Case 10: Back pain

Opening scenario

Justin Cooper, a 26-year-old male; , comes to the emergency department because of back pain.

Vital signs

• Temperature: 98.6°F (37°C)
• Blood pressure: 120/80 mm Hg
• Heart rate: 74/min
• Respirations: 16/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• You are not aware of the meanings of medical terms (e.g., x-ray) and ask for clarification if the examinee uses them.
• When the examinee presses on both sides of your hip (iliac crest) while you are lying supine, tell the examinee that this hurts.
• If the examinee raises your leg as part of a clinical test (straight leg test), this does not cause you any pain.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Is this my fault because I do not work out enough?”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• My back hurts. And I feel stiff in the morning.
• Location
• Hmmm...it is almost the whole back that hurts.
• Intensity (on a scale from 0–10)
• I would say a 4.
• Quality
• It is a dull pain.
• Onset
• I think 3 months ago.
• Precipitating events
• None.
• Progression/constant/intermittent
• It started with a very subtle pain but has become worse.
• Previous episodes
• None.
• Radiation
• No.
• Alleviating factors
• The stiffness in the morning improves over time. Twenty minutes after waking up, after showering and making coffee, I have the feeling that I am more flexible.
• Aggravating factors
• None.
• Associated symptoms
• Sometimes I have some pain in my right knee and in both of my hands. Unlike the back pain, this pain comes and goes. It is not there all the time, only a few days per month. But it is also worse in the morning and gets better throughout the day.

Ask about morning stiffness in patients with chronic joint pain!

Review of systems specific to chronic back pain

• Trauma
• None.
• Fever/chills
• None.
• Night sweats
• None
• Fatigue
• Yes, I feel a bit more tired than usual.
• Rash/skin and nail changes
• No.
• Shortness of breath
• No.
• Urinary problems
• None.
• Bowel problems
• None.
• Appetite
• I have a normal appetite.
• Weight changes
• No.
• Recent infections
• Four months ago I had diarrhea that was treated with antibiotics.
• Eye problems
• None.
• Tingling sensation
• No.
• Muscle weakness
• No.
• Numbness (esp. in the lower limbs)
• No.
• Erectile dysfunction
• No.

Always ask about the red flags of lower back pain: fecal/urinary retention/incontinence, saddle anesthesia, progressive weakness, significant weakness localizing to a single nerve root, history or high risk of malignancy, fever, immunosuppression, and osteoporosis.

Past medical history, family history, and social history

• Past medical history
• As I told you, I had diarrhea 4 months ago after eating chicken. It was pretty awful and I was prescribed some antibiotics. And I have asthma.
• Allergies
• I am allergic to pollen.
• Medications
• I use a salbutamol inhaler.
• Hospitalizations
• Never.
• Past surgical history
• I had my appendix removed when I was 18 years old.
• Family history
• My mother has thyroid disease. She has to take some drugs because her thyroid is overactive. My father has psoriasis.
• Work
• I work as a software engineer.
• Home
• I live with my girlfriend.
• Alcohol
• I drink 1 or 2 beers on the weekends.
• Recreational drugs
• I smoke marijuana.
  • Marijuana consumption (duration, frequency, last use)
  • I have smoked twice per week for the past 5 years; the last time was 2 days ago.
• Tobacco
• Never.
• Exercise
• No, I do not have time to exercise.

A family history of psoriasis in a patient with joint pain makes psoriatic arthritis a possible differential. In some cases, arthritis can precede psoriatic skin eruptions.

Sexual history

• Sexually active
• Yes.
• With whom
• With my girlfriend.
• Number of partners over the past year
• 3 partners.
  • Protection
  • All my former partners, including my girlfriend, take birth control, so I don't need to wear a condom.
  • History of STI
  • No.

