Back Pain
Back Pain
Back Pain
Back pain
Key points:
I) Any back pain stations if it is not acute then: Start
with psychosocial questions:
∙ How is it affecting your life?
∙ How is it affecting your daily activities?
∙ What do you do for living ?
∙ How is it affecting your job ?
∙ How is your mood ?
II) DDS of back pain:
1-AAA (abdominal aortic aneurysm
Pulsatile mass in the abdomen
2- Cauda Equina syndrome:
Unable to control urine, bowel & pain, and numbness
around the back passage
3- Multiple Myeloma:
DM (polyuria, polydipsia, weight loss) dt increase Ca
Decrease blood (RBCs: anaemia/ platelets: bleeding,
bruises/ WBCs: repeated infections)
4- trauma / fall / accident
5- disc prolapse:
Pain after lifting heavy objects
III) Always ask FLAWS ( to exclude cancer)
IV) If it is a male & old age, back pain ask about prostration:
∙ Difficulty in starting urination
∙ Weak stream
∙ Terminal dribbling
V) In examination:
∙ Observation
2|P ag e
∙ Back
∙ Back passage (PR)/ prostate
∙ Tummy (AAA)
∙ SLRT (disc prolapse)
VI) In management:
∙ Don’t forget pain killers
∙ In investigations: (x-ray back )
∙ Safety netting always (Cauda equina): if unable to control
urine/ bowel/ pain around the anus come back
Tell me more?
SOCRATES
S: site : can you point with one finger to the site of the pain
3|P ag e
A: Is there anything that makes the pain worse or
better?
P2 (HTN/DM)
4|P ag e
⮚ Pain in the back that radiates to the back of legs, pain started
after lifting heavy weight
⮚ FLAWS
P2:
Management:
1- Admit
2- Senior
5|P ag e
3- Investigations :
⮚ Blood (CBC/ blood group/ cross matching) vvvimp + routine
blood
⮚ US scan on tummy
4- Symptomatic: O2 + fluids IV
Life style: we can arrange a meeting about lifestyle
modification
5- Specialist:
Refer to vascular surgeon depending on the size of aneurysm &
leaking or not
⮚ Open aneurysm repair: a cut in tummy & graft will be
placed
⮚ Endovascular repair : a graft will be inserted through a
blood vessels in your groin
6- Safety netting:
Dizziness or feeling you are about to faint inform
us immediately
6|P ag e
I) AAA ( ask about previous questions for AAA): Tummy pain /
pulsatile mass / have you had a scan where you were told
you have abnormal blood vessel in your tummy
II) Trauma ( did you sustain any trauma or fall or accident or any
sport) yes then explore , have you had this pain before or
after the sport
III) Disc prolabse:
⮚ Has the pain started after lifting heavy
weight suddenly
⮚ Do you feel that pain is radiating to the back
of your leg?
IV) FLAWS + DM symptoms (polyuria/ polydipsia/ weight loss) +
decrease blood ( RBCS: anaemia/ WBCS: infection/ platelet:
bruises & bleeding) = multiple myeloma
P2:
P3:
DESA
MAFTOSA
Examination:
⮚ Observations
⮚ Back (tenderness over paraspinal area)
⮚ Tummy
⮚ SLRT (+ve)
Provisional DX:
7|P ag e
From what you have told me it seems that you have muscle sprain
( you have overstretched your muscles after sports) it’s self-limited
, will subside on its own
Management:
1- No admission
2- Senior
3- No investigations needed
4- Symptomatic pain killers (advice to rest unlike disc prolapse)
5- If not relieved after two weeks refer to physiotherapist
6- Safety netting (pain not relieved or cauda equina symptoms)
7- Follow up
SO
⮚ It radiates to back of legs
⮚ Started after lifting heavy weight
Psychosocial:
DDS:
1- AAA
2- Multiple Myeloma (FLAWS + DM symptoms + Decrease blood)
8|P ag e
3- Trauma/ sport/ accident / fall
4- Cauda equina symptoms ( unable to control urine/ bowel/ pain
around back passage)
FLAWS
P2:
P3:
DESA
MAFTOSA
Examination:
⮚ Observations
⮚ Back
⮚ Tummy
⮚ Back passage
⮚ SLRT (+VE) vvvimp
Patient will be lying down on his back on an examination table,
examine you lift the patient leg while knee is straight between
(30-70) pain
Management:
1- Senior
2- Investigations
⮚ Blood routine
⮚ X-ray back
⮚ MRI by orthopaedic
9|P ag e
⮚ US tummy
3- Symptomatic
Pain killers
4- Refer to physiotherapist (most improve)
5- Refer to surgeon if pain persists after 6 weeks 6-
Safety netting (cauda equina)
N.B: make sure advice about lifestyle modification and to
avoid lifting heavy objects or change their job if it is the cause
Sick note
DDS:
1- Multiple myeloma:
10 | P a g e
⮚ DM ( it doesn’t cause DM , but it causes DM symptoms dt
increase Ca so easy to remember : polyuria- polydipsia-
weight loss ) Bones/ moans/ groans/ stones/ sitting on the
king throne
⮚ Blood components: (RBCS: anaemia: tiredness/ SOB/ heart
racing)
Symptoms of decrease WBCS (recurring sore throat/
fever/ cough)
Symptoms of decrease platelet (bleeding easily and
bruises)
⮚ FLAWS
2- Trauma / accident/ fall / sport
3- Disc prolapse questions (2 questions)
4- AAA
5- Cauda equina
P2:
⮚ Back pain before?
⮚ Past medical conditions?
P3:
DESA
11 | P a g e
Provisional DX:
First explain the blood results you had to remember
Management:
1- Senior ( as you are in GP)
2- Investigations ( has been done in GP)
3- Symptomatic (pain killers) Morphine
4- Referral urgent to haematologist (blood specialist)
⮚ Bone marrow biopsy ( sample of your bone marrow)
⮚ MRI
Multidisciplinary team:
⮚ Psychologist
⮚ Physio therapist
⮚ Occupational therapist
⮚ Dietitian
⮚ Clinical and palliative physicians
12 | P a g e
1- Anti- myeloma medicine: to destroy myeloma cells & control
cancer when it come back
2- Medicine & procedures to prevent problems caused by MM
such as bone pain, bone fracture
NB : your job in this station is pain killer
13 | P a g e