CASE 3 - Back Pain

Question 1

I don’t think I can go to work, doctor. Can you write a letter to my boss so that I can have some time off?

Answer 1

You’re right. Heavy construction work can worsen your back pain or cause it to heal more slowly.

I will ask your boss to reassign you to light duty for a while.

Question 2

Specific questions for back pain:

Answer 2

1. Weakness, numbness.
2. Fever — night sweats — weight loss.
3. Urinary — fecal incontinence.
4. Difficulty urinating.

Question 3

PEx:

3

Answer 3

1. Back exam ==> I + P + ROM.
2. Extremities ==> I + P of peripheral pulses + Hip exam.
3. Neurologic ==> Motor, DTRs, Babinski, gait (including toe and heel walking), passive straight leg raising, sensory exam.

Question 4

Closure:

Answer 4

1. Discuss initial diagnostic impressions.
2. Discuss initial management plans ==> F/U tests: mention the need for a rectal exam.
3. Ask if the SP had any other questions or concerns.

Question 5

Sample closure:

Answer 5

Mr. Meyer, I am concerned about your difficulty urinating, so I would like to do a rectal exam and assess your prostate for benign growths or cancer.

I would also like to run some blood tests and order an x-ray and possibly an MRI of your back so that I can better determine the cause of your pain.

In the meantime, as we discussed, I will write a note to your employer requesting that you be given only light duties while you are at work.

Do you have any questions for me?

Question 6

DDx 1 — Disk herniation:

Answer 6

1. Low back pain.
2. Pain started after lifting heavy boxes.
3. Pain radiated to left thigh and foot.
4. Pain worsens with movement and is relieved by lying still.

Question 7

DDx 2 — Lumbar spinal stenosis:

Answer 7

1. Hx of intermittent low back pain and leg pain with ambulation.
2. Pain resolves with sitting.
3. Walks with back slightly bent forward.

Question 8

DDx 3 — Metastatic prostate cancer:

Answer 8

1. Difficulty urinating.
2. Incomplete emptying of the bladder.
3. Low back pain.

Question 9

Workup:

Answer 9

1. XR — L-spine.
2. MRI — L-spine.
3. Rectal exam.
4. PSA.

Question 10

Additional DDx:

Answer 10

1. Lumbar muscle sprain.
2. Degenerative arthritis.
3. Multiple myeloma.
4. Malingering.