Team Sergeant with Low Back Pain
 

Scenario:
You and your team are deployed to train a special operations element of a friendly host nation in CQB techniques. Your team picked up this mission at the last minute, and there was something of a rush to get everything and everyone ready for deployment. The only other US medical asset in country is a family medicine physician at the embassy 3-4 hours away by truck. The host nation medical system is… not providing a standard of care with which you feel comfortable.

You’ve been in country for about a week when your team sergeant pulls you aside and asks you for some “Motrin.” Being a good medic, you ask him why he wants the ibuprofen, and he tells you that he has some “low back pain.”

I will give you the following:

The patient WDWN 45 y/o steely-eyed barrel-chested team sergeant in moderate distress.

C/C: “Low back pain”
O: “It’s been kinda funky for the past few days but it’s really pissing me off now.”
P: “No, nothing seems to help. Running around in full kit hurts.”
Q: “Sharp”
R: “The pain doesn’t seem to go anywhere else but my back.”
S: “Its pretty f’ing bad or I wouldn’t be asking you for meds.”
T: “It hurts pretty constantly.”

What other questions do you want to be sure to ask this patient as part of the history? What “red flags” in the history would differentiate a typical lumbago from something more serious? (physical exam will come after we discuss history)

Any numbness/tingling/weakness in the legs?

Change in bowel and urinary frequency (both increased and decreased)? Any bowel or bladder incontinence?

Patient denies all of the above.

Tell him to stop experimenting with autofellatio.:D

Patient denies adventurous solo sexual activity.

:D

This is of course the most likely etiology for low back pain in this demographic. Part of the reason for the scenario is that this is a common thing medics see all the time, but there are some things you don't want to miss....


The patient has had lower back pain before. "he's 45 y.o., for pete's sake." ;) But now that you mention it this seems different....

Flexion is more painful than extension, but no position brings total relief.

Negative.

Did he first notice this pain during/after any particular activity (or trauma)?

Where on his back does it hurt?

Is the pain constant or intermittent (crampy/colicky)?

Happened to me.

Turned out, I had a Pars defect in the L5, subjugal and degenerative arthritis, spondylolithesis at the sacral plane, and my coccyx was broken off and just dangling there.

Subsequent irradiation discovered a cervical fracture.

My first soap reads: "SM snivelling about sharp lower back pain", or something like that. :D

I love it when you talk dirty. :D

lol Kiss my coccyx (if you can find it). :D

There is no particular incident that stands out in the patient's mind, although you have been training hard for the past few days.

When asked, the patient points to an area you approximate as L3/L4. (more details will be available when we get to physical, but I want to cover history thoroughly first).

The pain is constant.

OUCH.

I wrote the scenario because most of the time, LBP is just LBP, except when it isn't.

Any increased/unusual bruising, nosebleeds or other abnormal bleeding? Any pallor, decreased exercise intolerance/dyspnea on exertion?

Negative

Negative

The patient does appear slightly pale, and admits that he's been feeling like he's "lost a step" the past few days during training, not entirely due to the pain.

Any fevers or night sweats?

What medications is he taking (including antimalarials/prophylactic medications deemed necessary for the AO)?

The patient admits that he has felt a bit hot and woken up in sweaty sheets, but attributed it to the "God-forsaken climate in this @#$hole of a country."

Current Meds:
Lisinopril
Atovaquone/Proguanil
Various nutritional supplements for weight-lifting

Covered above.

Alright, lets start the physical exam. Your visual examination of the lower back is unremarkable.

"Dad always had lower back pain, and mom had RA."

No.

Has urine been darker?

If you're moving into exam - CVA tenderness? Distribution of tenderness on palpation of the back (over the spine, paraspinous muscles, etc?)

Can we look at the shoulders for evidence of petechiae/bruising?

No CVA tenderness.
The patient is exquisitely tender on the vertebral prominence of L3 & L4 with a conspicuous absence of tenderness in the paraspinous muscles. Shoulder exam unremarkable.

See above.

BP 130/85
HR 90

What exactly are you checking with valsalva? There are a number of possible PE techniques with valsalva. Are you checking volume status?

Straight leg raise results in mild bilateral hamstring pain w/o paresthesias radiating below the knee.

