A 35 Year Old Man Presents With Back Pain

A 35 Year old man comes to your clinic with back pain. He says he was not able to bend to tie his shoe laces because of the sharp pain in his back. It started a day ago . The pain does not radiate and he denies any pain, numbness or weakness in his legs. His vitals are within normal limits.

Q 1. Obtain a focused history of this patient ?

Answer:

1. Since the main complain is back pain the details about pain should be asked:

• Site of pain
• Intensity of pain
• Quality of pain
• Onset of symptoms
• Radiation of Pain
• Aggravating and relieving factors.
• Previous episode of similar pain.

2. History of any trauma

3.  Ask about any medicines the patient might be taking.(prescription and Over the counter)

4. History of any allergies, hospitalization, surgery , major illness.

5. Review of systems must include any urinary symptoms like pain on urination or blood in urine.

6. Any sensory loss or motor weakness in the legs . 

Q 2. List the main points you would like to perform during examination? 

Answer:

1. Notice the general appearance if the patient is comfortable or in distress (to determine the severity of pain) 

2. Inspect the cervical, thoracic and lumbar spine posteriorly.

3. Palpate the lower thoracic and lumbar spinous processes, and check for any tenderness. 

4. Determine the range of motion of spine. 

5.Check the motor strength in both lower legs

6. Check the sensation in both lower limbs. 

7. Reflex: Achilles and patellar bilaterally.

8. Check pulses in feet bilaterally.

9. Palpate the abdomen and look for tenderness in the lumbar region.   

Q 3. List the possible causes of Back pain in this patient? 

 Answer: 

• Muscle strain of the back
• Joint strain
• Vertebral fracture
• Renal colic
• Ankylosing spondylitis
• Osteomylelitis.
• Psychogenic 

Q 4. What initial Workup would you order in this case?

Answer:

1. Complete blood count: Increased WBC count may indicate infection. 

2. ESR; Increased in ankylosing spodylitis and other inflammatory disorders. 

3. Urinalysis: to rule out UTI 

4. Spine X ray: may show fractures, signs of other diseases like osteorthritis. 

5. Ultrasound KUB to rule out renal stones