Case 3 - 51 yo M with back pain

Question 1

Information gathering

Answer 1

CC
Onset
Precipitating events
Progression
Severity
Location
Radiation
Quality
Alleviating and exacerbating factors
Weakness/numbness
Difficulty urinating
Urinary or fecal incontinence
Fever, night sweats, weight loss
Past episodes
PMHx
PSHx
FHx
Social Hx (occupation, tobacco, alcohol, drug use, diet, exercise, sexual activity)
Current medications
Drug allergies

Question 2

If a patient mentions they drink alcohol, use the CAGE questionnaire.

Answer 2

Cut down
Aggravated by people complaining
Guilty
Eye opener

Question 3

Physical exam

Answer 3

Back exam (inspection, palpation, range of motion)
Extremities (inspection, palpation of peripheral pulses, hip exam)
Neurologic exam (motor, DTRs, Babinski's sign, gait [including toe and heel walking], passive straight leg raising, sensory exam)

Question 4

Closure

Answer 4

Mention need for rectal exam

Light duty at work only

Question 5

Differential diagnosis

Answer 5

Disk herniation
Lumbar spinal stenosis
Metastatic prostate cancer

Question 6

Diagnostic work-up

Answer 6

XR - L-spine (vertebral osteomyelitis, fractures, cancer)
MRI - L-spine (herniation, infection, malignancy)
Rectal exam (including “saddle area” sensory exam)
PSA
CBC, calcium, BUN/Cr (to detect anemia, hypercalcemia and renal failure, al of which can be clues to underlying multiple myeloma)
Serum and urine protein electrophoresis (to detect monoclonal paraprotein in myeloma)