USMLE Forum Archives - USMLE Step 2 CK - Back pain
Back pain
laparotomy - 02-02-08 00:19
A 64 year old male presents to your emergency department with a sudden onset of severe back pain. He does not remember but may have lifted something in a wrong way. Bp 130/85, P 87.
What is your next step in management?
A. Give analgesia and send home
B. Do an urgent MRI scan
C. Send straight to the OR for urgent discectomy
D. Do a CT to rule out an AAA
E. Other
laparotomy - 02-02-08 00:19
A 64 year old male presents to your emergency department with a sudden onset of severe back pain. He does not remember but may have lifted something in a wrong way. Bp 130/85, P 87.
What is your next step in management?
A. Give analgesia and send home
B. Do an urgent MRI scan
C. Send straight to the OR for urgent discectomy
D. Do a CT to rule out an AAA
E. Other
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#1
Re: Back pain radhamesramos - 02-03-08 19:32 First>: neurologic exam, if negative: give analgesia and send home, but a simple x-ray of the spine should be done first, to see any fracture or vertebral body compresion or any other affection of the vertebrae.
CT would be done if any positive neurologic finding
#3
Re: Back pain InSitu - 02-04-08 09:23 
posted by laparotomy on 02-02-08 00:19
A 64 year old male presents to your emergency department with a sudden onset of severe back pain. He does not remember but may have lifted something in a wrong way. Bp 130/85, P 87.
What is your next step in management?
A. Give analgesia and send home
B. Do an urgent MRI scan
C. Send straight to the OR for urgent discectomy
D. Do a CT to rule out an AAA
E. Other
A 64 year old male presents to your emergency department with a sudden onset of severe back pain. He does not remember but may have lifted something in a wrong way. Bp 130/85, P 87.
What is your next step in management?
A. Give analgesia and send home
B. Do an urgent MRI scan
C. Send straight to the OR for urgent discectomy
D. Do a CT to rule out an AAA
E. Other
Sudden and severe back pain with normal BP makes me think of a compression frature due to a tumor or mets to the spine (Porstate). Do MRI
#4
Re: Back pain taghrid - 02-04-08 10:32 You should do carefull examination to R/O disc compression, But if there is a history of trauma like lifting heavy object, I think the best thing is A give analgesics and send home.
#8
Re: Back pain
laparotomy - 02-07-08 08:31 posted by InSitu on 02-07-08 07:39
Waht is the answer laparotomy. :)
Waht is the answer laparotomy. :)
It is a tough one. There are two right answers.
1. The easy way out: Here you simply give him analgesia in a cocktail form, so 100mg Tramadol TDS PO, 75mg Diclofenac PO BD and Valium 2mg nocte for 10 days and if there is no improvement then you need to do further investigations like an MRI and possibly nerve root block or discectomy, depending on what you find.
2. But what I would do, (and this is simply because I am a catious guy/Doc), is to do an abdominal CT to rule out an abdominal aortic aneurysm. I know it is a long shot but if it does turn out to be a leaking AAA then it is a question of life or death. Leaking AAAs often present with new onset back pain.
And Oh yeah if the CT turns out negative then do 1. above.
#9
Re: Back pain laparotomy - 02-08-08 01:36 posted by laparotomy on 02-07-08 08:31
It is a tough one. There are two right answers.
1. The easy way out: Here you simply give him analgesia in a cocktail form, so 100mg Tramadol TDS PO, 75mg Diclofenac PO BD and Valium 2mg nocte for 10 days and if there is no improvement then you need to do further investigations like an MRI and possibly nerve root block or discectomy, depending on what you find.
2. But what I would do, (and this is simply because I am a catious guy/Doc), is to do an abdominal CT to rule out an abdominal aortic aneurysm. I know it is a long shot but if it does turn out to be a leaking AAA then it is a question of life or death. Leaking AAAs often present with new onset back pain.
