Physiotherapy 90 (2004) 73–76 Margaret: a tragic case of spinal Red Flags and Red Herrings Sue Greenhalgh a,* , James Selfe b,c a Bolton PCT, Ashburner St, Lever Chambers, Bolton, UK b Allied Health Professions Unit, University of Central Lancashire, Preston, UK c Satakunta Polytechnic, Pori, Finland Abstract Objective This case illustrates how easily patient misattribution can influence the clinical reasoning process and it alerts physiotherapists to safeguard from the influences of Red Herrings. Design It is the second in a series of case studies considering patients with serious spinal pathology. Setting This paper considers the case of a 49year old lady who was referred to a Spinal Assessment Clinic in a district general hospital. The clinic was established specifically to deal with more complex spinal patients, identifying those at risk of chronicity, surgical cases or those with more complex pathology. Unfortunately this case was subsequently diagnostically triaged as serious spinal pathology. Conclusion As misattribution of symptoms by the patient is common, it is essential that the clinician considers a thorough subjective and objective assessment. When drawing inferences from the findings it is vital to stand back and consider if the attributed cause and effect is an inherent likelihood and consider whether there may be important information missing. © 2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Serious pathology; Spine; Red Flags; Misattribution Introduction A previous paper [1] highlights the difficulty faced by therapists in detecting serious spinal pathology in the early stages. The following case also serves to illustrate this problem, especially when the clinical presentation is complicated by misattribution of symptoms. In the late stage of this case the serious pathology emerged clearly but unfortunately progressed very rapidly, Margaret first attended for physiotherapy in September and had died by the end of January. It is very likely that Margaret would have died even with earlier identification of her cancer as it progressed so rapidly, however earlier iden- tification could have decreased her level of suffering and discomfort. The patient Prior to serious pathology being diagnosed, at her first attendance at physiotherapy, Margaret had the following symptoms, which appear on the Clinical Standards Advisory * Corresponding author. Group [2] list of Red Flags: • Violent trauma (road traffic accident); • Constant progressive non-mechanical pain; • Thoracic pain; • Past medical history of carcinoma (family history of breast cancer, mother and sister); • Weight loss; • Persistent severe restriction of lumbar flexion. In addition she had also developed two breast lumps, which she did not report to the physiotherapist. When faced with this list of symptoms most therapists would agree that this appears as a very clear-cut case of a patient with serious pathology. However it is important to consider how the symptoms developed over time and also to consider how the clinical reasoning process was strongly influenced by the initial presentation of the case. To illustrate this two scenarios are presented: 1. A patient with no significant past medical history or spinal problems attends for physiotherapy following a road traffic accident with thoracic and rib pain. 2. A patient with a lump in the left breast and a family history of breast cancer (mother and sister) attends for physiotherapy with thoracic and rib pain. 0031-9406/$ – see front matter © 2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0031-9406(03)00008-7