Week 6 - Back pain

Question 1

Mrs. M.P. is a 54-year-old Caucasian woman who present to her local GP on a Friday morning requesting a medical certificate for work. She has had back pain for the past month.

Take a history of this patient.

HPC:
• Back pain 1/12, severe, 6/10, located at T12, aching pain. No radicular symptoms.
• Play tennis, may have twisted my back, strained at work?
• No fall, no weakness, sensation normal. Neurofen + helped a bit.
• PMHx - coeliac disease, iron deficiency, menopause at 44 (ageing and post menopausal changes - 10 years).
• Melanoma R lower leg 2 years, no treatment (?recurrence, metastasis).
• Job involves weight lifting (trauma possible)
• FHx - mother died of breast cancer at 48.

Answer 1

• Site of pain?
• Onset of pain?
• Character of pain? i.e. aching/dull, sharp.
• Radiating pain?
• Alleviating factors?
• Timing - experienced it before? Constant or intermittent? How long do the episodes last? Worse at a particular time?
• Exacerbating factors?
• Severity?
• Associated symptoms?
• Effect on lifestyle?
• Weight loss/fatigue?
• Trauma/falls?
• Previous cancers/red flags for cancer? (metastatic disease?)
• Abnormalities of bowel or bladder habits? (what nerves would be involved if defection and urination were affected?)
• Social history? (aggravating factors for pain and ability to still work).
• Diet? (calcium intake - note history of coeliac disease and post-menopausal - what is the recommended daily intake of calcium for a post menopausal patient?)
• History of coeliac disease? (increased incidence of osteoporosis in patients with coeliac disease).

PMHx:
• Past history of injury/trauma, cancer, coeliac disease, anaemia? Post menopausal?

PSHx:
• Past/recent surgeries i.e. surgical adhesions/obstructions.

Medications:
• Any regular medications.

Allergies:
• Agent, reaction, treatment.

Immunisations:
• E.g. Fluvax, pneumococcal.

FHx:
• Family history of injury/trauma, cancer, coeliac disease, anaemia?

SHx:
• Background
• Occupation
• Education
• Religion
• Living Arrangements
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands.
2. General inspection: consciousness/orientation, distressed/pain, anxious, habitus (i.e. thin, cachetic), wasting, walk slowly, pain getting up, pallor, bruising.

3. Vital signs:
• HR - tachycardic
• BP
• RR - tachycardic.
• Temp - normal, may be febrile.
• O2 sats, BMI (low).

4. Hands:
   • Warm/cold, dry/sweaty, pallor, koilonychia, CRT, clubbing, flap.
5. Face:
   • Eyes - conjunctival pallor.
   • Mouth - angular stomatitis, glossitis, chelitis, ulcers.
6. Back:
   • Inspection - bruising, scars, swelling, erythema, signs of trauma/deformity, asymmetry.
   • Palpation - tenderness to palpate, paraspinal muscle spasms. Check for bony tenderness.
   • Movement
7. CVS:
   • No scars, apex beat palpable 4th MCL, DHSNM, no heaves or thrills, JVPNE.
8. Abdomen:
   • Renal colic, gallstones.
   • Genital examination.
9. NEURO:
   • Power, sensation, reflexes lower limbs normal.
10. RESP/ENT/GU examination normal.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

Because of age, many aetiologies possible - trauma, soft tissue, fracture (due to severity). Complex history - consider different things.
• Soft tissue injury (acute MSK pain).
• Disc prolapse (no radiation?) - common cause of back pain.
• Fracture (traumatic/osteoporotic/pathologic - e.g. metastasis, disorders/sepsis of bone - abnormal bone fracturing - pathologic. Osteoporotic also pathologic).
• Abdominal pathology (renal colic, gynaecologic, gallstone, surgical - e.g. adhesions/obstructions).

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC
• U+Es
• LFTs
• Iron studies
• CT scan lumbrosacral spine.
• X-ray thoracolumbar spine - shows wedge compression fracture T12, no spinal cord compromise, no evidence of bony metastases.

Question 5

What management is relevant to this patient?

Answer 5

• Pain relief.
• Explore work environment/financial stressors/family supports - affects ability to recover/take time off work/degree of stress if financial concerns.
• Commence weight bearing exercises once pain is under control.

Question 6

The patient has coeliac disease. What are 6 other conditions she is at increased risk of?

Answer 6

• Increased association with osteoporosis though some studies have suggested there is not enough evidence to screen all patients for osteoporosis and osteopenia.
• Increased risk of small bowel lymphoma and NHL - though these are both rare.
• Decreased fertility.
• Autoimmune thyroid disease.
• Type 1 diabetes.
• Dermatitis herpetiformis.

Also decreased risk of cardiovascular disease due to decreased BMI, lower BP and lipids.

Question 7

Identify 6 risk factors for osteoporosis.

Answer 7

• Family history.
• Post menopausal females.
• Low BMI.
• Low calcium and vitamin D intake.
• Medications - corticosteroids, some chemotherapy agents and anti epileptic medications.
• Some chronic diseases - RA, renal and liver failure, hyperparathyroid disease, conditions which may lead to malabsorption - IBD, coeliac disease.
• Lifestyle risk factors - reduced exercised, smoking, high alcohol intake.

Question 8

When serum calcium levels fall this stimulates in which of the following?

Answer 8

Parathyroid hormone.

Question 9

An 80 year old woman falls and breaks her hip. The most appropriate medication to help prevent further fractures in this lady is?

Answer 9

Alendronate.

Question 10

A 75 year old woman is commenced on a bisphosphonate to treat osteoporosis. Which of the following is the most common side effects she should be aware of?

Answer 10

• Bisphosphonates commonly cause worsening reflux symptoms and have also been associated with oesophageal cancer.
• ONJ - estimated incidence 1 in 10,000 to 1 in 100,000 patient years - in patients where it is used to treat osteoporosis.