Reflective 2: Simulation Patient

Thursday, 15/3/2011
BSKK 9

As a medical student, I have to learn how to take informations from the patients regarding to their illness.

Encik Shaiful, a 45 year old gentleman gardener, came today because of the onset pain of low backache when he try to bend his body and also when he try to lift load. There is no other symptom of pain in the backbone. He is a smoker with a pack per day and not take the alcohol. His history with his father has gout and stroke while his mother already passed away. He has healthy wife and kids.

All this information is a summary from what I've got. When time for feedback from the simulation patient, he said that I already got 90% of the information. I'm not ask him about his mother, wife and kids. I'm just asking about his father. About the pain, I'm should asking about the radiation of the pain. I should actually know about the red flags symptom of the backache. I also should ask how the pain fell whether its just a pain at the skin, or throbbing or other else. I should ask more open ended question so that the patient can describe the pain that he feel.

This the example of red flags symptom of back pain I should know:


Red Flags: Cancer Related Red Flags with Low Back Pain

1. History of cancer
2. Unexplained weight loss >10 kg within 6 months
3. Age over 50 years or under 17 years old
4. Failure to improve with therapy
5. Pain persists for more than 4 to 6 weeks
6. Night pain or pain at rest

Red Flags: Infection Related Red Flags with Low Back Pain

1. Persistent fever (temperature over 100.4 F)
2. History of intravenous Drug Abuse
3. Severe Pain
4. Lumbar spine surgery within the last year
5. Recent bacterial infection

• Urinary Tract Infection or Pyelonephritis
• Cellulitis
• Pneumonia
• Wound (e.g. Decubitus Ulcer) in spine region

Immunocompromised states

• Systemic Corticosteroids
• Organ transplant
• Diabetes Mellitus
• Human Immunodeficiency Virus (HIV)
• Rest Pain

Red Flags: Cauda Equina Syndrome Related Red Flags with Back Pain

1. Urinary Incontinence or retention
2. Saddle anesthesia
3. Anal sphincter tone decreased or fecal Incontinence
4. Bilateral lower extremity weakness or numbness
5. Progressive neurologic deficit
6. Major motor weakness
7. Major sensory deficit

Red Flags: Significant Herniated nucleus pulposus

1. Major Muscle Weakness (strength 3 of 5 or less)
2. Foot drop
3. Red Flags: Vertebral Fracture related red flags with Low Back Pain
4. Prolonged use of Corticosteroids
5. Age greater than 70 years
6. History of Osteoporosis
7. Mild trauma over age 50 years (or with Osteoporosis)
8. Recent significant trauma at any age
9. Ejection from motor vehicle
10. Fall from substantial height

Red Flags: Abdominal Aortic Aneurysm red flags with Low Back Pain

1. Abdominal pulsating mass
2. Atherosclerotic vascular disease
3. Pain at rest or nocturnal pain
4. Age greater than 60 years

Red Flags: General (weak Test Specificity)

1. Vertebral tenderness
2. Limited spine range of motion

The symptom That i should include:

Symptoms: Low Back Pain Timing
Duration

• Acute Low Back Pain onset within 3 months
• Chronic Low Back Pain persistent beyond 3 months

Follows Trauma, bending, or lifting
Suggests Lumbar Disc Disease
Morning back stiffness with pain and onset before age 40 years
Suggests Spondyloarthropathy
Age of onset
Age under 20 years
Diskitis
Vertebral Metastases
Scoliosis
Pyelonephritis
Sickle Cell Anemia
Slipped Vertebral apophysis
Age under 20 years: Athletes
Spondylolysis (with risk of Spondylolisthesis)
Vertebral Stress Fracture
Hyperlordosis
Age 20 to 50 years old
Lumbar strain or sprain
Lumbar Disc Disease
Lumbar Spinal Stenosis
Spondyloarthropathy
Genitourinary causes (e.g. Pyelonephritis, Nephrolithiasis, Endometriosis, Pelvic Inflammatory Disease)
Gastrointestinal causes (e.g. Cholecystitis, Peptic Ulcer Disease, Pancreatitis)
Age over 50 years
Vertebral Compression Fracture
Spinal stenosis
Spondylosis
Vertebral Metastases
Vertebral Diskitis or Vertebral Osteomyelitis
Abdominal Aortic Aneurysm
Herpes Zoster
Symptoms: Low Back Pain Location and Radiation
Dermatomal

• Herpes Zoster

Spine
Midline (especially with Vertebral tenderness and limited range of motion suggests )
Vertebral disorder

• Traumatic Vertebral Fracture (major trauma)
• Compression Fracture
• Vertebral metastases
• Vertebral Osteomyelitis

Disc disorder

• Herniated Disc
• Vertebral diskiitis

Sacroiliac Joint

• Sacroiliac joint dysfunction
• Spondyloarthropathy
• Paraspinous or lateral low back
• Lumbar strain or lumbar sprain

Abdomen
Epigastrium and upper quadrants radiating to upper portion of the low back
Peptic Ulcer Disease
Pancreatitis
Cholecystitis
Constipation
Unilateral Abdominal Pain radiating to flank
Nephrolithiasis
Pyelonephritis
Periumbilical Abdominal Pain radiating to midline of low back
Abdominal Aortic Aneurysm

Buttock
Piriformis Syndrome
Sacroiliac Joint Dysfunction
Pilonidal Cyst
Perirectal Abscess

Leg
Vertebral levels L1 to L3 radiates to hip and thigh
Vertebral levels L4 to L5 radiate below the knee

• Radiation below knee is most specific for herniated disc

Symptoms: Low Back Pain Provocation
Prolonged sitting provokes pain

• Lumbar Disc Disease
• Spondylosis (disc pain)

Valsalva (cough, sneeze, or straining) provokes pain

• Lumbar Disc Disease

Hyperextension provokes pain

• Spondylolisthesis
• Spondylolysis
• Spondylosis (facet pain)
• Sacroiliac Joint Disease

Standing or Walking

• Lumbar Spinal Stenosis
• Pseudoclaudication with pain radiating into legs
• Spondylolisthesis
• Spondylosis (facet pain)

Symptoms: Low Back Pain Palliation


Rest (relative or complete?)

• Lumbar Strain or sprain

Ice or heat?
Medications?
Lying with knees flexed relieves pain

• Lumbar Disc Disease
• Spondylolisthesis

Sitting relieves pain

• Lumbar Spinal Stenosis