And Oh yeah if the CT turns out negative then do 1. above.
It is a tough one. There are two right answers.
1. The easy way out: Here you simply give him analgesia in a cocktail form, so 100mg Tramadol TDS PO, 75mg Diclofenac PO BD and Valium 2mg nocte for 10 days and if there is no improvement then you need to do further investigations like an MRI and possibly nerve root block or discectomy, depending on what you find.
2. But what I would do, (and this is simply because I am a catious guy/Doc), is to do an abdominal CT to rule out an abdominal aortic aneurysm. I know it is a long shot but if it does turn out to be a leaking AAA then it is a question of life or death. Leaking AAAs often present with new onset back pain.
And Oh yeah if the CT turns out negative then do 1. above.
Ofcourse after an xray to rule out a fracture or mets...
#10
Re: Back pain rehaseen - 02-08-08 01:56 well the leaking AAA also present with the declining BP I think better take the complete history and do the examination before deciding for investigation/s and also give analgesics for the pain
#11
Re: Back pain laparotomy - 02-09-08 08:25 posted by rehaseen on 02-08-08 01:56
well the leaking AAA also present with the declining BP I think better take the complete history and do the examination before deciding for investigation/s and also give analgesics for the pain
well the leaking AAA also present with the declining BP I think better take the complete history and do the examination before deciding for investigation/s and also give analgesics for the pain
You know to be perfectly honest, medicine (and life) is not always clear cut like in the text books. I have seen acute appendicitis with left lower quadrant pain and very very mild almost non existing right lower quadrant pain, I have seen acute appendicitis with a normal WBC count, I have seen acute MI's with no symptoms apart from being just a bit weak, and I definately have seen leaking AAA's with normal BP. The BP crashes usually when it is too late....
I think it is of the essence to rule out the things that can kill you/the patient. But I do agree that some doctors treat patients the Casino way. That is they look at a patients symptoms and then think of what may be the most likely diagnosis and go by that. But you know this technique is good if you plan to practice medicine for 2 months and then go on to some thing else, but if you plan to practice medicine for a life time then the unexpected rare killer is bound to come some time and then neither the patient (his/her life) nor the lawyers will understand when you say..."Oh I did not think of a AAA because it is rare and usually presents with low BP"....
This is just what I feel.
But then again for simply USMLE purposes the answers need to be classical, you can never have a patient with left lower abdominal pain, very minimal RLQ pain, and high WBC count to be appendicitis, because it is not classical, but believe me in the real world it can happen....
#12
Re: Back pain InSitu - 02-09-08 09:06 like what Dr. Fischer said "In real life anything can be anything...but for board purposes its only one thing"
#13
Re: Back pain laparotomy - 02-10-08 01:20 posted by InSitu on 02-09-08 09:06
like what Dr. Fischer said "In real life anything can be anything...but for board purposes its only one thing"
like what Dr. Fischer said "In real life anything can be anything...but for board purposes its only one thing"
Exactly I also watched Conrad Fischer live during his lectures and remember him saying that...
#14
Re: Back pain laparotomy - 02-10-08 01:20 posted by laparotomy on 02-10-08 01:20
Exactly I also watched Conrad Fischer live during his lectures and remember him saying that...
Exactly I also watched Conrad Fischer live during his lectures and remember him saying that...
Sorry Dr. Conrad Fischer..or Conrad Fischer M.D
#15
Re: Back pain ammulufy - 06-29-10 20:51 First of all,LBP is a common phenomenon in dis age group.....however the term severe is been used which necessisates further evaluation.....moreover a BP of 130/80 in dis age group shud raise suspicion of a possible internal haemorrhage frm ruptured AAA leading to decreased BP.....derfore I go wid d option of doing CT to rule out AAA.....ie.....
#16
Re: Back pain bingousmle - 06-30-10 16:51 the old man has developed a sudden onset back pain without any identifiable source of injury, i think he should get a CT scan to r/o AAA
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