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Old 12-04-2013, 09:46   #16
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Any fevers or night sweats?
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."

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What medications is he taking (including antimalarials/prophylactic medications deemed necessary for the AO)?
Current Meds:
Lisinopril
Atovaquone/Proguanil
Various nutritional supplements for weight-lifting
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Old 12-04-2013, 09:54   #17
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Also curious about his medications. Looking for any kind of blood thinner...
Covered above.

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What does his low back physically look like? Any visible rubor/calor/tumor? Blisters or rash?
Alright, lets start the physical exam. Your visual examination of the lower back is unremarkable.

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Any family history of this kind of LBP, or disease that causes joint pain?
"Dad always had lower back pain, and mom had RA."
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Old 12-04-2013, 10:02   #18
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Hyperkalemia is a genuine concern in "older" male users. Has he noticed any irregularities in his heartbeat?
No.
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Old 12-04-2013, 10:16   #19
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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?
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Old 12-04-2013, 10:39   #20
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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.

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May as well begin at the beginning...

Agree with Ped's palpation of the affected area and shoulders check.

BP, HR

Valsalva's, SLR tests
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.
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Old 12-04-2013, 10:44   #21
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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...)
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Old 12-04-2013, 10:56   #22
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Good call on fleshing out the history!

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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),
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.

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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.
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.

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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.
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.

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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...)
I promise this won't be a complete Zebra.
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Old 12-04-2013, 10:58   #23
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(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...)
LMAOROF Now that's funny rat there!
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Old 12-04-2013, 11:04   #24
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SOL, volume status. I've personally seen cases of the following start out febrile and with LBP:

- Malaria
- Meningitis
- Extradural primary spinal cancer
- Conus Medullaris Syndrome after intradural disc herniation

These are zebras, but clinical experience with similar S/S, nonetheless.
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.
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Old 12-04-2013, 11:05   #25
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SOL, volume status. I've personally seen cases of the following start out febrile and with unremitting LBP:

- Malaria
- Meningitis
- Extradural primary spinal cancer
- Conus Medullaris Syndrome after intradural disc herniation

These are zebras, but clinical experience with similar S/S, nonetheless.
Acute leukemia and mutliple myeloma may also present in a similar fashion.
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Old 12-04-2013, 11:08   #26
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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....
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Sun-Tzu, "The Art of Warfare"

Hearing, I forget. Seeing, I remember. Writing (doing), I understand. Chinese Proverb

Too many people are looking for a magic bullet. As always, shot placement is the key. ~TR
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Old 12-04-2013, 11:09   #27
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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?
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Last edited by Trapper John; 12-04-2013 at 11:11. Reason: added question
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Old 12-04-2013, 11:22   #28
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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.)
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Old 12-04-2013, 11:23   #29
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This is turning into a "Get on the next truck running back to the hospital, sit upright, get a cushioned seat. I've radio'ed ahead but don't lose this order script" situation, isn't it?

Yeah, DDx - Stone.... maaaaybe posterior disc herniation pressing on ALL.
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.
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Old 12-04-2013, 11:25   #30
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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.

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