· Students will:
· Evaluate abnormal
musculoskeletal findings
· Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the musculoskeletal system
· Evaluate musculoskeletal X-Ray imaging
· Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
· Review the following case studies:
Case 1: Back Pain
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
With regard to the case study you were assigned:
· Review this week’s Learning Resources and consider the insights they provide about the case study.
· Consider what history would be necessary to collect from the patient in the case study you were assigned.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Note:
Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3 of Week 8: Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
“Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A
.
Differential Diagnoses (list a minimum of 5 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
Differential Diagnosis Example:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
4)
5)
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.
© 2019 Walden University
Page 1 of 3
• CHAPTER
24 Low Back Pain (Acute)
A report of acute low back pain (ALBP),
~}though quite common, requires a thor
ough evaluation. The underlying pathophysi
o logy of back pain is frequently multifactorial
and includes both physiological and psy
chological components . The most common
causes ofALBP relate to musculoligamentous
injuries and age-related degenerative pro
cesses. A bout 90% of ALBP episodes in
adults are related to mechanical causes that
resolve within 4 weeks without serious se
quelae. A smaller percentage of patients will
continue to have chronic symptoms without
organic pathology or have underlying disease.
In chi ldren, the prevalence of back pain
increases with age and with involvement in
sports. Anthropometric variations in children
place them at risk for excess strain on the
spine, producing back pain. These variations
include reduced hip mobility, decreased lum
bar extension and increased lumbar flexion ,
poor abdominal muscle strength, tight ham
string muscles, and lumbar hyperlordosis.
Acute low back pain is defined as activity
intolerance producing lower back or back
related leg symptoms of less than 3 months ‘
duration. The Agency for Healthcare Research
and Quality (AHRQ) guidelines provide
the fo llowing framework for causes of
ALBP:
• Potentially serious conditions (e.g., spinal
fracture, tumor, infection, or cauda equina
syndrome)
• Sciatica, or leg pain and numbness of the
lateral thigh, leg, and foot, suggesting
nerve root compression (Fig. 24. I)
• Nonspecific back problems such as mus
culoskeletal strain, diskogenic pain, or
bony deformity secondary to inflamma
tory diseas e
• Nonspinal causes secondary to abdominal
involv~ment (e.g., gallbladder, l iver, renal,
336
pelvic inflammatory disease, prostate
tumor, ovarian cyst, uterine fibroids, aortic
a n eurysm, or thoracic disease)
• Psychological causes such as stress related
to work environment (e.g ., disability,
workers’ compensation, secondary gains).
When evaluating ALBP, the goal of the
clinician is to first identify signs and symp
toms of potentially serious conditions through
a careful history and physical examination. A
holistic approach to the patient is needed to
appreciate the extent to which pain affects the
patient’ s daily routine or work- related activi
ties. Because ALBP is a common occupation
related complaint and a cause of disability
and lost productivity, the clinician must gain
insight into the patient’s psychosocial and
economic situation to help arrive at a correct
diagnosis.
DIAGNOSTIC REA s n.:. )NG: FOCUSED
HISTORY
Is this a potentially serious cause ofALBP?
Key Questions
• Do you have a fever?
• Have you experienced any trauma to the
spine or back?
• Do you have any other health problems?
• Have you b een treated for cancer?
• What is your age?
• Have you had loss of control of your
bowels or bladder?
• Are you taking any medications?
Fever
The pre sence of a fever indicates an inflamma
tory condition such as spondyloarthropathy or
systemic infection. Infection is a likely diag
nosis when there are chills and fever, weight
loss, a recent history of bacterial infection,
Chapter 24 • Low Back Pain (Acute}
Nerve root
Pain
Numbness
Motor
weakness
Screening
examination
Reflexes
f.1GURE 24.1 Testin g for lumbar nerve root compromise. (From Bigos S, Bowyer OR, Braen GR, et a l : A c ute
/ow back problems in adults, clinical practice guidelines, Quick Reference Guide Number 14, Rockville ,
~d., 1994, Department of Health and Human Services, U.S. Public H ea lth Service, Age ncy for H ealt h Care
Policy and Research, AHCPR Publication No. 95-0643.)
L4 LS S1
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I ,1′
/({_./_/
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I
Extension of Dorsiflexion of Plantar flexion
quadriceps great toe and of great toe
foot and foot
Squat and rise Heel walking W a lking on
toes
Knee jerk None reliable Ankle jerk
diminished diminished
Jntravenous drug use, or immunosuppression.
Ewing sarcoma is a malignant tumor and can
mimic spinal infection, occu rring as back pain
that can be accompanied by fever. Children
~ith discitis will h ave a fever and refuse to
~alk because of back pain. In adu lts, vertebral
steomyel iti s or disciti s occurs mos t ofte n as a
esult of h ematogenou s seedi n g of S. aure us,
troduced through invasive procedures or
urgery. Pain localizes over the infected disc
rea and is made worse with physical activity.
Pain may radiate to the a bdomen, leg, scro
tum , gro in, or perineum.
Trauma
Acute trauma to the spinal cord can result
in fracture, dislocation, or damage to muscles,
ligaments, and intervertebral disks. Trauma
may be cau sed by blunt impact, repetitive in
jury, or s udden str ess caused by lifting or
pulling. Low back p a in is the most common
occupational injury reported, so knowing a
Chapter 24 • Low Back Pain (Acute)
patient’s occupation helps assess specific risk
factors. Injury to the back usua]]y results in
contusions and abrasions but can a]so cause
spinal fracture if the force is major, such as
that sustained in a motor vehicle accident or
fa]J. Adults can have an acute compression
spinal fracture as a result of strenuous lifting
when osteoporosis is present. Most cases of
ALBP in adolescents who are athJeticaHy ac
tive are caused by injury to the posterior
structures of the spine.
Injury to the spinal column should be
suspected in anyone whose level of con
sciousness is impaired after an accident.
Cervical , thoracic and lumbar spine fractures
are sustained during flexion, extension, com
pression, rotation, or a combination of forces.
Systemic Disease and Cancer
Metabolic disease , inflammatory disorders,
and fibromyalgia can lead to back pain.
Patients with a history of cancer may have
increased risk of a metastatic spinal tumor.