Back and joint pain can be a symptom of reactive arthritis. A brief sexual history should therefore be conducted in this patient.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the conjunctivae
  • Inspection of the oropharynx
• Back examination
  • Inspection of the back
  • Examination of the spine
  • Straight leg raise test (Lasegue sign)
    • Negative
  • Mennell sign
    • Positive
• Chest examination
  • Inspection of the chest
  • Palpation of the chest
  • Percussion of the lung fields
  • Auscultation of the lungs
• Skin examination
• Extremities
  • Inspection of the upper extremities
  • Inspection of the hands
  • Inspection of the lower extremities
  • Examination of the knee
  • Examination of the ankle
• Neurologic examination
  • Focused examination of passive and active motion
  • Focused examination of gait

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on recreational drugs.
• Examinee offered counseling on safer sex practices.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mr. Cooper, I can tell that you are really concerned that a lack of exercise might have caused your back pain. I would like to order some tests to get to the bottom of what exactly is causing your symptoms, but, based on what I have heard from you so far, I do not think that a lack of regular exercise caused your symptoms directly. However, as your physician I would like to advise you that regular exercise helps with overall fitness, can prevent progression of your symptoms, and might even improve your back pain. If you are interested, I would like to put you in contact with our physiotherapist, who can teach you some exercises and talk about what kind of activities might be best for you. Do you have any other questions?”

Patient note

Differentials

1. Ankylosing spondylitis: Ankylosing spondylitis is more commonly diagnosed in men , particularly men between the age of 15–40, and typically presents with progressive, dull back pain and morning stiffness. Dactylitis and arthritis of other joints, which are also seen in this patient, are less characteristic but can occur. The Mennell sign is often positive due to inflammatory changes of the sacroiliac joint (sacroiliitis) and the sacroiliac joints are tender to palpation, as is the case here.
2. Reactive arthritis: Reactive arthritis most commonly occurs in males 20–40 years of age following urethritis or bacterial enteritis and presents with symptoms similar to those seen in this patient, such as sacroiliitis, dactylitis, and polyarthritis. This patient has a history of unprotected sex as well as bacterial gastroenteritis 4 months ago, which is consistent with the latency period of reactive arthritis (1–4 weeks) before the onset of symptoms 3 months ago. However, his morning stiffness and the absence of dermatological, constitutional, and ocular symptoms are not typical for the condition.
3. Psoriatic arthritis: Psoriatic arthritis typically presents in individuals 20–40 years of age. Although it is usually preceded by the typical skin findings of psoriasis, in some cases arthritis can be the initial presenting sign of the disease. However, while dactylitis, oligoarthritis, and spinal involvement with sacroiliitis are common in psoriatic arthritis, and this patient has a family history of psoriasis, his morning stiffness and the absence of any other findings associated with psoriasis (e.g., scaly plaques, brittle nails) make this diagnosis less likely than the other two.

Diagnostic studies

• Genital examination: may show skin lesions of the glans in reactive arthritis
• CBC, ESR: Patients with reactive arthritis may have leukocytosis and normocytic normochromic anemia. ESR would likely be elevated in ankylosing spondylitis, reactive arthritis, and psoriatic arthritis.
• Rheumatoid factor, antinuclear antibodies, HLA-B27 testing: Autoantibodies are negative in ankylosing spondylitis, reactive arthritis, and psoriatic arthritis. HLA-B27 is positive in 90–95% of patients with ankylosing spondylitis and is also often positive in patients with reactive arthritis.
• Nucleic acid amplification tests for chlamydia and gonorrhea: to assess for chlamydial infection as a cause of reactive arthritis; patient should also be screened for gonorrhea given his history of unprotected sexual intercourse
• Stool and urine cultures: may detect causative organisms of reactive arthritis
• HIV test: history of unprotected sexual intercourse. Reactive arthritis might be the initial manifestation of HIV.
• X-ray of the spine and sacroiliac joints: to assess for a bamboo spine , which is a sign of ankylosing spondylitis, as well as syndesmophytes , ankylosing of the sacroiliac joints, and sacroiliitis , which can occur in both ankylosing spondylitis and psoriatic arthritis
• X-ray of the hands and right knee: to rule out degenerative changes; to assess for the pencil-in-cup deformity of fingers as a sign of psoriatic arthritis

Other differentials to consider

• Rheumatoid arthritis
• Spinal disc herniation
• Vertebral osteomyelitis
• Osteophytes of the spine
• See also differential diagnoses of low back pain.