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)

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.

Tell him to stop experimenting with autofellatio.:D

Patient denies adventurous solo sexual activity.

:D

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....


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....

Flexion is more painful than extension, but no position brings total relief.

Negative.

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)?

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. :D

I love it when you talk dirty. :D

lol Kiss my coccyx (if you can find it). :D

There is no particular incident that stands out in the patient's mind, although you have been training hard for the past few days.

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).

The pain is constant.

OUCH.

I wrote the scenario because most of the time, LBP is just LBP, except when it isn't.

Any increased/unusual bruising, nosebleeds or other abnormal bleeding? Any pallor, decreased exercise intolerance/dyspnea on exertion?

Negative

Negative

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.