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Old 12-04-2013, 07:45   #1
ender18d
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Team Sergeant with Low Back Pain

Scenario:
You and your team are deployed to train a special operations element of a friendly host nation in CQB techniques. Your team picked up this mission at the last minute, and there was something of a rush to get everything and everyone ready for deployment. The only other US medical asset in country is a family medicine physician at the embassy 3-4 hours away by truck. The host nation medical system is… not providing a standard of care with which you feel comfortable.

You’ve been in country for about a week when your team sergeant pulls you aside and asks you for some “Motrin.” Being a good medic, you ask him why he wants the ibuprofen, and he tells you that he has some “low back pain.”

I will give you the following:

The patient WDWN 45 y/o steely-eyed barrel-chested team sergeant in moderate distress.

C/C: “Low back pain”
O: “It’s been kinda funky for the past few days but it’s really pissing me off now.”
P: “No, nothing seems to help. Running around in full kit hurts.”
Q: “Sharp”
R: “The pain doesn’t seem to go anywhere else but my back.”
S: “Its pretty f’ing bad or I wouldn’t be asking you for meds.”
T: “It hurts pretty constantly.”

What other questions do you want to be sure to ask this patient as part of the history? What “red flags” in the history would differentiate a typical lumbago from something more serious? (physical exam will come after we discuss history)
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Old 12-04-2013, 08:25   #2
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Any numbness/tingling/weakness in the legs?

Change in bowel and urinary frequency (both increased and decreased)? Any bowel or bladder incontinence?
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Old 12-04-2013, 08:28   #3
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Quote:
Originally Posted by PedOncoDoc View Post
Any numbness/tingling/weakness in the legs?

Change in bowel and urinary frequency (both increased and decreased)? Any bowel or bladder incontinence?
Patient denies all of the above.
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Old 12-04-2013, 08:32   #4
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Tell him to stop experimenting with autofellatio.
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Old 12-04-2013, 08:41   #5
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Tell him to stop experimenting with autofellatio.
Patient denies adventurous solo sexual activity.

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Old 12-04-2013, 08:52   #6
ender18d
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Originally Posted by DocIllinois View Post
At first glance, he's 45 y.o., for pete's sake. Spinal joints are beginning a normal process of degeneration, especially after a lifetime of heavy duty physical stuff.
This is of course the most likely etiology for low back pain in this demographic. Part of the reason for the scenario is that this is a common thing medics see all the time, but there are some things you don't want to miss....


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But...

Has this ever happened before?
The patient has had lower back pain before. "he's 45 y.o., for pete's sake." But now that you mention it this seems different....

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Is there any position or action that makes the pain worse?
Flexion is more painful than extension, but no position brings total relief.

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Originally Posted by DocIllinois View Post
Any trouble urinating (blood in urine, painful micturition)?
Negative.
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Last edited by ender18d; 12-04-2013 at 08:54.
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Old 12-04-2013, 09:12   #7
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Did he first notice this pain during/after any particular activity (or trauma)?

Where on his back does it hurt?

Is the pain constant or intermittent (crampy/colicky)?
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Old 12-04-2013, 09:12   #8
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Happened to me.

Turned out, I had a Pars defect in the L5, subjugal and degenerative arthritis, spondylolithesis at the sacral plane, and my coccyx was broken off and just dangling there.

Subsequent irradiation discovered a cervical fracture.

My first soap reads: "SM snivelling about sharp lower back pain", or something like that.
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Old 12-04-2013, 09:16   #9
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Quote:
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...and my coccyx was broken off and just dangling there.
I love it when you talk dirty.
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Old 12-04-2013, 09:17   #10
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I love it when you talk dirty.
lol Kiss my coccyx (if you can find it).
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Old 12-04-2013, 09:19   #11
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Quote:
Originally Posted by PedOncoDoc View Post
Did he first notice this pain during/after any particular activity (or trauma)?
There is no particular incident that stands out in the patient's mind, although you have been training hard for the past few days.

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Where on his back does it hurt?
When asked, the patient points to an area you approximate as L3/L4. (more details will be available when we get to physical, but I want to cover history thoroughly first).

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Is the pain constant or intermittent (crampy/colicky)?
The pain is constant.
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Old 12-04-2013, 09:23   #12
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Quote:
Originally Posted by Dusty View Post
Happened to me.

Turned out, I had a Pars defect in the L5, subjugal and degenerative arthritis, spondylolithesis at the sacral plane, and my coccyx was broken off and just dangling there.

Subsequent irradiation discovered a cervical fracture.

My first soap reads: "SM snivelling about sharp lower back pain", or something like that.
OUCH.

I wrote the scenario because most of the time, LBP is just LBP, except when it isn't.
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Old 12-04-2013, 09:30   #13
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Any increased/unusual bruising, nosebleeds or other abnormal bleeding? Any pallor, decreased exercise intolerance/dyspnea on exertion?
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Old 12-04-2013, 09:33   #14
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Quote:
Originally Posted by PedOncoDoc View Post
Any increased/unusual bruising,
Negative

Quote:
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nosebleeds or other abnormal bleeding?
Negative

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Originally Posted by PedOncoDoc View Post
Any pallor, decreased exercise intolerance/dyspnea on exertion?
The patient does appear slightly pale, and admits that he's been feeling like he's "lost a step" the past few days during training, not entirely due to the pain.
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Old 12-04-2013, 09:36   #15
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Any fevers or night sweats?

What medications is he taking (including antimalarials/prophylactic medications deemed necessary for the AO)?
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‎"The dignity of man is not shattered in a single blow, but slowly softened, bent, and eventually neutered. Men are seldom forced to act, but are constantly restrained from acting. Such power does not destroy outright, but prevents genuine existence. It does not tyrannize immediately, but it dampens, weakens, and ultimately suffocates, until the entire population is reduced to nothing better than a flock of timid, uninspired animals, of which the government is shepherd." - Alexis de Tocqueville
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