Neuroblastoma is common in young chil
dren , and although it occurs in the abdomen,
metastases to the spine may produce back
pain. People younger than 20 years and
older than 50 years are at increased risk for
tumor, as are those with a history of cancer.
Age
In the absence of trauma, the sudden onset of
severe low or middle back pain in people older
than 30 years might suggest a dissecting aortic
aneurysm; the pain is not alleviated by rest.
Patients older than 50 years are at increased
risk for compression fracture as we11 as cancer.
Bowel and Bladder Sy mptoms
Loss of urinary or stool c o ntinence are early
s igns of conus rnedulari s syndrome (verte bral
involve ment at L2) and late signs of cauda
equina s yndrome which involv e s nerve root
compromise in the lower lumbar and sacral
nerve roots secondary to a herniate d disk, nerve
root entrapment, spinal stenosis, infection, or
tumor. Cauda equine is considered a surgical
emergency. Other symptoms include constant
lumbar pain with saddle anesthesia, urinary
retention or overflow incontinence, and fecal
incontinence due to an atonic anal sphincter.
Cauda equina
Children are embarrassed to talk about urj.
nary or bowel habits and changes . Hidder
spinal cord tumors might have a relation.
ship to deve l opmental delays in bladde1
and bowel control. Children younger than
4 years of age who have back pain should be
evaluated for serious diseases, such as intra
spinal tumors , dermoid cysts, and malignant
astrocytomas.
Medications
Long-term use of corticosteroids can lead to
compression fractures of the vertebrae. Use
of intravenous drugs may suggest infection as
a cause.
What does the location ofpain tell me?
Key Question
• Where does it hurt?
Location of Pain
In general, children are less specific than adults
when describing location of pain. Traumatic
lesions are more likely to occur in the cervical
and lumbar portions of the spine, where there
is more motion and less protection. General
ized pain or pain over a fairly wide anatomical
area is frequently seen with overuse problems
and inflammatory conditions.
Sciatica pain is a sharp, burning pain that
radiates down the posterior and lateral leg to
the foot or ankle . Rheumatoid arthritis pro
duces pain in the upper back and neck. Local
ized pain is seen with spondylolysis and
tumors. Flank pain in adults may indicate a
kidney infection. Pain from gallbladder disease
radiates to the subscapular areas. Compression
fractures of vertebrae associated with osteopo
rosis or malignancy may produce pain over
the area where the fracture has occurred.
Chi ldren with traumatic low back derange
ment will have pain and muscle spasm in the
lumbar area from the shock ofan impact injury.
What does the pattern ofpain t ell me?
Key Questions
• When did the pain start?
• How long have you had this pain?
Chapter 24 • Low Back Pain (Acute)
What does the pain feel like?
• Does it interfere with s leep?
• Ha e you had this pain before?
onset
The onset of ALBP is sudden, and more than
half of patients do not associate it with a spe
cific precipitating event or injury. The vast
majority of cases of ALBP resolve with con
servative treatment in 4 weeks, and radio
graphic or further diagnostic studies are not
recommended unless it associated with
trauma or symptoms such as radiating pain to
an extremity, extremity weakness or bladder
or bowel dysfunction.
Children are frequently poor historians,
and parents may have a difficult time remem
bering when the pain started. Association with
events such as birthdays, holidays, and activi
ties is helpful in establishing the onset of
a child’s pain. Mild pain of short duration
(1- 2 weeks) is rarely serious.
Back pain lasting longer than 4 weeks needs
to be reevaluated for further diagnostic studies.
Duration
Subacute back pain is of 6 to 12 weeks’ dura
tion. Chronic back pain is pain lasting for
more than 3 months. In people younger than
40 years of age, the cause may be postural,
related to weak abdominal or back muscles,
or may indicate congenital spinal deformity,
such as scoliosis or ankylosing spondylitis. In
older people, chronic back pain is more likely
to indicate degenerative disease, such as spi
nal stenosis or disk herniation. In children,
back pain present for more than 3 weeks is
often caused by organic and serious causes.
Pain Characterist ics
lo chi ldren, express ion of pain depends on the
child’s ability to put feelings of pain into
behavior; observing for these behaviors is
important. Ask childr en to rate the pain using
a IO-point pain s c a le with happy to sad faces
(see Chapter 3 ). A s k adults to rate pain from
0 (no pain) to 10 (worst pain ever) and assess
how much the pain interferes with daily ac
tivities. Intractable back pain, especially night
pain with constitutional findings, i s li kely to
indicate neoplastic disease. Hyperalgesia is
increased sensitivity to pain in damaged
tissue; this can develop after long-term use
of opioids for chronic pain.
Night Pain
Nighttime back pain is a worrisome symptom
that often signals a serious problem, such as
tumor, infection, or inflammation. Generally,
muscle strains, overuse injuries, spondyloly
sis, spondylolisthesis, and Scheuermann dis
ease (an exaggeration of the normal posterior
convex curvature of the thoracic spine) pro
duce less pain at night. Morning stiffuess
that improves as the day progresses suggests
osteoarthritis or ankylosing spondylitis.
Nighttime back pain is unusual and indicates
the need for a complete and thorough workup.
Recurring Pain
Back pain in young children who have had
previous injuries or fractures may be a symp
tom of child abuse. In older adults, it may be
an indication of compression fractures of the
spine. As with young children, it may also
signal abuse by a caregiver.
What does the pain in relation to activity
tell me?
Ke y Questions
• What makes the pain worse?
• What makes the pain better?
• School children: do you carry a backpack?
Aggravating Factors
Pain in the lumbar area after strenuous sport
ing activities is usually the result of trauma to
the muscles and tendons, causing contusions
and sprain. It occurs when the patient pushes
the muscles and ligaments past the normal
level of tolerance. Repeated injury can cause
soft tissue scarring and shortening.
Stress and fatigue fractures of the pars in
terarticularis, the region between the superior
and inferior articulating facets of the vertebra,
occur when lumbar lordosis places more
stress on the pars, such as in gymnastics and
tennis.
Pain that is aggravated by activity is usually
musculoskeletal in origin. Pain of ankylosing
spondylitis is relieved with exercise. Spinal
Chapter 24 • Low Back Pain (Acute)
stenosis is associated with increased pain with
stand.in& sneezing, or coughing. In an active
aduJt, poor preparation before exercise can lead
to back injwy and pain. Severe low back pain is
often the first symptom reported with spinal cord
compression. When pain is not improved with
lying down it suggests cancer or infection. Pain
with movement suggests vertebral instability.
