reports that his pain
started over the summer months but that it has increased substantially
since school started and with basketball practice. He does not
remember any specific injury to his knee. His parents believe the pain
is due to a growth spurt but are concerned now that the symptoms are
worsening and not improving with rest. Upon examination of his knee,
mild range of motion deficits are found in flexion and extension. Mild
swelling and warmth is noted above the knee. Patient reports pain
with deep palpation to the distal femur. Manual muscle testing of the
knee is limited by pain. Tests of ligamentous and meniscal integrity are
negative. Past Medical History: Unremarkable.
Correct Survey Response: Medical Referral Required Urgent
Intended Diagnosis: Osteosarcoma
Rationale: Cancer in children is a time-sensitive and imperative diagnosis to
make in order to treatment to be initiated. 1 in 285 children will be
diagnosed with cancer each year; as part of the medical team, physical
therapists need to be detailed and accurate with referrals for suspicious
clinical presentations in children. The patients presents with a swollen distal
femur and restricted ROM which is a typical presentation with an
osteosarcoma. He has no mechanism of injury and fits a typical profile for
osteosarcoma (teenage, male). (Tebbi & Gaeta)
Tebbi CK and Gaeta J. Osteosarcoma. Pediatric Annals (1988). 17(4):285-300.