CSA Course Case Back Pain PDF

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CSA course case
CANDIDATES BRIEF
Patient medical records
Name: Luigi Bianco (42 year old)
Past medical history:

nil
Drug history: nil
Consultation (1 year ago)

Patient complaining of difficulty sleeping at night. Requesting short course of sleeping tablets. States
some relationship problems. Short course of zopiclone offered. Advised about side effects and use.
Avoid heavy machinery and driving.
Contact us: csaprep123@gmail.com visit us www.csaprep.co.uk

CSA course case Back pain - CSA prep 2011

CSA course case Back pain
ACTORS BRIEF
You are Luigi Bianco, a 42 year old man who works as an accountant in a large firm
Approach: You are dressed smartly but pressured for time. You want answers quickly
Opening statement: Doctor. You need to help me with my back!
History
Open history:
You complain of back pain that shoots down to your right foot that you have had for the last five days.
It is very painful and you want it sorted out as soon as possible
You are quite stressed at work as your employers are sacking people and you are worried you may be
next. Your work is very busy and you cannot be away from work for long periods of time. Already they
are harassing for you to return back
CUE: Only a week ago you were asked to move out your work colleagues furniture as he got the sack
If explored you remember that you were carrying a heavy table out of the room that you struggled to do
on your own. That could explain your symptoms
You want a sick note for the 5 days off you have had as your boss wants an explanation why you are
off
Reveal history if asked:
Ideas You do suspect sciatica (nerve root pain) but want to rule out possible lung cancer
Concerns you are worried you may have lung cancer as your father had similar pain and was
eventually diagnosed with lung cancer that had spread to the spine. You do not want to end up like my
dad. You do smoke and this has increased recently due to the stress
Expectations MRI scan of your body to rule out lung cancer and sick note for work
The pain is a sharp pain that goes down to your toe which is ever present.
It does not wake you up from sleep but is interfering with your work and preventing you from playing
weekly football that you do to escape from work
There are no red flag or neurological symptoms i.e. no weight loss, no power loss, pins and needles,
no loss of continence and no numbness over his buttocks, no cough, no shortness of breath, no
haemoptysis, no chest pain
If doctor offers self certification, state: My boss is never going to accept that. You would accept a
private certificate begrudgingly. If offers sick note you would like to have 1 month and back dated
If doctor reassures you that you do not have lung cancer, accept this if adequate explanation has been
offered. However request an explanation of what problem he has i.e. sciatica
If doctor offers chest x-ray, be adamant you want an MRI as an x-ray is useless and you can get that
for free

If doctor offers simple analgesia (paracetamol or ibuprofen) state these do not work on me. They are
like eating peanuts!
Leave the consultation discontent regardless of outcome however more so if not engaged
Medical history
Nil otherwise
Drug history
Nil. No previous allergies
Social history
You smoke 5 cigarettes a day for the last 10 years but the last 6 months this have gone up to 10 a day
You do not drink alcohol
You live alone and broke up from your partner 1 year ago - but do not want to explore this
You play football once a week with friends
Family history
Lung cancer dad aged 76



EXAMINER
DATA GATHERING
Positive indicators:
Use open questions to clarify the problem and establishes detailed history of nature of back pain
Takes detail history to include red flag symptoms i.e. nocturnal pain, weight loss, sphincter
disturbance, saddle paraesthesia
Performs focused examination (inspects back, examines forward, lat flexion, SLR and ankle reflexes)
Negative indicators:
Fails to exclude potential serious complications i.e. cauda equina
Fails to perform focused examination
INTERPERSONAL SKILLS
Explores ICE (concerns of cancer) and psychosocial history (cannot play football)
Picks up and addresses verbal (moving furniture) and non-verbal cue (pressure for time)
Reassure patient no evidence from history or examination to suspect cancer
An explanation that currently no need for investigations at current stage
Offer suitable explanation of likely diagnosis sciatica rather than lung cancer
From the symptoms you have described as well as the examination findings it appears that you are
experiencing sciatica. This is where you have a trapped nerve where a nerve emerging from the
spinal cord is irritated and compressed. Often the pain goes down your leg and into the foot
Fails to adopt empathic approach
Does not explore underling issues or concern i.e. patient smoking and worried of FH of lung cancer
Offers unrealistic advice or management Strong opioid and immediate MRI scan
CLINICAL MANAGEMENT SKILLS:

Offers treatment options i.e. continue to mobilisation, safe lifting, physiotherapist if persisting, contact
occupational health if persists
Offers analgesia simple to consider or codeine based medication - cocodamol
Offers self certification or private certification. Can offer short sick note with review not back dated
Follow up is offered to monitor situation and safety netting advice warning symptoms


Fails to offer suitable management plan or negotiate one
MRI scan is offered instantly


CSA course case
CARDS
Examination card
Good ROM in back (lateral & forward flexion of spine)
SLR 50 degrees on the right, and 80 on left
Reflexes normal
Difficulty walking on heels


APPROACH
HISTORY
Enquire about the presenting complaint by starting off asking several open questions before asking a few
select closed questions:
Open questions
Can you tell me more about your back pain?
Closed questions
History
When did it first start? Were you carrying or lifting anything heavy at the time? Did you
fall down or injure your back?
Pain
Where is the pain located? Does the pain move anywhere? How severe is the pain
(out of 10)? Did it come on suddenly or gradually? What does the pain feel like? Is it
there during a particular time of day?
RED FLAGS
Pain
Severe night pain, thoracic pain
Age
Less than 20 or older than 50 years of age
Cancer
Past medical history of cancer, weight loss
Unwell
Systematically unwell, fever
Cauda equina
Saddle paraesthesia, bladder urinary retention or incontinence, bowel faecal

incontinence, leg weakness
Other
HIV, steroids
YELLOW FLAGS
Psychological and social reasons that may make acute back pain develop into a chronic problem & disability
Social
Financial, relationship problems
Mood
Anxieties, stressed, social withdrawn
DRUG HISTORY
Medication
Are you taking anything for the pain?
PAST MEDICAL HISTORY

Previous
Have you suffered from back pain in the past?
Surgery
Have you had any previous operations (back surgery)?
SOCIAL HISTORY
Home
How are things at home (home circumstance)? Who lives with you?
Work
Do you have any problems at work with your back pain?
IDEA, CONCERNS, EXPECTATIONS


Idea
What did you think was causing your back pain?
Concerns
Do you have any particular worries about it?
Expectations
How were you hoping I could help you with it (investigation/pain relief)?
Impact on life
How has your back problem affected you (walk/employment)?
PHYSICAL EXAMINATION (3 minute)

Consent
Explain the examination to the patient and seek consent

I would like to perform a quick examination of your back to find out the cause of the pain.
This will involve walking up and down the room as well as carrying out a few commands
which I will show you. I will also need you to lie on the couch and assess the strength and
reflexes in your legs
Expose
Ask the patient if they can undress to their undergarments
Gait
Ask the patient if they could walk to the end of the room and return back
Look
Inspect the patients back whilst standing. Observe the skin, shape and posture
Signs to Observe in the Back Examination

Skin
Muscle
Posture
Scars, pigmentation, abnormal hair (spina bifida), unusual skin creases

Wasting
(paravertebral, gluteal muscles), fasciculations
Scoliosis
Lateral curvature of the spine
Kyphosis
Undue bending of the spine
Kyphos
Sharp bend of the spine
Lordosis
Hollowing of the lumbar spine
Asymmetry Chest, trunk or pelvis (may appear with patient leaning forwards)
Feel
Palpate the spine over the spinous processes, paraspinal muscles and sacro iliac joints
Move
Ask the patient to replicate your movements. Note for any limited range of movement or the
citing of pain during a movement
Extension
Stand behind the patient and ask them to lean backwards as far as they can
Flexion
Ask the patient to touch their toes while keeping their knees straight
Lat. flexion Ask the patient to slide their right hand down their right leg. Repeat on the other side
Leg raising With the patient lying supine, lift their foot off the couch keeping the leg straight. Note the
angle at which the patient experiences pain and then repeat the test for both legs. Test is

positive if the patient has pain on the affected side within the sciatic distribution between 30 70 degrees of passive flexion
Normal
Ask the patient to lie completely flat on their
back with their legs straight
Sciatic Stretch test

