Case #7

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Chief Complaint

Case 7 A sixty-seven year old man comes to see you because of low back pain which has been getting worse over the last few weeks.

 
  1. What are the causes of low back pain in older patients?

History of Present Illness

You have taken care of Mr. Zeiders and his wife Emily for a number of years. His health has been good except for some nagging arthritis in the neck and back which has been fairly well controlled with occasional use of Advil, and for mild hypertension controlled nicely with diet and exercise.

Mr. Zeiders comes about every six months for his blood pressure check, but decided to schedule an appointment earlier this time because of his back pain. He's had back pain before, but not as aggravated as it is now. What bothers him is that he has noticed that the Advil no longer relieves the pain the way it has in the past.

 
  1. What specific information do we need (if any) from Mr. Zeiders in order to clarify our thinking? Briefly describe how you would start taking the history.
  2. Could this be just his DJD which is no longer responsive to Ibuprofen?
  3. Mr. Zeiders came today "because of pain". Is that the only reason he has come?

Medical & Social History

The pain is described as sharp like a knife, and felt in his back. It is intermittent with occasional radiation down his right leg. What is new and bothersome is that he is being awakened at night with the pain. He has to get up and pace the floor, getting some relief, but eventually spends the night in the lounge chair where he is most comfortable. He states this has been going on for some weeks and seems to be getting worse.

Nothing in his life has changed recently. He does a bit of gardening but doesn't remember straining his back. What he has noticed in the last few weeks is that he seems a bit more tired than usual - i.e., he seems to be able to do less before simply feeling worn out. After he lies down for a while, though, he's okay.

PMH:
History is positive for hypertension, otherwise no major illnesses or injuries.

Medications:
Hydrochlorothiazide 25 mg each day

ROS:
Appetite off recently but no other GI problems; a bit more shortness of breath (but no chest pain) on climbing the stairs than usual, but able to walk about half mile with Emily 2-3 times every week without problems; urination is slower and stream is not what it used to be, has noticed a bit more of a sense of urgency - no burning or blood.

SH:
Married to Emily for thirty-five years, two grown children who live in the area. Own their own home, he does all the repairs, both active in the local community, attend the Lutheran church in town. Mr. Zeiders is a retired cabinet maker, was active in local politics before his retirement, reads voraciously, watches only the news on TV. Used to smoke a pipe but nothing for the last twelve years, both take an occasional drink (anniversaries, holidays, etc), no other drugs.

Emily's health is good, she dotes on Charlie incessantly, as long as you have known them they have had a loving, supportive relationship.

 
 
  1. Formulate an initial hypotheses about this patient's problem(s), ranking your hypotheses:
  2. What specific findings do you need to look for on physical exam?

Physical Examination

Wt=155, BP=180/98, P=88 irreg, R=18 ret.

Affect appropriate but patient is tense & eyes look worried.

HEENT:
normal

CV:
rhythm is irregular but slow - heart tones unremarkable - II/VI radiating murmur over the aortic valve - carotids = bruit over the right carotid, no JVD.

Lungs:
clear

Abdomen:
unremarkable

Genitalia:
small direct hernia on the right side but otherwise unremarkable.

Rectal:
sphincter tone good, no noticeable hemorrhoids or tags, no ampullar masses, Stool Hemocult = neg, prostate is enlarged, non-tender, no palpable nodularity but a mid-zone area of hardness at the 6 o'clock position.

Ext:
no apparent muscle atrophy, no leg length discrepency, no swelling or joint deformities, full range of motion in hips and knees without pain

Back:
tenderness over the spinous processes of L1-L2, para-spinous muscles are supple, decreased lumbar lordotic curve, difficulty with anterior flexion of the spine, no difficulty with side-to-side motion

Neuro:
SLR = neg to 45 degrees, reflexes bilaterally equal, no motor/sensory deficits, gait satisfactory.

Circ:
equal with good distal perfusion.

 
  1. Have you learned anything from your examination? What specifically?
  2. What are the 3 most likely diagnostic possibilities to explain his back pain?
  3. What are your working diagnoses at this point?

Diagnostic Work-up

Select from the following menu the diagnostic test you think appropriate:

(You should order those diagnostic studies necessary to evaluate your working diagnosis/diagnoses. Each test should be ordered with a specific question in mind [i.e. avoid a "shotgun" approach])

  1. Complete Blood Count with Differential
  2. Platelet Count
  3. Urinalysis (dip stick and microscopic)
  4. Serum Uric Acid
  5. Serum Protein Electrophoresis
  6. Routine Chest X-Ray PA & LAT
  7. Intradermal Tuberculin Skin Test
  8. Blood Culture
  9. Erythrocyte Sedimentation Rate
  10. Serum Electrolytes
  11. Bun and Creatinine
  12. Serum Calcium and Phosphorus
  13. Amylase
  14. Acid Phosphatase
  15. Liver Profile
  16. GGT
  17. Serum Total Protein and Albumin
  1. Fasting Glucose
  2. Psychiatry Consult
  3. TSH
  4. Thyroid Profile
  5. Prostate Specific Antigen
  6. Urology Consult
  7. Prostate Biopsy
  8. CT Scan of Chest
  9. CT Scan of Abdomen
  10. CT Scan of Lumbar Spine
  11. Renal Ultrasound
  12. Ultrasound of the Abdomen
  13. Lumbar Spine Series (plain films)
  14. Thoracic Spine Series (plain films)
  15. Nerve Conduction Velocities
  16. EKG
  17. Nuclear Medicine Study Hepatobiliary Imaging
  1. Please list your final diagnosis/problem list in your e-mail window.
  2. How are you going to break the news to the Zeiders that he has cancer?

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This page was last updated on April 24, 2006
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