I noticed that the Hx kind of bypassed the time frame for this attack (onset, severity increase over time, and loss of mobility over time, what helps what aggravates), and the timing/severity of other similar attacks for the Pt... Are the attacks consistent, when was the first remarkable attack he can remember, excluding 'normal' training pain. Have there been any remarkable changes in activity, medication, hydration. Has the Pt been at depth or altitude for long periods in the recent past? Do altitude or depth change the symptomology? We know the big green tick or armor will change things / aggravate symptomology, but.... to what degree has this changed, and does it scale the pain or refer it to other areas. What are the postural locations that aggravate or relieve symptomology, in any degree.

Ok, those are my add ons to the Pt Hx questionnaire and where I'd go with the phys exam...

(Is this going to be a Rocky Farr question... with an answer like "He's been eating a 1/4 lb of black licorice a day for the last week?"... huh Ender? If it is, I know where to find you... and this time it won't be pleasant...:eek:)

Good call on fleshing out the history!

As noted, there was no clear precipitating incident, and the onset was gradual over a few days. The pain has continued to increase, and this morning it was the worst its been. The patient is clearly in discomfort, exacerbated by movement, especially flexion.

The patient has had sporadic lower back pain in the past, typically associated with heavy leg days. However, this feels "different." As noted, he first noticed this pain a few days ago. You are one week in country.

The patient had been in "normal" SF pre-mission training (lets say various vendor schools and other team training). Now, the team is out at ranges all day every day training the LNs. No significant depth or altitude exposures (team flew commercial FWIW). PT admits he hasn't been drinking enough water. Medications as noted.

Wearing body armor or carrying gear is particularly unpleasant. No ruck training, but he has been wearing body armor for much of the range training. He prefers sitting with a fairly straight posture. As noted, all movement exacerbates the pain, but flexion most of all.

I promise this won't be a complete Zebra. :D

LMAOROF :D Now that's funny rat there! :D :D

Got it. Just wanted to make sure I gave you correct feedback for what you were asking.

Normal CV response to valsalva and no increase in pain is noted.

Acute leukemia and mutliple myeloma may also present in a similar fashion.

Pfff.... kidney stones seem to be the least zebra Dx right know... Lisinopril, recurring but increasing severity, palpation or striking causes increase in pain, and increased activity causes pain.... reduced hydration has reduced volume, 'bad' water increases mineralization coupled with the lisinopril and the attendant hyperkalemia...

Tell Top he needs to drink more water dammit, especially with lisinopril and heavy physical activity.

the other Dx option is gouty arthritis in combination with arthroarthritis in the lumbosacral joint (multiple damage does not r/o this area even though it is not an initial joint for attacks in most cases) - same reasons as above - need to get the diff on them and run a couple of blood panels... K levels and Uric acid levels will be key in the r/o on this... but it's gonna suck with no lithotripsy available for relief if it is a stone....

I'd like to go back to the Hx for a minute. Patient said he does weight lifting. Deadlifts? When was the last time he was at the gym? What was the routine? Weight? Did he increase the weight during the last workout? Did he notice any back pain during the workout? Immediately after?

Did the patient do clean-and-jerk or standing overhead presses in the last workout?

Last gym trip was a few days before deployment. He did dead lifts and squats as is normal for him, without any unusual increases in weight. He did not notice any pain during or immediately following the workout, and a number of days passed before he first noticed any symptoms (based on our hypothetical timeline, you've been in theater a week, and he noticed symptoms a few days in.)

Yep, if I were the Team Medic I would evac him to a facility that can take a peak (X-ray/MRI). I'm thinking herniated disc, vertebral process avulsion fracture, R/O kidney stones.

Before we start trying to nail our differential, I think it would help to complete our history and physical exams, and maybe do a problem list.

Nearest facility is a few hours away, and the trip will seriously disrupt training. Still wanna go?

300F-1, San Antonio, The 2005 reclass.... CPT Rocky Farr.... "We're going to work on your ability to get a good Hx, and diagnose to a diff Dx level wit h4 options.... 30y/o white male in good health (soldier) and normal vitals presents c/o black tarry stools x 1 wk.... Start asking, raise your hands...." every zebra in the world came running.... but I learned how to hit the easy hx questions early, and start with easy Dx for r/o...:rolleyes:

Just throwing that out there as a reminder.

Advise him to avoid 200+ pound snatch. :D

We are thinking the same, Bro. ;)