Any child who has voluntarily given up a
pleasurable activity because of back pain has
a severe symptom.
Alleviating Factors
Back pain not associated with any activity and
not relieved by rest may indicate tumor. In
children, back pain relieved with aspirin
or nonsteroidal antiinflammatory drugs may
indicate an inflammatory cause. Pain that is
alleviated by rest and heat indicates a muscu
loskeletal cause. Pain of spinal stenosis is
relieved by flex ion of the spine.
Suspect spondylolisthesis, or forward slip
page of one vertebra over another, if the onset
of pain is during hyperextension, which can
occur with a back handspring, butterfly stroke
in swimming, or a tennis serve. The defect
can be the result of degenerative processes in
older patients or arise from a stress fracture or
stress reaction of the isthmus of the pars inter
articularis in the area of L5 to SI. The pain
localizes to the low back and occurs during a
growth spurt and after engaging in sporting
events. The pain improves with rest and is
worse with standing.
Backpack
School children often cany heavy backpacks,
increasing the risk of b ack pain and injury.
What does radiation of1miu 11:·ll r.u! ?
• Does the pain travel?
• Can you show me where the pain travels?
Radiation of Pain
Referred pain is of two types: (1) pain referred
from the spine into areas lying within the lum
bar and upper sacral dennatomes and (2) pain
referred from the pelvic and abdomina l
viscera to the spine. Pain from the upper lumbar
spine us ually radiates to the anterior aspects of
the thighs and legs, and pain from the lower
lumbar spine radiates to the gluteaJ regions,
posterior thighs, and calves (see Figure 24.4).
Pain from visceral di sease is us ually felt
within the abdomen or flanks. Gallbladder
pain radiates around the trunk to the right
scapula. Position does not affect the pain.
ln children and adolescent athletes, spondy
lolysis typically represents a fracture of the
posterior arch in the lower lumbar s pine due to
overuse and is a relatively common cause of
low back pain. Spondylolisthesis, an anterior
displacement of a vertebra, is less common.
Patients often develop pain that spreads across
their lumbar region and radiates into their
buttocks or posterior legs.
Pain that is sharp and burning and radiates
down the lateral or posterior aspect of the leg
to the lateral ankle or foot is called sciatica
and is a classic symptom of nerve root irrita
tion most often caused by disk herniation.
Are there signs ofneurological damage?
Key Questions
• Have you been stumbling?
• Have you noticed any change m your
balance or coordination?
• Does the child frequently stumble or fall?
• Do you have numbness or tingling in your
extremities?
Stumbling
Spinal cord twnors, such as astrocytoma or epen
dymoma, may present as a disturbance of move~
ment, posture, or strength in the spine or extremi
ties . lmpainnent of proprioception or sensation
from an upper motor neuron lesion, exhibited by
foot drop or ataxia, may produce stumbling.
Numbness and Tingling
Radiculopathy (nerve root pain) is sharp pain
fe lt in a dermatomal pattern and is sometimes
a ssociated with numbness and tingling.
ls there a family history of back pain?
Key Question
• Does anyone in your fan1ily have scoliosi
or a crooked spine?
http:stand.in
Chapter 24 • Low Back Pain (Acute)
Does Lou• Back Pain in Adolesce11ts2 EVIDENCE-BASED PRACTICE
/11tficllte a Serious Prob/e111?
Astudy of more than 200,000 adolescents who
presented to a health care provider with low back
pain were followed for 1 year. At 1 year, more
than 80% of the adolescents had no identifiable
diagnosis. The most common diagnoses found at
1 year were lumbar sprain-strain, less than 8%;
scoliosis, less than 4 %; and lumbar degenerative
disk disease, less than 1%. Spondylolysis, spon
dylolisthesis, i nfection, tumor, and fracture had
a less than 1 % association with LBP.
Reference: Yang et al , 201 7.
Family History
Spondylolysis and scoliosis are often seen in
families, with a 40o/o familial occurrence in
Native Alaskans.
Could this pain be caused by systemic
disease?
Key Question
• Have you been ill?
Illness
Pharyngitis or upper respiratory tract infec
tions, such as pneumonia, can be the precur
sor to diskitis, inflammation of the vertebral
disk space, in children. The intervertebral
disk in children receives its blood supply
from the surface of the a djacent vertebral
bodies, providing the mechanism necessary
for infection. Uveitis and iritis may be associ
ated with juvenile rheumatoid arthritis or
juvenile ankylosing s pondylitis.
A female patient with pelvic inflammatory
disease (PID) may h ave mild to moderate dull,
aching, lower abdominal, pelvic, or possibly
back pain. With pyelonephritis, the patient
may report fever, nausea and vomiting, head
ache, and back or flank pain. A urinary tract
infection may present as back pain.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAM INATION
Observe the Patient’s General Appearance
and Behavior
Any person appearing ill with a fever, limp, or
unwillingness to walk is highly suspect for
having an infectious cause of back pain; how
ever, a number of these symptoms may have
a psychological component that should be
explored.
Observe for symmetry of posture and
movement from direct anterior, posterior, and
lateral views ofthe patient. Note the amount of
thoracic kyphosis (anteroposterior curve) and
lumbar lordosis (anterior convexity) and the
alignment of the head and neck above the
center of gravity. Children with diskitis often
protect their backs by sitting in a hyperex
tended position, u sing the arms as support, and
may lie down and cry if they are made to sit.
Observe Gait
Shifting or leaning to one side (listing) and
atypical scoliosis may indicate a tumor. List
ing is caused by asymmetric sustained muscle
contraction. The spinal curvature serves to
relieve the discomfort and reduce pressure on
a nerve root.
Severely affected gait in spondylosis is
caused by hamstring tightness and results in
uneven s tride length with a persistently fixed
knee to prevent hip flexion, which would stretch
the tight hamstring muscles and increase pain.
Assess Vital Signs
Fever may indicate systemic infection as
well as diskitis. Unexp la ined weight loss may
suggest n eoplasm, infection, or depression.
Examine Skin
Dermal cysts or a h a iry patch over the s pine
may indica te spina l a nomaly or tumor.
