MS2.2 PCC Case Review 1

Below are some notes regarding cases I saw in my family medicine rotation yesterday.

• Chronic Lower Back Pain
  • HPI
    • Review of systems
  • Objective
    • Physical Exam
    • Diagnostic data
  • Assessment
  • Plan

Chronic Lower Back Pain

X is a 28 year old female presenting with 14 years of progressive, chronic lower back pain and stiffness, with recent increased frequency of acute exacerbations.

HPI

Symptoms began following a fall on her back 14 years ago. She currently describes a baseline of prolonged morning stiffness lasting ~20 minutes, along with recurrent exacerbations of 6/10 pain localized to the lower back. These episodes are often triggered by movement from prolonged static positions. She experiences occasional tingling and numbness that radiates down her legs that alternates legs, depending on which side of her back is most painful.

Her pain follows a mechanical and cyclic pattern. Exacerbating factors include prolonged static postures, heavy exertion, and spinal flexion (more so than spinal extension). She has had one exacerbation that was triggered by sneezing. Her symptoms worsen during menses, after which they return to her usual chronic baseline.

Palliating factors include light movement and heat packs. She has tried acetaminophen, ibuprofen, and chiropractic interventions, but these were ineffective.

For the past month, she has had prolonged sleep latency (1-2 hours) and middle-of-night awakening, both occurring most days of the week. She attributes her sleep changes to increased stress from her studies as a respiratory therapy student.

Past medical history is significant for nephrectomy 4 years ago for renal cancer (? stage and surveillance history). Prior CT showed findings suggestive of possible endometriosis. Pelvic ultrasound is pending.

Family history is significant for gallbladder or biliary cancer in her mother (patient is uncertain), and chronic low back pain in her father (patient is uncertain).

She takes no medications or supplements. Smoking, alcohol, and recreational drug use were not assessed.

Questions based on Ddx:

• Inflammatory back pain:
  • Denies waking up from pain in the middle of the night
  • Unclear:
    • whether improvement occurs with exercise (+/- warm showers) in addition to light movement
    • whether pain moves from one buttock to the other, and over what time range (alternating buttock pain in ankylosing spondylosis)
    • whether pain in addition to stiffness are worse during the morning or night
• Endometriosis:
  • Denies changes/pain to bowel movements and urination
  • Unclear:
    • severity of dysmenorrhea?
    • infertility concerns?
• Spondyloarthritis:
  • Denies family history of arthritis, psoriasis, IBD, other autoimmune conditions
  • Denies history of uveitis, psoriasis, IBD symptoms

Review of systems

• Constitutional: denies fever, chills, night sweats, unintended weight loss, generalized fatigue; reports proonged sleep latency and middle of night awakenings.
• MSK: denies joint swelling, redness, or warmth in peripheral joints; denies symptoms in neck or upper extremity.
• Neurologic: denies muscle weakness, drop foot, or changes in coordination or gait; denies sensory changes, including saddle anesthesia; denies changes to bowel or bladder incontinence
• Gastrointestinal: denies abdominal pain, nausea, or vomiting
• Dermatologic: denies rashes, photosensitivity, skin ulcers, hair loss, or nail changes
• Hematologic: denies easy bruising, bleeding, or localized lymphadenopathy
• Pyschiatric: symptoms of depression/anxiety were not assessed
• Gynecologic: menses are heaviest and most painful on the first day; often irregular; no history of pregnancy

Objective

Physical Exam

On physical exam, the patient appears well and in no acute distress. There is notable tenderness over the midline sacrum and bilateral paraspinal sacral regions.

• Neurological: straight leg raise test is negative; lower extremity motor strength is 5+ bilaterally; lower extremity sensation is intact bilaterally; patellar reflexes are 2+ bilaterally.
• MSK: FABER test elicited pain in the posterolateral hip bilaterally.

Tests not performed:

• Spinal mobility: Schober, lateral flexion, chest expansion
• Pelvic exam: uterosacral nodularity, adnexal masses

Diagnostic data

She reports being seen by multiple physicians over the years, and was told her symptoms were due to soft tissue injury or muscle pain. She recalls receiving a spine X ray many years ago that found no abnormalities.

Assessment

Plan

Initial imaging with AP pelvis/SI joint X rays. If radiographs negative but suspicion remains high for axial spondyloarthritis or spinal metastases, MRI of spine and sacroiliac joints with contrast. Given menstrual pain pattern and prior CT findings suggestive of endometriosis, expedite pelvic ultrasound.

Initial labs include CBC, renal function, ESR/CRP for inflammation, and HLA-B27 for axial spondyloarthritis.

Counsel patient to avoid actions/movements that exacerbate symptoms, e.g. prolonged sitting or standing, forward bending, and heavy exertion. Counsel on sleep hygiene and stress reduction strategies.

Counsel patient to return (and order emergent MRI) if red flag symptoms arise: new/progressive sensory or motor deficits, including saddle anesthesia and bowel/bladder dysfunction; unexplained weight loss, fever, or night pain.

Consider rheumatology referral if inflammatory features (elevated CRP/ESR, rashes, etc.) present or imaging shows sacroiliitis.