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Yr 4 - OSCE Stations > History: Back Pain > Flashcards

History: Back Pain Flashcards

1
Q

What questions might you want to ask to a patient presenting with back pain (exploring HPC)?

A

Site: where is it?

Onset:
- sudden or gradually?
- any triggers?

C:
- what kind of pain is it?
- continuous or intermittent?

R: does the pain move anywhere?

A:
- e.g. weakness, numbness, saddle anaesthesia, urinary or faecal incontinence, weight loss, fevers, sweats

T: how has it progressed/changed?

E:
- what makes it better or worse?
- does it change with position/walking etc?
- tried analgesia?

S: 1-10 severity

Previous episodes

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2
Q

Questions to ask in PMH in back pain?

A
  • MSK conditions e.g. osteoarthritis
  • Rheumatological conditions e.g. RA
  • Malignancy
  • Previous trauma
  • Previous spinal surgery
  • Other medical conditions
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3
Q

Questions to ask in SH in back pain?

A
  • Accommodation (& e.g. ability to get up stairs)
  • Home situation & support
  • Level of functional independence & impact of back pain
  • Current occupation
  • Smoking status
  • Alcohol history
  • Recreational drug use
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4
Q

What are considered red flags in the context of back pain?

A

Concern for spinal fracture/spinal stenosis/spinal abscess/MSCC/cauda equina/sciatica.

  • Back pain in those younger than 20 or older than 50
  • Non-mechanical pain
  • Thoracic pain
  • Saddle anaesthesia
  • Bladder dysfunction (e.g. urinary retention, incontinence)
  • Faecal incontinence
  • Limb weakness
  • Associated trauma
  • Weight loss
  • Fever
  • Structural abnormality of the spine
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5
Q

What clinical exams might you want to perform in back pain?

A

1) Spinal exam / GALS exam

2) Lower limb neuro exam

3) Consider PR exam (if concerned about cauda equina)

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6
Q

Purpose of PR exam in back pain?

A

to assess peri-anal sensation and sphincter competence (reduced in cauda equina)

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7
Q

What lab investigations may be indicated in back pain?

A

1) FBC:
- iron deficiency anaemia may suggest malignancy
- raised WCC may suggest an infective cause

2) U&Es (especially if patient on nephrotoxic drugs e.g. NSAIDs/ACEi)

3) LFTs:
- ALP elevation may point towards skeletal disease – e.g. bony metastases

4) Bone profile:
- Hypercalcaemia – e.g. bony metastases

5) CRP & ESR:
- raised e.g. discitis, ankylosing spondylitis

6) Urinalysis

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8
Q

If there is hypercalcaemia in a patient with back pain, what further investigations may you want to do?

A

1) PTH levels

2) TFTs

3) Serum protein electrophoresis

4) Vit D levels

5) Urine protein electrophoresis (Bence Jones proteins)

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9
Q

What are the most common features of myeloma?

Mneumonic: CRAB

A

hyperCalcaemia: cytokines result in osteoclast dysregulation

Renal failure: light chains clog up the renal tubules

Anaemia: the bone marrow becomes overcrowded with plasma cells

Bone lesions: cytokines result in osteoclast dysregulation

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10
Q

How is a diagnosis of myeloma confirmed?

A

A bone marrow aspirate and trephine biopsy looking for a clonal plasma cell proliferation are needed to confirm the diagnosis.

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11
Q

Management of hypercalcaemia?

A

1) IV fluids

2) Bisphosphonates

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12
Q

What examinations would you like to do for a patient presenting with back pain?

A

1) Spinal exam: look for deformity or abnormal curvature, localise tenderness

2) Lower/upper limb neurological exam: assess gait, active and passive ranges of motion, and neurological signs e.g. numbness, paraesthesia, weakness, and reduced tendon reflexes.

3) PR exam (if concerned about cauda equina)

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13
Q

General management advice for sciatica?

A

1) Offer analgesia with an NSAID and advise the patient that sciatica usually improves within a 6 weeks.

2) SAFETYNET –> Advise the patient to seek follow up if symptoms are worsening, if new symptoms develop, or if they have severe pain that has not subsided within 1 week etc.

3) Advise the patient to keep active and avoid prolonged bed rest.

4) Get in contact with their Occupational Health department to make work adjustments.

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14
Q

If the patient were to have a prolapsed disc at the L5 nerve root level, what features would you expect to see on examination?

A
  • Sensory loss over the dorsum of the foot
  • Weak foot and big toe dorsiflexion
  • Positive sciatic nerve stretch test
  • Intact reflexes
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15
Q

What serious causes of back pain are there and their red flags?

A

1) Cauda equina syndrome:
- urinary/bowel incontinence
- bilateral sciatica
- severe or rapid progression of weakness
- saddle anaesthesia
- reduced anal tone

2) Cancer:
- fever
- unexplained weight loss
- night sweats
- unrelenting back pain that persists when resting/lying down
- nocturnal back pain
- pain aggravated by activities such as straining or sneezing

3) Infection
- fever
- recent infection
- IV drug use
- history of HIV or immunosuppression

4) Fracture:
- trauma
- point tenderness over a vertebral body
- older age (>55 years old)

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16
Q

What are some risk factors for an infection causing back pain?

A
  • IVDU
  • History of HIV or immunosuppression - Diabetes
  • TB, or recent UTI
17
Q

What are some key symptoms to ask about when taking a back pain history?

A

1) Motor or sensory disturbances:
- radiculopathy
- spinal cord compression (e.g. cauda equina syndrome)

2) Urinary retention or incontinence:
- cauda equina

3) Haematuria:
- 2ary to back trauma (due to renal injury)
- UTI
- renal tract malignancy

4) FeverL
- UTI
- pneumonia
- discitis

5) Malaise:
- consider discitis or malignancy

6) Weight loss:
- malignancy

7) Early morning stiffness:
- inflammatory arthritis (e.g. rheumatoid arthritis, ankylosing spondylitis)

8) Muscular spasms:
- spinal fracture
- primary muscular injury

18
Q

What are some causes of cauda equina syndrome?

A
  • prolapsed intervertebral disc
  • displaced vertebral fracture
  • haemorrhage
  • epidural abscess
19
Q

What are some red flag symptoms of a spinal fracture?

A
  • Sudden onset of severe central spinal pain which is relieved by lying down
  • There may be a history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids
20
Q

What are some red flags for malignancy in back pain?

A
  • Age >50
  • Gradual onset of symptoms
  • Severe unremitting pain that is NOT relieved by lying down
  • Nocturnal back pain that prevents or disturbs sleep
  • Back pain aggravated by straining (e.g. opening bowels, coughing or sneezing)
  • Thoracic pain
  • Unexplained weight loss
  • Localised spinal tenderness
  • No symptomatic improvement after four to six weeks of conservative lower back pain therapy
  • Past history of cancer: breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasise to the spine
21
Q
A

Yr 4 - OSCE Stations (19 decks)

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