A doughy, fatty m ass in the midline of the
back (sometimes covered with h air [a Faun
beard]) is evidence of a lipoma, which may
extend into the spi nal cord and produce
n eurologic symptoms.
Chapter 24 • Low Back Pain (Acute)
Examine Eyes, Ears, Nose, and Mouth
Uveitis iritis is seen in juvenile rheumatoid
arthritis and ankylosirtg spondyli tis. P h aryn gi
tis, otitis media, or infect ion of h ematogenous
origin may be t he cause of diskitis in chi ldren.
Inspect the Back and Extremities
Observe for spinal a lignment and symmetry of
the t ips of the scapula, iliac crests, and g lutea l
crease. If ind icated, measure and compare leg
lengths from the anterosuperior ili ac crest to
th e medial mal leo lus. Measurements can be
performed with the patient standing or sup ine.
Legs should be of equal length or have less
than 1 cm differen ce in length. Leg length dif
ferences are associated with pathologic condi
tions of the sacroiliac, facet joint, and disk.
From posterior and lateral viewpoints,
observe the patient bending forward with feet
together to detect scoliosis, kyphosis, or stiff
ness and guarding.
Percuss and Palpate Back and Spine
Painful scoliosis and stif:llless are common in
osteoid osteoma. I diopathic scoliosis is usu
a lly painless without functional limitation .
Point tenderness over the affected area is a
finding associated with a compression fracture
of the vertebrae or an infection of the spin e.
Palpate and percuss the back to determine
if tenderness is in the paravertebral muscular
or midline spinou s processes, which may
indicate diskitis or osteomyelitis. To rule out
the sacroi li ac joint as the si te of origin of
ALBP, cond~ct ~ FABER . test (~ig. 24.2).
Place the patient m the supme pos itio n . Flex
the leg and put the foot of the tested leg on the
opposite knee. The motion is that of tlexion
abduction , external rotation at the hip. Slow1;
press down on the superior aspect of the
tested knee joint lowering the leg into further
abduction. The test result is positive if there is
pain at the hip or sacral joint or if the leg can
not lower to the point of being parallel to the
opposite leg.
Use fist percussion over the costovertebral
angles to discriminate flank pain caused by
renal disease from spinal pathology. Apply
fist percussion over the costovertebral angles
and over the spine to localize tenderness.
Perform Range of Motion of the Spine
Ask the patient to flex, extend, rotate, and
bend the spine laterally. Decreased mobility
and back pain along the spine may indicate
muscle spasm, neoplasm, or bony deformity.
Pain with forward flexion usually indicates
a mechanical cau se. Back exten sion pain
increases with spinal stenosis.
Look for compensating effects of hip
motion on the spine. The absence of lumbar
flexion may be totally masked by a normal
range of hip flexion when the patient bends
forward. Test lumbar flexion by placing a mark
FIGURE 24.2 The FABER maneuver (flexion, abduction, externa l rotation at the hip) . (From Cummings
Stanley-Green S, Huggs P: Perspectives in athletic training, St. Louis, 2009, Mosby.)
—
I
Chapter 24 • Low Back Pain (Acute) I 343
0
,,er the fourth lwnbar vertebra and another
over the sacrum. Lumbar flexion is demon
strated by an increased distance between these
rwo marks when the patient bends forward.
A modified Schober test can be used to
assess lumbar mobility. With the patient
standing erect and heels together, draw a mark
on the skin 5 cm below an imaginary line be
rween the buttock dimples overlying the pos
terior superior iliac spine. A second mark is
made 15 cm above this line. Then have the
patient bend forward touching their toes. An
increase in distance between these lines of
6 cm or more is normal; less than 6 cm indicates
decreased lumbar spine mobility (Fig. 24.3).
Observe for limitation of motion on for
ward bending caused by hip flexion contrac
ture. Lumbar lordosis does not flatten with
forward bending and is an organic cause for
back pain. In children, Scheuermann disease,
an exaggeration of the normal posterior con
vex curvature of the thoracic spine, produces
pain with forward flexion , and spondylolysis
produces pain with hyperextens ion.
Perform Straight Leg Raising
The straight leg raising (SLR) test can assess
sciatic (L5 and S 1) nerve root tension. With the
patient supine, place one hand above the knee,
the other cupping the heel, and slowly raise the
limb. Instruct the patient to say when to stop
because of pain. Observe for pelvic movement
and the degree of leg elevation when the pa
tient tells you to stop. Ask the patient to tell you
the most distal point of pain sensation, such
as the back, hip, thigh, or knee. While holding
the leg at the limit of elevation, dorsiflexing the
ankle and internally rotating wi ll add tension to
the neural structures and increase the pain if
nerve root tension is present.
Pain below the knee at less than 70 de
grees of elevation that is aggravate d by
dorsiflexing the ankle or hip rotation is a
sign of LS or S 1 nerve root te nsion, sugges
tive of a herniated dis k. This test can also
be performed with the patient sitting. In a
positive test res ult, the patient will resist
extension or will compensate with hyperex
tension of the spine.
Lift each leg in succession to detect con
tralateral pain in patients with nerve root
compression.
Results of the SLR test in children with a
tumor can be unremarkable.
Check Hip Mobility
With the patient prone and supine, check active
hip flexion , extension, interna l and external
Finger-to-floor distance
Modified Schober test (normal: total >20 cm)
t ·.i: cm
S2 —–r- . –
T · ~n·1—:r- . -‘-·• I
/ —l~~-cm ,
S2 – – – – – – –
5cm
Finger-to-floor
~—- distance
B Flexion
FIGURE 24.3 Performing the modified Schober test for spina l flexibility. (From Lawry G, Kreder H, Hawker G,
Jerome D: Fam’s musc uloskeletal examination and joint injection techniques, ed. 2, Philadelphia, 2 011, M osby.)
Chapter 24 • Low B ack Pain (Acute)
rotation , and strength against resistance. Weak
ness of the gluteus maxi mus is associated with
lumbar or referred pain from LS nerve roots or
gluteal nerve injury. In small children, check
for congenital hip dysplas ia with the child su
pine and abducting the hips (see C hapte r 22).
The knees s h ould appear of equal height and
should rotate externally by equal degrees. The
presence of a hip c lick, joint instability, uneven
hip-to-knee length with hips and knees flexed ,
and uneven gluteal skinfolds suggests congen i
tal hip dislocation.
