back pain

Question 1

Mrs MS, a 53 y.o. lady presents to A+E with back pain which has been there for the past week. she tells you that she has flu-like sx but is normally fit and welll. on further questioning, she tells you she is an ex-smoker, has eczema and has recently loss 1/2 stone in weight for the last month. O/E: she is tender, particularly over the upper lumbar area but neurological system examination of the lower limbs is normal. you note she had an early menopause at the age of 40.

(a) apart from osteoporosis, what would your top 2 differential dx be in this lady and why?

Answer 1

1. osteomyelitis
2. mechanical back pain
3. cancer (wt loss and smoking)

Question 2

(b) list 4 risk factors that you would enquire about in a pt in whom the dx is suspected to be osteoporosis?

Answer 2

1. hx of steroid therapy
2. age of menarche/menopause +/- whether or not she used HRT (HRT decreases risk)
3. family hx e.g. of hip fracture
4. bone protection i.e. calcium intake, sun exposure
5. social hx - smoking, alcohol use
6. PMH: prolonged periods of immobility
7. occupational hx

Question 3

(c) an X-ray confirms a crush fracture at L1. what key ix would you now wish to perfrom to confirm the dx of osteoporosis?

Answer 3

DEXA scan

Question 4

(d) Mrs MS has been receiving rx with HRT for the past 5 years for post-menopausal sx. bearing in mind recent research developments, what advice would you now give her about this form of rx?

Answer 4

after 5 years:

• risk breast CA, stroke, DVT/PE and CV disease but risk is still low
• risk colon CA and hip fracture

Question 5

(e) what advice and rx would you now give to the pt on discharge? list 4 separate items.

Answer 5

1. alendronic acid 70mg once weekly
2. cholecalciferol 600 units OD
3. regular exercise, strength and balance training
4. avoid excess alcohol and cut down smoking
5. increase dietary calcium intake and sun exposure/vitamin D intake
6. ensure there are no trip hazards around the house