| | BACK PAIN
the patients is a 60-year-old woman who comes to the clinic due to 2 months of back pain
Vital signs
. Temperature: 36.7’C
. Blood pressure : 122/80 mmHg
. Pulse : 90 /min
. Respirations : 14/min
Approach to the patient
most patient with acute (<4-6 weeks) , uncomplicated low back pain have etiology and will have spontaneous resolution . However , patients with chronic or atypical symptoms are more likely have to require diagnostic and therapeutic intervention. For this reason , the evaluation of patients with back pain should give careful attention to duration of symptoms and other features that might suggest a poor prognosis.
Inanition , patients with possible infection , malignancy , or bony injury (eg , compression fracture 0 may require more aggressive evaluation . These -red flag- features include:
. Age > 50
. History of cancer
. Constitutional symptoms(eg,fever, weight loss)
. Nocturnal pain
. No response to appropriate treatment
. Significant neurologic deficits
Different diagnosis
Causes of low back pain
Musculoskeletal
1 Mechanical (eg, muscle strain)
. Normal neurologic examination
. Paraspinal tenderness
2 Radiculopathy (eg, herniation disk)
. Radiation below the knee
. Positive straight-leg raise
. Neurologic defects
3 Spinal stenosis
. Pseudoclaudication
. Relived by leaning forward
4 Compression fracture
. Osteoporosis
. Onset following minor trauma
Malignancy
1 Metastatic cancer
. Age>50
. Worse at night
. Not relieved with rest
Infectious
Osteomyelitis, discitis , abscess
. Recent infection of intravenous drug use
. Fever ,m spine tenderness
The differential diagnosis os heavily dependent on age , comorbid and historical conditions (eg, history of malignancy) , and risk factors ( eg , intravenous drug use for infectious causes, menopausal status for osteoporosis) . the most common cause son back pain and the major clinical clues are listed in the table.
HISTORY AND PHYSICAL EXAMINATION
Inanition to the standard medical history and physical examination , the following sections , include most common items should be included in the evaluation of a patient with back pain.
History
History of present illness
. When did the pain start?
. Can you show me where the pain is ?
. What were you doing when the pain began?
. On a scale 1 to 10 , how severe is the pain?
. Please describe the pain (eg , sharp , burning , aching)
. Have you had pain like this before ?
. Dose this pain wake you up at night?
. Dose anything make the pain worse ? Is it better or worse with resting?
. Have you tried any medications of other treatments for your pain?
. Nerve root compression / radicular pain:
1 Can you feel the pain down your legs or in your feet?
2 Do you have any weakness , numbness s, or tingling in your legs?
3 Have you control of your bowel or bladder?
. Have you had any injuries to your back?
Past medical history
. Do you have a history of cancer ? Any recent infections?
. Have you used nay glucocorticoid medications , such as prednisone?
Social history
. Do you smoke ?
. Do you drink alcohol ? how much ? How often ?
. Do you use recreational drugs?
Review of systems
. General : weight loss , fever , night sweats
. Musculoskeletal : other joints pain/swelling , joint stiffness
. Neurologic L Weakness , loss of sensation
. Genitourinary : Menopausal state, dysuria / frequency / urgency
Physical examination
General
. Posture , body habits , pain behaviors
neurologic
. Lower extremity strength
. Lower extremity sensory function
. Lower extremity reflexes
. Straight 0leg raise test
. Gait
1 walk normally
2 walk on toes
3 walk on heels with toes dorsiflexed
Musculoskeletal
. Visible deformity of spine (scoliosis, loss of lumber lordosis)
. Spinal or paraspinal tenderness
. Range of motion of lumbar spine
Genitourinary
. Costoverterbral od suprapubic tenderness
Extremities
. Lower extremity pulses
Closing the encounter
Treatment is not tested as part of Step2 CS , but diagnostic testing for a patients with back pain is oriented toward identifying which patients can be managed conservatively with simple analgesics and which will need more aggressive treatment. In light of this , discuss the factors in the history and physical examinations that are most relevant in guiding subsequent testing and treatment:
. Patients with acute, -uncomplicated back pain- are manage conservatively , without additional testing, Advise the patient to maintain moderate activity.
. Patient with -prolonged or recalcitrant pain- may require more complex interventions(eg, physical therapy).
. Patients with -“red flag” features”- warrant specific imaging test.
. Patients with severe or worsening -neurologic deficits- may require surgical intervention and will need and imaging and /or electrodiagnositc studies.
Diagnostic studies
Imaging for uncomplicated low back pain is not recommended . If no additional testing is required , write “ No studies indicated “ in the Diagnostic Studies section of the patient notes.
Diagnostic tests that can be considered for patients with back pain include:
. X-rays : Reduced range of motion , suspected malignancy , compression fracture
. Inflammatory markers (eg , ESR or C-reactive protein): Suspected malignancy of infection
. MRI : Neurologic deficits , cauda equina syndrome
. Radionuclide bone scan : Patients unable to undergo MRI
. Electrodiagnostics (eg , nerve conduction studies) : Radicular pain likely to require surgery
. Urinalysis : Kidney stones , pyelonephritis
. CBC: Infection , hematologic malignancy
. BUN, creatinine : kidney stones , urinary obstruction
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2018/06/05 10:48pm 
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