Examine Feet
Perform active range of motion of the ankle,
feet, and toes against resistance. Weakness,
pain, or limitation of dorsiflexion movement
indicates an L4 nerve root injury. Similar
symptoms produced by plantar flexion indi
cate S 1 involvement, while symptoms pro
duced by dorsiflexion of the big toe indicate
LS involvement. Deformities of the foot,
such as talipes equinovarus (clubfoot) or
hallux malleus (claw toes) , may aggravate
misalignment of back structures because of
asymmetry.
Evaluate Muscle Strength
Evaluate strength against resistance of the
lower extremity muscle groups. Test the pa
tienCs ability to stand on the toes and heels
and to squat. A person with SI nerve root in
volvement may have little motor weakness but
may demonstrate difficulty in toe walking.
Difficulty with heel walking or squatting indi
cates invo lvement of LS and L4 nerve roots.
Leg extension at the knee against resistance
tests L4 root function. In young children who
are unable to cooperate for measurement of
muscle strength, use measure ments of s imilar
limb girths as an estimate of the bilateral sym
metry of muscle strength.
Measure Muscle Circumter em·;e
Differences in muscle circumference greater
than 2 cm in two opposite limbs may signify
atrophy secondary to neurologic impairment.
T~~~t. Sensory Function
Neurologic test res ults are evaluated by
comparing the symmetry of responses or
perceptions. Bilateral comparison is the sirn.
plest, most efficient way to detennine the
presence, location, and ex tent of any abnor
mality. A sensory examination is a general
guide in determining the level of spinal cord
involvement. Test for light touch and pain
sensation in the sensory areas of L3 to SJ
dermatomes (see Fig. 24.4). Dennatornes
overlap a nd vary greatly in individuals; thus
‘ on ly gross chan ges can be detected by
pinprick. Test 5 to l 0 pinpricks in each der
matomal area if the patient reports numbness
and tingling. Disk lesions rarely produce
bilateral symptoms. It is sometimes difficult
to distinguish numbness from a cutaneous
nerve versus a dennatomal origin. Numbness
from cutaneous nerve lesions does not occur
in a dermatomal pattern. Numbness and tin
gling are uncommon symptoms in most chil
dren with back pain. When these symptoms
are present, it suggests a serious problem.
Assess Deep Tendon Reflexes
Normal deep tendon reflexes (DTRs) are
symmetrical. DTRs are increased when an
upper motor neuron lesion is present and de
creased with a lower m otor neuron lesion. A
positive Babinski sign indicates a disorder of
upper motor neurons affecting the motor area
of the brain or corticosp inal tracts c aused by
spinal tumors or demy e linating disease. DTRs
are decreased if a tumor is pressing on a
peripheral nerve. A symmetric abdominal
reflexes are seen in tumors of the spine.
An absent or a decreased ankle-jerk reflex
suggests an S 1 nerve root lesion. An L3 to L4
disk herniation is the most common cause of
a diminished knee-jerk reflex.
Palpate the Abdomen
The abdomen is palpated to detect possible
visceral causes of back pain. In adu lts older
than 50 years, a ruptured aortic aneurysm can
cause acute, severe, midthoracic back pain. If
an aortic aneurysm is s uspected, immediate
s urgical referral is critical.
Check Rectal Sphincter Tone
In cauda equina syndrome, the compression
of S 1 to S2 nerve roots results in decreased
sphincter tone and decreased sensation in the
Chapter 24 • L ow Back Pa i n (Acute)
AGURE 24.4 Dermatomes of the body, the area of body surface innervated by particular spinal nerves; Cl
has no cutaneous distribution. A , anterior v iew. B , posterior view. (From A: Rudy, EB: Advanced neurological
andneurosurgical nursing. 1984, M osby, St Louis. 8 : Thibodeau, GA, Patton , KT: Anatomy and physiology.
ed 5, 2003, Mosby, St Louis)
perianal area. This syndrome 1s a surgical
emergency.
LABORATORY AND DIAGNOSTIC
STUDIES
According to national practice guidelines, no
diagnostic tests are w arranted within the first
4 weeks for onset of A LBP without neuro
logical signs or sympto m s.
Spinal Radiographs
Aflat lumbosacral spi n e:! •::ldiograph is obtained
when there is a history ~ f trauma or in people
older than 50 years who hav e ALBP with s igns
of neurologic deficit a his tory of straining or
lifting. Anterior and p osterior view radiographs
are useful in ruling out :fracture, tumor, osteo
phytes (bone spurs), or vertebral infection.
Oblique and flexion views increase the sensi
tivity for determining insta bility.
Bone Mineral Density
Bone mineral density (BMD) uses radiography
to assess the amount of calcium in bone. The
dista l wrist and lumbosacral spine can be
scanned to assess BMD and the risk of osteopo
rosis. Density is measured as a T-score, re
ported as the number of standard dev iations that
a patient’s BMD value is above or below the
referen ce value for a h ea lthy 30-year-old adult.
AT-score cutoff value for osteoporos is is -2.5.
Bone Scan
Bone scanning uses a radioisotope to assess
b lood flow and bone formation or d estruction.
It can reveal inflammatory and infiltrative
processes and occu lt fractures.
Chapter 24 • Low Back Pain (Acute)
2 EVIDENCE-BASED PRACTICE Hou’ /111porlt111t Is Obtt1i11i11g Rt1dio1-:raphic
/111l1J.:i11g When ll1a11t1gi11g Acute Lo•v Back Pain?
A systematic review and meta-analysis was
conducted to compare ca re with and without
immediate routine lumbar imaging for ALBP
without indications of serious underlying condi
tions. Outcomes examined included pain , func
tion , mental health, qual ity of life, patient
sat isfaction, and overall patient improvement.
Reference : Andersen JC: 2011 .
Electromyography
E lec tromyography (EMG) with nerve conduc
tion study is a diagnostic proce dure to assess
the health of muscles and the nerve cells
(motor neuron s) that control them. In n erve
conduction e lectrodes are placed on the skin to
meas ure speed and strength of s ignals traveling
between two points.
