Back pain

[admin]

Stem:
You are the surgical SHO on call. Mrs. Janice Green, a 54-year-old woman, has been complaining of chronic back pain. She has asked you to help her in your FY1 colleague, and an MRI was performed previously. The consultant has asked you to go in and take a focused history from her to narrow down the cause.
Please take a history from the patient. You do not need to perform a physical examination. At the end of the consultation, you should try to explain and ask you to summarize your findings and ask you questions about the case.

[admin]

Introduction

-Start by introducing yourself, washing your hands, confirming patient's details, and gaining consent for history taking

You: Hello good morning. I am Dr _____. I am one of the surgical doctors working here, can I have your name and date of birth please?
Patient: Hello doctor, I am Janice green I am 54 years old
You: Nice to meet you, we are happy for me to call you Janice?
Patient: Yes of course, no problem
You: Today I will be asking you few questions. I will be writing down this piece of paper to remember my thoughts, would that be alright with you?
Patient: Yes sure doctor.

Main complaint and analysis of main complaint

You: So what brings you in today Janice?
Patient: Oh doctor. I've been having this bad back pain for 4 months now. It has been really bad I cannot take care of my husband at home and I am worried about financial issues as well

You: I am really sorry to hear about this. I can see this is quite tough for you. how is your husband?
Patient: Not so well, he is disabled and cannot walk around
You: I see that is very difficult for you to have some one that can help you with him?
Patient: It is very difficult to take care of him because of this pain.
You: We may consider talking to social services if that's ok with you, we will try to help you to
the best of our abilities to deal with this pain problem.
Patient: Thank you a lot doctor.

-Take the main complaint by asking the patient an open ended question.
-Here the actor is giving you a problem, you should try to present some form of solutions, such as trying to give them some solutions for their pain, but NEVER GIVE FALSE REASSURANCE, for example, do not say "we will take care of your pain", you can say that you can try your best.
-Analyze the main complaint using SOCRATES
Site: Lower back pain is usually due to disc pathology, the most common site of disc prolapse is L4/L5 or L5/S1, clarify whether the pain is central or lateral, high back pain in the thoracic region usually suggests malignancy.
Onset: Acute back pain may suggest acute disc prolapse, cauda equina, or a fracture, chronic back pain may also be due to disc prolapse, malignancy, or inflammatory condition such as ankylosing spondylitis.
Character: Radicular back pain is usually shooting in nature or electric, inflammatory conditions usually cause dull aching, deep pain associated with stiffness, neoplastic pain is usually boring persistent and not responsive to simple analgesia.
Radiation: The patient may complain of radiation down one or both legs, if there is disc prolapse impinging on spinal nerve roots, keep in mind that some conditions may present with back pain but no radiation e.g. spinal stenosis, which can actually cause neurogenic claudication commonly present with back pain, an abdominal aortic aneurysm also commonly present this way.
Associated symptoms: We will keep this in the end.
Timing: Pain in the morning improved with activity is classical for ankylosing spondylitis, especially if there is stiffness lasting more than 30 minutes, pain that is worse at night, especially awakening the patient from sleep is a RED FLAG feature seen with malignancy.
Exacerbating and relieving factors: Radicular pain is usually worsened with activity, sneezing, coughing or laughing and with certain postures, focal point arthrosis is usually worsened with extension of the spine, pain that is worsened with rest and improved with movement is associated with inflammatory conditions, especially ankylosing spondylitis.
Severity: Ask about the level of pain from 0 to 10
-In associated symptoms, the most important part is to ask about RED FLAG symptoms, these include:
Cauda equina syndrome:

Painless urine retention.
Fecal incontinence.
Perineal numbness.
Severe bilateral motor weakness in both legs.

Malignancy:RetryCHere's the extracted text from this image:

Severe back pain awakening the patient from sleep.
Unintentional weight loss.
Loss of appetite.
Presence of any lumps or bumps in the body.

Spine osteomyelitis:

Fever.
Chills and rigors.
History of intravenous drug drugs (will be asked in social history).

Fracture/Dislocation:

History of any injuries, including minor injuries (may be a pathological fracture)
Pre-existing history of osteoporosis, previous fragility fractures, pre-existing cancer (covered in past medical history).

-Ask about any pulsatile abdominal swelling (abdominal aortic aneurysm).
-Ask about other joint problems (swelling, redness, difficulty with movement) as this may part of a systemic arthropathy such as rheumatoid arthritis, ankylosing spondylitis, or inflammatory bowel diseases.
-Ask about heavy lifting, as this may suggest disc prolapse.

