STUDY - Technical - New Dacian's Medicine
back
pain (Classical / Allopathic Medicine)
Back pain affects
about 80% of the U.S. population, and it's the second-leading
reason - after the common cold - for lost time from work.
Although this symptom may herald a spondylotic disorder, it
may also result from a genitourinary, GI, cardiovascular, or
neoplastic disorder. Postural imbalance associated with
pregnancy may also cause back pain.
The onset,
location, and distribution of pain and its response to
activity and rest provide important clues about the causative
disorder. Pain may be acute or chronic, constant or
intermittent. It may remain localized in the back or radiate
along the spine or down one or both legs. Pain may be
exacerbated by activity - usually, bending, stooping, or
lifting - and alleviated by rest, or it may be unaffected by
both.
Intrinsic back
pain results from muscle spasms, nerve root irritation,
fracture, or a combination of these mechanisms. It usually
occurs in the lower back or lumbosacral area. Back pain may
also be referred from the abdomen or flank, possibly signaling
a life-threatening perforated ulcer, acute pancreatitis, or a
dissecting abdominal aortic aneurysm.
ALERT:
If the patient reports acute, severe back pain:
- take his vital signs
- ask him when the pain began and if he can relate it to a cause.
If the patient describes deep lumbar pain unaffected by activity:
- palpate for a pulsating epigastric mass; if this sign is present, suspect dissecting abdominal aortic aneurysm.
If the patient describes severe epigastric pain that radiates through the abdomen to the back:
- assess him for absent bowel sounds and for abdominal rigidity and tenderness; if these occur, suspect a perforated ulcer or acute pancreatitis.
If life-threatening causes of acute back pain are ruled out, perform a focused assessment.
If the patient reports acute, severe back pain:
- take his vital signs
- ask him when the pain began and if he can relate it to a cause.
If the patient describes deep lumbar pain unaffected by activity:
- palpate for a pulsating epigastric mass; if this sign is present, suspect dissecting abdominal aortic aneurysm.
If the patient describes severe epigastric pain that radiates through the abdomen to the back:
- assess him for absent bowel sounds and for abdominal rigidity and tenderness; if these occur, suspect a perforated ulcer or acute pancreatitis.
If life-threatening causes of acute back pain are ruled out, perform a focused assessment.
HISTORY:
Review the patient's medical history for past injuries and illnesses, and ask the patient for family history.
Ask the patient about activities that may affect the back.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
Ask the patient to describe the pain. Is it burning, stabbing, throbbing, or aching? Is it constant or intermittent? Does it radiate to the buttocks or legs? Any leg weakness? Or does the pain seem to originate in the abdomen and radiate to the back?
Ask the patient about unusual sensations in his legs, such as numbness and tingling.
Ask the patient if he has had pain like this before.
Ask the patient if anything makes it better or worse. Is it affected by activity or rest? Is it worse in the morning or evening? Does it wake him up?
Review the patient's medical history for past injuries and illnesses, and ask the patient for family history.
Ask the patient about activities that may affect the back.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
Ask the patient to describe the pain. Is it burning, stabbing, throbbing, or aching? Is it constant or intermittent? Does it radiate to the buttocks or legs? Any leg weakness? Or does the pain seem to originate in the abdomen and radiate to the back?
Ask the patient about unusual sensations in his legs, such as numbness and tingling.
Ask the patient if he has had pain like this before.
Ask the patient if anything makes it better or worse. Is it affected by activity or rest? Is it worse in the morning or evening? Does it wake him up?
PHYSICAL
ASSESSMENT:
Observe skin color, especially in the patient's legs, and palpate skin temperature.
Palpate femoral, popliteal, posterior tibial, and pedal pulses.
Observe the patient's posture, if possible.
Observe the level of the shoulders and pelvis and the curvature of the back.
Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note the rotation of the spine on the trunk.
Palpate the dorsolumbar spine for point tenderness.
Ask the patient to walk - first on his heels, then on his toes.
Place the patient in a sitting position to evaluate and compare the patellar tendon, Achilles tendon, and Babinski's reflexes.
To reproduce leg and back pain, place the patient in the supine position on the examination table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica.
Note the range of motion of the hip and knee.
Observe skin color, especially in the patient's legs, and palpate skin temperature.
Palpate femoral, popliteal, posterior tibial, and pedal pulses.
Observe the patient's posture, if possible.
Observe the level of the shoulders and pelvis and the curvature of the back.
Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note the rotation of the spine on the trunk.
Palpate the dorsolumbar spine for point tenderness.
Ask the patient to walk - first on his heels, then on his toes.
Place the patient in a sitting position to evaluate and compare the patellar tendon, Achilles tendon, and Babinski's reflexes.
To reproduce leg and back pain, place the patient in the supine position on the examination table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica.
Note the range of motion of the hip and knee.
SPECIAL
CONSIDERATIONS:
Until a tentative diagnosis is made, withhold analgesics, which may mask symptoms. Also withhold food and fluids in case surgery is necessary.
Be aware that back pain is notoriously associated with malingering.
Until a tentative diagnosis is made, withhold analgesics, which may mask symptoms. Also withhold food and fluids in case surgery is necessary.
Be aware that back pain is notoriously associated with malingering.
PEDIATRIC
POINTERS:
Because a child may have difficulty describing back pain, be alert for nonverbal clues, such as wincing or refusing to walk.
While taking the patient's history, closely observe family dynamics for clues suggesting child abuse.
Back pain in a child may stem from intervertebral disk inflammation (diskitis), a neoplasm, idiopathic juvenile osteoporosis, or spondylolisthesis.
Because a child may have difficulty describing back pain, be alert for nonverbal clues, such as wincing or refusing to walk.
While taking the patient's history, closely observe family dynamics for clues suggesting child abuse.
Back pain in a child may stem from intervertebral disk inflammation (diskitis), a neoplasm, idiopathic juvenile osteoporosis, or spondylolisthesis.
AGING ISSUES:
Suspect metastatic cancer, especially of the prostate, if the patient is older than age 55 with a recent onset of back pain that usually isn't relieved by rest and worsens at night.
Suspect metastatic cancer, especially of the prostate, if the patient is older than age 55 with a recent onset of back pain that usually isn't relieved by rest and worsens at night.
PATIENT
COUNSELING:
Teach the patient pain-relief measures as an alternative to taking an analgesic. Refer the patient to physical therapy, occupational therapy, a psychologist, or support groups, as appropriate.
Teach the patient pain-relief measures as an alternative to taking an analgesic. Refer the patient to physical therapy, occupational therapy, a psychologist, or support groups, as appropriate.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)