Diagnostic Imaging
Magnetic resonance imaging (MRI) is useful
in evaluating soft tissue detail , such as disk
herniations, tumors, and spinal cord patho lo
gies, especially in vertebral osteomyelitis.
Computed tomography is usually used for
bone visualization.
Urinalysis
Urinalys is is performed to assess kidney and
metaboli c function , including infectious pro
cesses, to rule out a v isceral cause of back
p ain , such as the pain of pyelonephritis.
Erythrocyte Sedimentation Rat e
The erytlu·ocyte sedimentatio n rate ( E SR) will
be elevated in about 90°/o of p a tie n ts with a
serious mus culoskeletal infection; h owever,
there is no direct rela tionship b etwe e n ESR and
severity o f infection. The test is nonspecific.
Complete Blood Count
The complete blood count will detect anemia
as well as other c onditions that might mani
fest a s back pain, such as tumor or infection.
The a nemia of chronic disease is u s u a lly hy
pochromic or normochromic with low iron
indices .
Results showed no differences in short-term
or long-term follow-up between the group that
underwent imaging and the group that did not. In
addition to no c linical benefit from immediate
imaging w ith ALBP, routi n e lumbar imaging is
associated with radiation exposure and increased
cost related to u nnecessary procedures.
DIFFERENTIAL DIAGNOSIS
Potentially Serious Causes of Acute Low
Back Pain
Spinal fracture
The patient may r e la te a history of major
trauma to the back from an impact or fall or,
if the patient is an older a dult, a history of
strenuous lifting or a minor fall. Pain is felt
near the site of injury. Any suspicion of spinal
fracture should be treated as an emergency.
The patient is immobilized t o prevent further
damage and transported by emergency per
sonnel to obtain radiogra phs of the suspected
area of fracture .
Tumor (osteoblastom a, spinal metastasis,
osteoid osteoma)
Whereas primary tumors ar e a more common
cause of back pain in c h ildren, metastases are
a more common cau se in adults. The lower
thoracic and upper lumbar vertebrae are the
most common sites of bony metastatic disease
from marrow tumors . A h ealth history and
diagnostic tests may reveal other signs of
poor general health, s u c h as weight loss,
fati g ue, weakness, and a n emia .
Infe ction (osteomyelitis, dis kitis, epidural
abcess)
The spine is t he mos t commo n s ite of osteomy
e litis in adults, secondary to a djace nt infection
or following invasive instrumentation that
results in bacterial seeding of the bone via arte
rial blood. Staphylococcus aureus is the most
Chapter 24 • Low Back Pain (Acute)
• tly identified organism. Vertebral osteo bProcCSS·uscle spasm may be seen m. verte ral os rnyelitis or septic t SJUtlS. at1ents may ave ‘ldren that results in intervertebral disk lk sit or stand. Pain will be aggravated bywa , , %a1 a recent bacterial infection, often second Epidural abscess is a rare and serious in Herniated disk
Disk herniation caus es nerve root irritation Cauda equina sy.”” t .¥o me
Compression o f the S 1 nerve root produces dysfunction, motor weakness of the Jower Nonspecific Back Problems
Sciatica
The most common cause of sciatica radicu Musculoskeletal strain (postural, overuse)
Back structures such as muscles and liga Spondylolisthesis
P a in can be the result of di s ruption of the Chapter 24 • Low Back Pain (Acute) disclose a palpable, prominent spinous pro Ankylosing spondylitis
Ankylosing spondylitis is a systemic inflam Spinal stenosis
Spinal stenosis is a bony encroachment on the Scheuermann disease
Adolescents develop this disease as a result Osteoporosis
Osteoporosis is loss of mineralized bone mass vertebral body, usually occurring in the tho Vertebral compression fracture
Causes of vertebral c01npression fractures are Nonspinal Causes
Aortic aneurysm (dissecting)
Sudden onset of severe low or middle back {;llllstones
Gallbladder problems increase w ith age. A Attacks may increase in frequency-00 5 5 RUQ mass may be felt if the gallbladder Pyelonephritis
With pyelonephritis, the patient will appear ill Pleuritis
Inflammation of the pleural lining of the ~ .. ..,· .
Chapter 24 • Low Back Pain (Acute) Pelvic inflammatory disease
The symptoms of PID depend on the extent of Psychogenic Causes
Psychologic back pain
A careful history is needed to gain insight . ‘ DIFFERENTl~l]f _.1AGNOSIS OF Co111111on Causes ofAcute Lo1v Back Pa111 .;1f. ·-::.! CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
POTENTIALLY SERIUUS CAUSES pain is felt near site of over site of fracture emergency; 1im and transport for Tumor History of cancer; Weight loss, fever, ESR; bone scan; MRI
unremitting; occurs at tumor Continued Chapter 24 • Low Back Pain (Acute) :: DIFFERENTIAL DIAGNOSIS OF Co111111011 Causes of.Acute i#jw Back ·-‘ ‘
I CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Osteoblastoma Neck or back pain not Osteoid osteoma Occurs primarily in ado Infection H istory of infection, pain ; chronic back pain ment; more common i n Herniated disk LBP radiating down the Cauda equina Constant pain in a urinary retent ion, NONSPECIFIC BACK PROBLEMS radiculopathy; history Musc u !oskeletal Pain in back, buttock s; or exertion; relief of Localized tenderness; Plain film shows an rounded by th in Painfu l , well-localized Bone scan Acute onset with fever, ESR; blood culture; Tenderness over ESR ; CT Positive S LR MRI
Positive SLR, abnormal MR I , s urgical Paravertebra l tender- MRI Paravertebral tender- None Chapter 24 • Low Back Pain (Acute) -~-‘ HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIESCONDITION
spondylol isthesis
Ankylosing Spinal stenosis Scheuermann Osteoporosis Vertebral NONSPINAL CAUSES Young person in a sport Younger than age 40 yr: Pain worse throughout Affects mostly adolescent Chronic, p oorly localized Pain, loss of sensation, Severe , acute-onset pain No neurological signs; Painful sacroiliac joints, Signs of osteoarthritis N o rmal examination; Palpable tenderness Palpable tenderness Intact aneurysm will be Lumbar s pine ESR ; spinal MRI Thoracic spi ne Bone densitometry; Radiograph to Emergency surgical Continued Chapter 24 • Low Back Pain (Acute) ‘”” .,…_. Pai11-co11t’tl “·:.. CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES Gallstones Increased incidence with Normal physical exami Su rgical referral Pyelonephritis Ill-appearing; sweating, Fever; cloudy, malodor Urinalysis; urine percussion pleuritic pain crackles and bron radiograph Pelvic Sexually active female; low Cervical and uterine Gonorrhea, or vaginal symptoms, cervic itis, fever PSYCHOGENIC CAUSES back pain stressors, depression, sistent reactions to CT, computed tomography; CVA, costovertebral angle; DTRs, deep tendon reflexes; EMG, electromyography; Turnitin Report Formatting Title Page Citation Outline
fre
brtll 111 . d. 1- : . p . h
1i:° in secondary to involvement of L2 to SI.
