STEP 2 CS- back pain
HISTORY TAKING :
LIQOR PAAPP- FOR D
Location
Intensity
Quality
Onset
Radiation
Precipitating factor
Alleviating factor
Associated symptoms(nausea ,vomiting, sob,sweating, cough,wheezing,abd pain,diarrhea,constipation,fever)
Progression
Previous episodes - FREQUENCY ONSET RELIEVING FACTOR DURATION
difficulty urinating?
urinary of fecal incontinence?
constitutional symptoms?fever?night sweat?weight losss?
+ PAM HUGS FOSS
PMH
ALLERGY
MEDICATION (COMPLIANCE,SE?)
HOSPITALIZE HX
URinARY CHANGES
Git changes
Sleep pattern change(DISTURB SLEEP?)
Family history
O&G HX
SEXUAL HX
SOCIAL HX(ALCOHOL USE,ILLICIT DRUG,SMOKING(ppd,years, EXERCISE?,DIET?)
ROS-THEN FR CS PUB SAW ID
TRAVEL RECENTLY? trauma?
Headache
Edema
Nausea/vomit
Fever/chills/night sweat
Racing of heart?rash?
Chest pain? / Cough?
SOB
Pain in the joint?
Urinary problems?
Bowel problem?
Sleep pattern
Apetite?
Weight changes?(how much? time?intentional?
Infection (recent?)
D izzy? (if yes,vision problem?)
PHYSICAL EXAMINATION
BAck exam -
inspection-warmth,erythma?
palpation-ROM,muscle tenderness?
special test? abnomrality? yes or no?
Lower limb neuro examination
Inspect: SWIFT(scars,wasting of muscle,involuntary movements,Fasciculation,tremor)
Gait: normal(including toe and and heel walking)
Tone: normal
Power :strength 5/5 throughout,include left greattoe dorsiflex.
Reflex: DTR:2+symmetric -ve babiski
sensation : intact (proprioception,,pin-prick,light touch)
EXtremities:
palpation: temperature,capillary refill normal
Pulses: 2+ popliteal,dorsalis pedis,and posterior tibial
Hips: normal,nontender,rom bilaterally.
CSE PE OF BACK PAIN
differential diagnosis of back pain:LIMCOOTS M
differential diagnosis of back pain:LIMCOOTS M
L umbar spinal stenosis
I ntervertebral disc herniation
I ntervertebral disc herniation
M ultiple myeloma
C auda equina syndrome/ Cancer(metastasis prostate cancer)
O steoporosis
O steoarthritis(degenerative arthritis)
Trauma/ TB
S train(lumbar muscle)
Malingering
LOW BACK PAIN
1) low back pain with paravertebral spasm after history of lifting heavy object----> lumbosacral strain
2) low back pain with extension and relief with flexion-------> spinal canal narrowing(lumbar canal stenosis)
3) low back pain in elderly which is exacerbates on minor exertion or touch-----> vertebral body fracture(due to osteoporosis)
4) low back pain with paravertebral spasm and @ with fever----> epidural abscess
5) low back pain in elderly(h/o tumor) which is continuous even in night(unable to sleep)-----> cord compression(due to metastatic tumor)
6) low back pain with saddle anesthesia ,sphincter problems, loss of DTR's---------> cauda equina syndrome(surgical emergency)
7) low back pain in adolescent with 'slip off or step off'(buzzword) in spine examination------>due to displacement of spinous process--->spondylolisthesis
8) low back pain in pregnancy----->due to lumbar lordosis(relaxation of pelvic muscles)
9. low back pain with loss of DTR's,severe exertional pain and straight leg raise test +ve-------> lumbar disc herniation
10.)Low back pain in IV drug abuser (S. aureus),Tenderness on palpation of spinous process
Markedly elevated ESR, Fever , elevated WBC may or may not present MRI most sensitive
IV antibiotics -- vertebral osteomyelitis
11) low back pain + hip,buttock,thigh claudication,
Accompanied by impotence and atrophy of lower extremities
Weak femoral pulses
Bruit heard over femoral area(male predominance)----->lehriche syndrome--
12) low back pain + male predominance ,25-35 yrs ,morning stiffness which improves with activity(may associate with diarrhea-IBD or uveitis)------> Ankylosing spondylitis
Diagnostic workup:4) low back pain with paravertebral spasm and @ with fever----> epidural abscess
5) low back pain in elderly(h/o tumor) which is continuous even in night(unable to sleep)-----> cord compression(due to metastatic tumor)
6) low back pain with saddle anesthesia ,sphincter problems, loss of DTR's---------> cauda equina syndrome(surgical emergency)
7) low back pain in adolescent with 'slip off or step off'(buzzword) in spine examination------>due to displacement of spinous process--->spondylolisthesis
8) low back pain in pregnancy----->due to lumbar lordosis(relaxation of pelvic muscles)
9. low back pain with loss of DTR's,severe exertional pain and straight leg raise test +ve-------> lumbar disc herniation
10.)Low back pain in IV drug abuser (S. aureus),Tenderness on palpation of spinous process
Markedly elevated ESR, Fever , elevated WBC may or may not present MRI most sensitive
IV antibiotics -- vertebral osteomyelitis
11) low back pain + hip,buttock,thigh claudication,
Accompanied by impotence and atrophy of lower extremities
Weak femoral pulses
Bruit heard over femoral area(male predominance)----->lehriche syndrome--
12) low back pain + male predominance ,25-35 yrs ,morning stiffness which improves with activity(may associate with diarrhea-IBD or uveitis)------> Ankylosing spondylitis
XR-Lspine
MRI L-spine
Rectal exam (including saddle area sensory exam)
PSA
CBC,Calcium,BUN?CR
serum and urine electrophoresis
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History:
PMI : 51 yo
male construction worker c/o low back pain that started after he lifted heavy
boxes 1 week ago. The pain is 8/10 and sharp and it radiated to the left thigh
and sometimes to the left foot. Pain worsens with movement,cough and sitting
for a long time. It is relieved by lying still and partially by ibuprofen. He denies
urinary/stool incontinence or weakness/loss of sensation in the lower
extremities. No fever,night sweats or weight loss. He does report difficulty
urinating and incomplete emptying of the bladder for 6 months as well as a 1
yeaqr history of intermittent low back pain. The pain is exacerbated by sitting
for long periods but it relieved by sitting after ambulation.
ROS: negative except as above.
Allergy : penicillin,cause
rash
Medication
: ibuprofen
PMH : none
SH : 1 ppd
for 18 years,1-2beers on weekend,CAGE 0/4.
FH : noncontributory
Physical
examination
Patient is
in mild distress due to back pain
VS : WNL
Back: mild
paraspinal muscle tenderness bilaterally, normnal ROM,no warmth or erythema
Extremities
: no edema ,peripheral pulse 2+ popliteal,dorsalis pedis,posterior tibial
pulses bilaterally. Hips normal,nontender ,normal ROM bilaterally.
NEuro :
motor:strength 5/5 throughout including dorsiflex of greattoe.
DTR: 2+symmetric ,absent Babinski
bilaterally.
Gait : normal (including toe and
heel walking),although he walks with back slightly bent forward. Straight leg
raising negative bilaterally.
Sensation: intact
Differential
diagnosis :
Diagnosis 1 : Disc herniation
History findings :
Low back
pain
Pain started
after lifting heavy boxes
Pain radiated
to left thigh and foot
Pain worsens
with movement and is relieved by lying still
Diagnosis 2 : lumbar spinal
stenosis
History findings :
Hx of
intermittent low bad pain and leg pain with ambulation
Pain resolves
with sitting
PE finding:
Walks with
back slightly bend forward
Diagnosis 3 : metastatic prostate cancer
History findings :
-difficulty
urinating
-incomplete
emptying of the bladder
-low back
pain
Diagnostic
workup:
Xray and
mri -l-spine
Rectal exam
PSA
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BACK PAIN CASE 1:
45y F w/ low back pain radiating to lateral L foot. PE: +straight leg raise, unable to tiptoe.
DDX:
- Disk herniation
- Lumbar muscle strain,
- tumor in vertebral canal
W/U:
XR-L-spine, MRI-L-spine
BACK PAIN CASE 2:
45y F w low back pain s/p cleaning house. No radiation, no sensory deficit/weakness. PE: + paraspinal muscle tenderness & spasm.
DDX:
- Lumbar muscle strain
- disk herniation,
- vertebral compression fracture
W/U:
XR,MRI -L-spine
BACK PAIN CASE 3:
45y
M w pain in lower back and legs w prolonged standing and walking.
Pain relieved by sitting and leaning forward (e.g. pushing grocery
cart).
- Lumbar spinal stenosis
- lumbar muscle strain,
- vertebral canal tumor,
- PVD
W/U:
XR-L-spine, MRI-L-spine (preferred), CT-L-spine, ankle-brachial index
BACK PAIN CASE 4
17y
M w low back pain radiating to L leg s/p falling on knee in gym class.
+Loss of sensation in L foot. Pain and sensory loss do not match known
distribution. Insists on week off from school.
DDX:
- Malingering
- Lumbar muscle strain,
- disk herniation,
- knee/leg fracture, ankylosing spondylitis
W/U:
XR-L-spine/knee, MRI-L-spine
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