Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in General Practice. Your next patient is a 51-year-old woman called Rebecca Black, presenting with lower back pain. Please take a history and perform an appropriate examination.
Patient History:
Rebecca Black, a 51-year-old female, nurse
You have always been having lower back pain for the past few years, but this has been getting gradually worse. The pain is dull and intermittent. Very often, the pain can diffuse and radiate towards the buttocks, back of the thighs, and feet - when this happens, the pain feels like a burning or cramping sensation. It can be associated with weakness in both legs. The symptoms can be triggered or worsened by sitting down, standing straight and walking downhill. It goes away after a few minutes after being at rest. Bending forward improves symptoms. You tried paracetamol, which only helped a little with pain.
If you walk for more than 50 yards, you will start noticing numbness and weakness in your legs.
No previous injury/trauma. Waterworks normal. The bowels are working normally. No other abnormal sensations or weaknesses. No incontinence. No stiffness. No fever. No weight loss. No night sweats.
Ideas, Concerns, Expectations:
You think because you often have to bend your back due to work, the pain may be caused by poor posture. You are concerned because it is starting to affect your ability to work in the hospital as a nurse. You would like to see if you can get stronger painkillers and possibly have a scan of your back.
Past Medical History:
Obesity, hypercholesterolemia, acromegaly, T2DM.
No past relevant surgical history.
Drug History:
Atorvastatin, metformin NKDA.
Family History:
Father has ankylosing spondylitis.
Social History:
You work as a senior nurse in a local hospital.
You smoke around ten cigarettes daily for over ten years but don't drink alcohol.
Live with husband in a semi-detached house.
Independent.
Examination Findings:
Lower spinal tenderness on palpation at L4-5 region.
Complete motor and sensory neurological examinations are normal.
Features of acromegaly e.g. enlarged hands, feet and facial features.
Lower limb vascular examination is normal.
No cervical tenderness or restricted movement. Gait normal.
No cauda equina syndrome features.
Peripheral pulses and ABPI normal.
Differentials:
Lumbar spinal stenosis - likely to be due to degenerative changes
Osteoarthritis of the spine
To rule out cauda equina syndrome
Ankylosing spondylitis/spondylolisthesis
Rule out peripheral arterial diseases
Other causes of back pain: spinal tumour, disc herniation, trauma, fracture, and epidural abscess.
Investigations:
Imaging:
XR Lumbar spine (may show degenerative changes/spondylolisthesis)
MRI Spine. Alternatively, CT myelography/spine when MRI is not available or unsuitable.
Consider ABPI / CT angiogram to exclude peripheral arterial disease where intermittent claudications are present.
Special tests:
Consider electromyographic (EMG) walking test - increased F latency values in lumbar spinal stenosis
Consider electromyographic paraspinal mapping