htP~skitis is usually a benign disorder in
~h~ammation. Children will be reluctant to
10
otion and relieved by rest. History will re
~ry to pharyngitis or otit~s media,_ intravenous
drug use, diabetes melhtus, or 1mmunosup
pression. A small percentage of adults will
report an acute onset of fever, weight loss,
and genera l malaise; however, the majority
will only have the symptom of back pain,
present from 2 weeks to years.
fection of the central nervous system (CNS).
Abscesses that occur within the bony confines
of the skull or spinal column can expand to
compress the brain or spinal cord and cause
severe symptoms, permanent complications,
or even death. Prompt diagnosis and treat
ment is critical and treatment often includes
aspiration guided by magnetic resonance im
aging or surgical drainage of the abscess.
and produces ALBP that radiates down the
buttock to below the knee. Pain is the promi
nent symptom, with numbness and weakness
less common. Phys ical examination will re
veal a positive SLR tes t re s ult. If the pain
persists longer than 1 month consider MRI.
Urgent neuroimagin g is indicated if neuro
logic deficits , u rin:-uy retention , saddle anes
thesia are presen t, 0 r if neoplas m or e pidural
abcess are suspect~~.
constant back p ai n with saddl e distribution
anesthesia (buttock a nd medial and poste
rior thighs) , fecal incontine nce, bladder
limbs, and radiculopathy. The patient may
limp and guard lumbar s pine movement, will
not be able to heel walk or toe walk, and w ill
have abnormal or asymmetrical knee and an
kle DTRs. The SLR test result wilJ be posi
tive. This syndrome is a surgical emergency.
lopathy, or pain related to spinal nerve root
involvement, is h erniated vertebral disk. His
tory may disclose repetitive motion strain or
strenuous lifting , tw1stmg, and bending.
ALBP is associated with pain and burning
that radiates along the lateral thigh, leg, and
foot, sometimes associated with numbness
along the dermatomal areas. SLR and sitting
knee extension produce radicular pain below
the knee at less than 60 degrees of limb eleva
tion, and pain may be felt in the buttocks or
posterior thigh. Bowel and bladder functions
are normal.
ments can become inflamed from overuse or
strain. History often reveals no precipitating
event fo r the onset of pain. Patients may re
port that pain is alleviated by rest, especially
in the supine position with hips and knees
flexed, and by the application of heat or cold.
Pain is aggravated by sitting, walking, stand
ing, and with certain motions. On physical
examination, palpation will localize the pain,
and muscle spasms may be felt. Range of
motion of the spine will increase the pain,
especially with forward flexion. Neurologic
examination shows no abnormalities.
vertebral s pinous proc ess, where the disrup
tion results in subluxation of the vertebral
body onto adjacent structures. This usually
occurs between L5 and S 1. Pain is usually
chronic. Examination of the spme m ay
cess. Forward flexion may be limited.
matory condition of the vertebral column and
sacroiliac joints. Peak incidence is in people
20 to 30 years old; males are most often
affected. Patients report chronic LBP, which
is worse on morning rising and lessens as the
day progresses. Examination shows an exces
sive thoracic kyphosis and rounding of the
posterior thoracic spine with forward flexion
of the head, neck, and lower back. About 30o/o
of patients will have arthritis of other joints.
Radiographs may reveal fusion of vertebrae,
and ESR is elevated.
nerve roots of the lumbar spine and is the most
common cause of ALBP in adults older than
50 years. Patients report ALBP associated with
lumbosacral radiculopathy, pain with walking
or standing, and pain relief with sitting or for
ward flexion ofthe spine. Neurogenic (pseudo)
claudication pain of the lower extremities is
made worse with prolonged standing, walking,
bending, or hyperextending the back.
of anterior disk protrusion, causing wedging
of the thoracic vertebrae and exaggeration of
the normal posterior convex curvature of the
thoracic spine. The cause is unknown but
may develop from excessive lifting or spinal
flexion. The patient reports mild to moderate
pain, worsening toward the end of the day or
after physical activity but relieved by res t.
Physical examination demonstrates an in
crease in thoracic kyphos is on lateral view.
made sharper by forward bending.
that can result in a compression fracture of the
racic area. Back pain is often chronic and
poorly localized. Multiple compression frac.
tures may produce dorsal kyphosis and cervj.
cal lordosis. Estrogen deficiency, through
menopause or medications, is a risk factor. It
is also common in people older than 70 years
who have age-related reduction in vitamin D
synthesis. Osteoporosis can also be secondary
to endocrine imbalance (e.g. , hyperthyroid
ism), organ disease, drugs (e.g. , corticoste
roids), or excessive intake of alcohol. The
Fracture Risk Assessment Tool (FRAXR) is a
web-based algorithm used to calculate the
10-year probability of hip and femur fracture
based on clinical risk factors and BMD
results .
trauma, osteoporosis , and systemic disease. In
older adults, compre s sion fractures secondary
to osteoporosis m a y b e without symptoms.
Patients may report p ain, loss of sensation, or
loss of continence a fter a trauma. A history of
cancer may indicate a:netastasis. Radiograph
will detect a fracture.
pain that is not alleviated by rest in people
older than 30 years might suggest a dissecting
aortic aneurysm. The patient may exhibit
pallor, diaphoresis, and confusion. Pulses
and b lood pressure measured on each upper
<"'Xtre mity will be asymmetric. Emergency
surgery is indicated.
gallbladder attack often follows a fatty meal.