Systematic review:

GIT: A bloody or watery diarrhea may suggest inflammatory bowel disease, nausea and vomiting and intolerance to fatty food may suggest pancreatitis, a change in bowel habit may also suggest malignancy with spine metastasis.
Musculoskeletal: In addition to asking about other joints, ask about any lumps or bumps in the body, for example a neck lump or a breast lump may indicate the primary tumor if neoplastic cause is likely, also ask about morning stiffness, and for how long does it take for the stiffness to loosen up, ask about red eye or uveitis problems (extraarticular manifestations of inflammatory bowel disease).
Continue with other systems review just like in the "general principles of history taking".
Take care to be very quick in this part, because it tend to be the most time consuming part of the history.

Go back to SOCRATES:

You: Tell me more about this pain Janice, where do you feel it most (site)?
Patient: It is mostly in my lower back right in the midline.
You: Did happen suddenly or gradually (onset)?
Patient: It was gradual doctor.
You: How does it feel like? How can you describe this pain for me? (character)
Patient: It is dull aching, it feels very deep.
You: I see. And does it go anywhere or just around that same spot (Radiation)?
Patient: Yes, sometimes I feel shooting pains down my both legs, it does down to my foot.
You: And does it happen in any particular time of the day? (Timing)
Patient: It is mostly worst at night doctor.
You: Does it awake you from sleep Janice? (Red flag)
Patient: Yes, I find my self waking up at the night.
You: I see that this situation is quite difficult for you Janice, I am sorry. (Showing empathy).
Patient: Yes it is doctor, thank you.
You: And would you say it's getting worse, better, or just about the same?
Patient: It is definitely getting worse doctor.
You: Oh I am sorry about that Janice, and is there anything that make it better or worse in anyway?
Patient: Moving makes it worse, it gets better when I rest.
You: And on a scale of 0 to 10, with 0 being no pain, and 10 being the worst pain ever, how much would you rate this pain Janice?
Patient: Now it's around 3-7.
You: Oh that seems tough, and if you do not mind me asking is there any numbness in the private areas.
Patient: No, what do you mean doctor?
You: Any weakness in your legs?
Patient: No I can move them just fine.
You: It's a personal question Janice, is there any soiling in the underwears or difficulty with passing urine at all?
Patient: No doctor.
You: Did you injure yourself, however minor it may have been?
Patient: I think because I carry my husband around, I may have injured myself yes doctor.
You: Ok I see, have you noticed any changes in temperature, felt unwell or weather, chills or shivering at all?
Patient: No doctor.
You: And have you noticed any tummy swelling, especially a one that is pulsating?
Patient: No doctor.
You: Have you lost any weight unintentionally or lost your appetite?
Patient: I think my clothes do not fit my anymore, yes I think I lost a lot of weight.
You: Do you know how many kilograms and over how much time?
Patient: No doctor I did not measure it.
You: Have you experienced any back stiffness at all? Any problems with moving any of your other joints?
Patient: No doctor.
You: Any shivering or rigors, and any weakness of numbness in any part of your body?
Patient: I have noticed only that shooting pain I've told you about earlier.
You: I can see, and have you experienced any chest pain, tightness, cough or wheezes?
Patient: No
You: Any issues with the waterworks at all?
Patient: Not really.
You: Have you noticed any nausea or vomiting, or any changes in your bowel habits?
Patient: No.

-Notes:

Always try to stick to common terms that all people know, avoid medical jargon.
Significant weight loss is defined as loss of over 4-5 kg or 5% of body weight in 6
In the systemic review, try to group several questions together in one sentence, do not ask about individual symptoms as this will take a lot of time.

Past medical history

-Relevant past medical history here include:

History of osteoporosis or previous fragility fractures (suggests a spinal fracture).
History of known malignancy (suggests metastasis)
History of immunosuppression e.g. AIDS, organ transplant, which suggest spinal infection.

-Other medical conditions such as hypertension or diabetes will also be relevant here in the perioperative planning.

Past surgical history

As usual.

Social history

-Smoking will be relevant here, as it increases the likelihood of malignancy, it is also a risk factor for osteoporosis.
-Recreational drug use is essential to ask about in this case scenario, because intravenous drug use is associated with spinal osteomyelitis.
-In this scenario the patient is presenting you a social problem (taking care of her disabled husband) you can cover this part of the history in the start of the consultation, do not forget to ask about social support at home.
-Occupation is relevant also, any job that includes heavy lifting may suggest disc prolapse, also because she is unemployed and taking care of her husband, that may pose additional financial burden on the patient, always acknowledge these problems, by saying like:
"I can see that caring for your husband while not working must be very difficult. Your situation may also affect your health, and we want to make sure you get the right support."
-You are expected to offer some form of a solution, telling the patient that you may involve a social worker probably count marks in the exam, so whenever you see there throws a problem at you, deal with it in three steps:

Acknowledge.
Sympathise.
Offer a solution.

Drug history and allergies
In this case scenario it is very relevant, the patient may have tried over the counter analgesics, ask about this dose, frequency and effect, lack of response is considered a red flag as it may suggests malignancy.
Family history

Family history of malignancy is very important, the actor may say "my mother died of breast cancer 2 years ago" some candidates may just move to the next question without spending few seconds to show his assumed that they know it is a sensitive situation, showing empathy towards the patient is a key communication skill, do not forget this part.

You: Have you been seeing your GP for any medical condition in the past Janice, such as hypertension, high blood pressure, hypertension or diabetes?
Patient: I have high blood pressure, I take 3 mg of amlodipine for it twice daily.
You: And have you had any surgeries in the past?
Patient: No.
You: Has any of your immediate family members been diagnosed with any medical condition, such as similar symptoms to your, heart or cancer?
Patient: My mother died 2 years ago of breast cancer.
You: I am really sorry to hear about your mother, if you do not mind me asking, how old she was when she was diagnosed with this?
Patient: I think she was 58 years old doctor.
You: Ok Janice, and if you do not mind me asking, do you smoke or drink alcohol?
Patient: No doctor.
You: This may seem a bit odd, but we ask this to everyone, do you use any recreational drugs?
Patient: No doctor.
You: Ok Janice, and do you have a job currently?
Patient: No unfortunately doctor, it has been very difficult to support my husband these days.
You: I see, this must have been a very difficult time for you and your husband, I am sorry to hear about it, I think we should request a social worker to them, he also can be able to understand what you can do, and also look after your own health.
Patient: That would be great doctor thank you.
You: Ok Janice, do you feel you take any medications?
Patient: Yes doctor.
You: I see, it must be difficult to manage all of this on your own Janice, and have you been able to do your daily activities such as shopping independently, or doing the chores?
Patient: No doctor that has been very difficult because of the pain.

Summarize your case, thank the patient and close the consultation.

[admin]

Examiner: Please summarize your case.
"Mrs Janice Green is a 54-year-old woman with 4 months of chronic lower back pain, dull and aching, sometimes shooting down both legs to her feet, increasing in intensity, keeping her awake at night, worsening. She denies numbness, weakness, or bladder/bowel problems.
She has hypertension, is unemployed, and she primary carer for her disabled husband, reporting significant stress and functional limitation. She has had a previous MRI, and no other systemic symptoms.
This is most likely mechanical back pain, but red flags include night pain and possible weight loss, so further evaluation and broad support are appropriate."
Examiner: How would you manage this patient?
I would inform my seniors, perform a clinical examination, and order some investigations including:

Full blood count: Looking for anemia which may indicate malignancy, leukocytosis which may indicate infection or inflammatory causes.
Serology: Which may indicate an autoimmune process such as rheumatoid arthritis.
Plasma electrophoresis: For possibility of multiple myeloma.
Liver function tests: For possibility of metastatic disease or as part of an extraintestinal manifestation of inflammatory bowel disease.
Plasma amino-lipase: May be considered if pancreatitis is suspected.
Urea and electrolytes: May be ordered especially if the suspected diagnosis is multiple myeloma, which is associated with renal failure.

Radiological investigation may include:

X ray of the spine: Looking for bony abnormalities.
MRI of the spine: Looking for disc pathology, spinal cord/cauda equina compression, or to determine diagnosis such as facet joint arthropathy.
Abdominal ultrasound scan: if an abdominal aortic aneurysm is suspected.
CT scan of the abdomen: may be considered if a diagnosis of chronic pancreatitis is suspected.

Treatment will be tailored to the underlying cause, in this case the likely cause is primary or secondary spine malignancy, it needs to be discussed in a MDT meeting, if disseminated malignancy it will likely include radiotherapy, chemotherapy, and pain management, if her pain is complex pain management teams may be included.
Note: When formulating a management plan, inform the patient, it is not mandatory that you get the right diagnosis, just give a reasonable set of investigations that will help you reach the diagnosis, and treatment plan for the most likely diagnosis in a brief manner.
Note: When formulating a management plan, always remember that you are NOT ALONE, always involve other parts of the team, for example, pain management team, radiologist, pharmacist... etc. according to the case you are dealing with.