Patient is unable to raise their leg beyond a
certain angle due to the tension of the root by
the prolapsed disc
Neurology
Power
Checking for neurology may only be indicated if the patient reports neurological symptoms
Ask the patient to walk on their heels foot dorsiflexion, (L4/5)
Ask the patient to walk on their toes foot plantar flexion, (L5/S1)
Sensation
Perform a sensory examination if patient reports sensory loss or altered sensation
Reflexes
Perform focused reflex assessment depending on history. If patient reports sciatic pain
radiating to foot consider performing ankle reflex (S1) only. If pain only radiates to thigh
perform knee reflex (L3/L4). PR only indicated if cauda equina suspected
Neurological Signs of Back Pain based on Nerve Root

Root
L3
L4
L5
S1
Sensory loss
Inner thigh
Ant. Aspect of knee
Dorsum of foot
Lat aspect of foot
Weakness
Knee extension
Knee ext.+foot dorsiflexion
Foot + big toe dorsiflexion
Foot plantarflexion
Reflex loss
Knee
Knee
None
Ankle
Special test
+ve femoral stretch test
+ve femoral stretch test
+ve sciatic stretch test
+ve sciatic stretch test
INVESTIGATIONS
Bloods
FBC, ESR & rheumatoid factor (AS), bone profile, PSA (elderly)
Scan
X-ray: not routinely done in non-specific back pain. young (sacroiliac joints AS),
elderly (vertebral collapse), trauma
MRI (malignancy, infection, cauda equina, fracture), Bone scan (osteoporosis)
MANAGEMENT
Conservative management
Advice
Self help
Avoid prolonged bed rest and return to normal activities (including work) as soon as
possible. Increase physical activities over a few days or weeks. Avoid unsupported
sitting or heavy lifting.
Can contact self help groups: Backcare - The National Back Pain Association

Exercises
If not returned to normal activities structured exercise programmes should be

considered
Manipulation
Considered within first 6 weeks for those requiring not returning to normal activities
(physiotherapist, chiropractor, osteopath)
Acupuncture
Limited availability on NHS (chronic back pain)
Social
Sick note for period to recover can contact occupational health (ergonomic chairs),
advise about driving. Explore social aspect - CBT
Medical management
Analgesia
Initiate with paracetamol

2nd line consider NSAIDS (add PPI if >45 yr old)
Codeine based medication (codydamol, cocodamol)
Tricyclic antidepressants if others fail. Strong opioids for short period only
Muscle relaxant (diazepam) if back muscles spasm for short period only
Refer
Pain clinic (epidural), orthopaedic/neurosurgeon or rheumatology if not responding

after 6 weeks
Safety net
Cauda equina symptoms refer urgently


MANAGMENT NOTES
Prolapsed Disc
This is where you have a trapped nerve where a nerve emerging from the spinal cord is irritated and
compressed. Often the pain goes down your leg and into the foot and causes pin and needles. This is often
caused by a prolapsed or slipped disc. However, the disc has not really slipped rather a soft inner part of
the disc bulges out through the harder outer layer and irritates the nerve causing the pain
Prolapsed disc is a common cause of severe lower back pain. The prolapsed disc often presses upon a
nerve root which causes the pain and symptoms in the lower leg
Commonest sites include L4/5 and L5/S1 disc areas
Presents with back pain when patient lifts a heavy object with difficulty to straighten back thereafter
Sciatic leg pain (sciatica) characterised by severe pain localised in the lumbar region radiating to either
leg. Both the back pain as well as sciatica can be reproduced by coughing, sneezing or straining
Patients may stand with a list to one side, have limitation of spinal forward flexion and extension of the
back with tenderness of the lower vertebrae and paravertebral muscles.
The SLR test is limited often to the affected side
Treat as for mechanical back pain


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CSA scenarios with REAL CSA actors

As close to the CSA exam as possible

Book your place on the course NOW

CSA course case

Patient medical records

Name: Luigi Bianco (42 year old)

Past medical history:

Drug history: nil

Consultation (1 year ago)

Contact us: csaprep123@gmail.com visit us www.csaprep.co.uk

CSA scenarios with REAL CSA actors

As close to the CSA exam as possible

Book your place on the course NOW