Crampy right upper quadrant (RUQ) pain
followin g a fatty meal is produced by spasms
of the cystic duct that is obstructed with a
stone. Ga llbladder pain radiates around the
trunk to the right scapula. Position does not
affect the pain. Patients report belching and
btoatte;~rity and cause nighttime wakening.
and . g an attack, palpation will show RUQ
o:;;rness. Physical findings between at
ce k may be normal, or there may be tender
taC to palpation of the RUQ on inspiration
;::~by sign) if the gallbladder is inflamed.
AJ1 . .
. obstrocted. Obstruction 1s an emergency
tS • .
surgical s1tuat10n.
and diaphoretic and may report nausea and
vomiting, headache, and back or flank pain.
The patient may have a fever. Severe lumbar
tenderness will be found on fist percussion for
costovertebral angle tenderness. Urinalysis will
show cloudy, malodorous urine, and micros
copy will show casts and cells (i.e., red blood
cells, white blood cells, and epithelial cells).
lungs often follows an upper respiratory tract
infection. Pleuritic pain is sharp, worsens on
inspiration or with coughing, and is lessened
by lying on the affected side. Physical exami
nation ofthe lungs may be normal, or crackles
and bronchial breath sounds will be heard on
auscultation. A chest radiograph wiU provide
information on the condition of the lungs.
infection. In£ection usually begins in the
lower urinary tract or cervix and spreads to
the endometrium, Fallopian tubes, and perito
neum. The sexually active patient may have
mild to moderate dull, aching, lower abdomi
nal, pelvic, or possibly back pain. The patient
will report tenderness during cervical motion,
uterine motion, or palpation of the adnexa.
History may be positive for sexually transmit
ted infections (usually Neisseria gonorrhoeae
or Chlamydia trachomatis), vaginal symp
toms, or use of an intrauterine device for
contraception.
into the psychosocial and economic issues
surrounding report of back pain. The patient
may have a history of recent life stressors, be
involved in a legal injury or workers’ com
pensation action, or have a his tory of depres
sion or alcohol abuse. The clinician should be
aware of exaggerated signs of pain, such as
moaning, grimacing, or overreacting. A ma
lingerer pretends to suffer but, when dis
tracted, will show inconsistent and variable
results on examination such as SLR, or will
describe radiation of pain inconsistent with
dermatome distribution.
– ‘> …. .;!!;” . … …
.·· ,… J··
Spina l fracture Trauma to spine or back; Palpable tenderness Considered an
injury mobilize patient
radiographs
progressive pain is tenderness near
night and at rest
Pt1i11- co11t ·,1 .-_. ~
II
relieved by aspirin;
occurs in older adoles
cents and young adu lts
lescents ; rare in pa
tients older than age
40 yr; well – loca l ized
pain that may be more
severe at night and
relieved by aspirin or
other prostaglandin
inhibitors
(vertebra l invasive procedure;
osteomyel itis) continuous, dull back
D iski t is Pain aggravated by move
chi ldren
buttock to below the
knee , symptoms
present < 1 mo
syndrome sadd le distribution;
fec al incontinence,
radiculopathy
Sciatica Acute back pain with
of strain or trauma,
rel ief with sitting
strain history of new activity
pain with sitting
may have scol iosis expansive osteo
with muscle pain lytic lesion sur-
peripheral rim of
bone; bone scan;
CT scan
scoliosis may be
present
diaphoresis; tender- bone biopsy; CT
ness over affected scan; MRI
disk; positive S LR
aff ected disk
DTRs, motor weakness emergency
ness and spasm;
positi ve SLR; sitting
knee extension,
sensory findings
ness, scoliosis, or
l oss of lumbar
lordosis; no neurolog-
ica l sign s
~ DIFFERENTIAL DIAGNOSIS.~9F Co111111011 Cctuses ofAcute Lou’ Blick
‘· Pai11–co11t •d
spondylitis
disease
compression
fracture
Aortic aneurysm
that demands rapid
movement between
hyperflexion and
hyperextension or re
quires excess loading
in hyperextension
insidious onset; pro
gressive morning back
pain relieved with
exercise
day; aggravated by
standing, relieved by
rest; pseudoclaudication
males; mild to moder
ately severe pain,
worse at end of day,
re Ii eved by rest
bac k pain ; postmeno
pau sa i ; s l ight b uild ;
history of inactivity or
endocrine disorder
incontinence; trauma
to the spine; history of
ca n cer, osteoporosis
not related to activity
or movement; in
c reased risk older
tha n age 30 yr; pallor,
diaphoresis, anxiety,
confusion
pain localized to low
back, just below level
of i I iac crest; tight
hamstrings
reduced spine mobil
ity; may have uveitis
of joints; may have
neurological s igns
may show an exag
gerated thoracic
kyphosis that is
fi xed in attempted
hyperextension
over area of compres
s ion frac ture; kypho
sis or lordosis; loss of
heig ht
over fracture, obser
vation of s pine
deformity
a visible pulsatile
midline upper quad
rant abdominal mass;
in a dissected aneu
rysm, upper extremity
pulse and pulse pres
s ures are asymmetric;
posterior thoracic
pain may be felt
radiographs
radiographs
radiographs
FRAXR score; sp i
nal rad iograph to
assess fracture
detect fracture
referral
:;j DIFFERENTIAL DIAGNOSIS OF Co111111011 Cttu.•ies <~f'AcuteJ~o•v Back
,f .1w;-·
age; steady, intense pain nation or positive
in RUQ with radiation to Murphy sign on pal
right scapu la or shoul pation of abdomen
der; belching, bloating,
fatty food intolerance
nausea, back or flank ous urine; CVA culture
pain, headache tenderness on
Pleuritis History of recent URI; Normal examination or PPD; chest
chial breath sounds
inflammatory back and abdominal motion tenderness, Chlamyd ia
disease pain; history of urinary adnexal tenderness; cultures; ESR
sexually transmitted
disease, IUD, multiple
sex partners
Psychological History of psychosocial Exaggerated or incon None
exaggerated expres testing; normal
sions of pain examination
ESR, erythrocyte sedimentation rate; IUD, intrauterine device; LBP, lower back pain; MRI, magnetic resonance
imaging; PPD, purified protein derivative; RUQ, right upper quadrant; SLR, straight leg raising; URI, upper
respiratory tract infection. Order an Essay Now & Get These Features For Free:
