You are seeing Mr. Del Negro, an active 82 year old male in a walk-in clinic. He told your nurse that his back pain has recently become unbearable. Please take a focused history and perform a focused physical examination.
History
- Onset of back pain
- Location, and if pain is unilateral/bilateral
- Quality of pain (dull)
- Radiation of pain (none)
- Alleviating and aggravating factors
- Medications/therapies that have been attempted/are successful to relieve the pain
- Associated trauma or overuse injury
- Sensory loss (none)
- Parasthesia (none)
- Motor deficits (none)
- Fever, weight loss, or other systemic symptoms (none)
- Bladder or bowel incontinence
- Past history of back pain
- Personal history of peripheral vascular disease
- Smoking history (quantity in pack-years)
- Dyslipidemia
- Personal history of malignancy
- Effect on daily activities
Physical Examination
Inspection
- Comments on shape of spine – kyphosis, scoliosis, as well as posture
- Comments on any asymmetry of the back, including swelling, scars, or bruising
Range of Motion/Gait
- Observes all active ranges of motion for the back
- Assesses patient’s gait
Palpation
- Palpates along spinous processes and paraspinal muscles of the back for tenderness
- Performs straight leg raise on both sides, with and without ankle dorsiflexion (negative)
- Palpates peripheral pulses (present)
- States that an abdominal exam should be performed to rule out an abdominal aortic aneurysm
Neurological exam
- Tests foot sensation (L4, L5, S1)
- Tests for saddle anesthesia (S3, S4, S5)
- Tests knee (L4) and ankle reflex (S1)
- Tests Babinski response
- Tests power of big toe and foot dorsiflexion, as well as foot plantarflexion (S1)
- Assesses for hip abduction (L5); states that full hip examination should be performed
- States that rectal tone should be assessed
Case 4 – Worsening Back Pain