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Occ Med Clinical Concept Map 1

Student Review and Study



Name: Alex Meloy, Jesse Moses

Complaint: Acute severe Mid-Back pain x 1 day in a 60 y.o. male who works in the stockroom (lifting boxes)

Incidence and

Risk Factors
Signs and
Symptoms
Diagnostic Studies Gold Standard
of Diagnosis
Treatment Goal

Intervention or RX
Patient Education

and Follow-Up






Differential DX
1

Muscle Strain






Most common
mechanism of back
muscle strain is
sudden extension
of the spine in
combination with
rotational
movement.

Other causes of
back strains are
associated with
chronic faulty
posture.
1(p.506)


Risk factors
include excessive
lifting, poor
posture, improper
lifting technique,
smoking, and
obesity
2,3

Pain and
discomfort
present with
active extension
and passive
flexion.

Pain with
coughing and
deep breathing
may be present.

Swelling, heat,
and point
tenderness may
be present over
area of injury.
3,4

In depth history of
mechanism of
injury needed to
determine
location/type of
injury.

Physical and
neurological
examination of
cervical, thoracic,
lumbar and sacral
spine including
range of motion
(flexion, extension,
lateral bending,
rotation) and
palpation of
bilateral back
muscles for point
tenderness.
Neurologic
examination of
extremities for
radiculopathy such
as temperature,
Magnetic
Resonance
Imaging can
determine the
location and
severity of a
muscular strain.
3

Non-Pharmacological:
Initial ice packs or ice
massage to reduce
swelling for first 72
hours post injury.

Rest, avoid
movements that cause
pain, and avoid heavy
lifting.

Alternating with heat
and ice may reduce
pain.

Physical therapy may
be indicated
depending on the
severity of strain.
1(p.506),2,3


Pharmacologic:
NSAID such as
Ibuprofen or Naproxen
may be utilized to
reduce inflammation
Prognosis of acute
mechanical back
injuries is good.
70% heal within 1
week, 80% within 2
weeks, and 90%
within a month.
2


Follow up to assess
progress and
consideration of
further intervention
such as the need for
physical therapy
will be scheduled
for 4 weeks.
2


Re-occurance is
common. Patient
education will
include proper
lifting technique,
encouragement of
weight loss,
encourage regular
exercise including

vibratory,
sharp/dull
discrimination, and
drop leg test.

Radiographic
studies such as MRI
will determine
location and
severity of strain.
Spinal radiograph
will help rule out
skeletal injury as
source of pain
3,4,5

and pain.

Analgesics indicated
for severe pain include
Vicodin or Tramadol

Muscle relaxers such
as Soma and Flexeril
provide short term
benefit to pain
management
especially for muscle
strains.
2.4



back strengthening
and stretching. 2

The patient will be
instructed to seek
emergency medical
attention if pain
becomes
increasingly worse
or spreads to the
neck and
extremities. Patient
will also be
instructed to seek
medical attention if
he feels shortness
of breath,
weakness, or
lightheadedness.
4







Differential DX
2

Herniated Disk







60-80% of people
will have at least
transient episodes
of back problems in
their lifetime.

Risk Factors
include smoking,
chronic coughing,
stresses, not using
lumbar support,
sitting for
prolonged periods,
and lifting.
6

Mid to low back
pain, along with
various
locations/
manifestations
of potential
neurological
damage
depending
primarily on if
nerve
compression
exists, and if so,
how severe it is.
Thorough history,
physical
examination,
including
neurologic
examination.

Radiographic
studies, including
MRI if suspected
neurological
damage. CT scan as
initial study. MRI if
neurologic
abnormalities or
ligamentous/muscul
ar concerns. These
Magnetic
Resonance
Imaging if
neurological
deficits are
seen.
7





Initial conservative
management:
analgesic (NSAIDs or
opioids if severe) and
education. Muscle
relaxants may be
considered. 48 hours
of bedrest is
appropriate.
8(p1636)

Epidural
corticosteroids may be
used for short term
relief. If a major
neurological function
develops or continues
surgery should be
considered.
8(p798)

Patient will be
taught to avoid
movements which
cause nerve
compressions, and
proper lifting
techniques. Patient
will be advised to
return promptly to
light activity after
short period of
bedrest.
9(p1274),8(pp798
,1636)
Advise patient
to return if pain is
not relieved, or if
neurological
symptoms develop.

serve in both ruling
in and ruling out
many problems.
7
May also use
straight leg raise
test.
5(p703)







Differential DX
3

Vertebral
Fracture






Two groups with
highest risks are
those with
osteoporosis or
with bone cancer
Age over 50, lifting
heavy objects,and
smoking increase
risk.

Compression
fractures are more
common in thin
women with early
menopause. Other
vertebral fractures
are 4 times more
common in
males.
10


Neuro deficit
occurs in 15-20%
of thoracolumbar
injuries.
If sudden may
feel severe pain
in back, may
continue to
extremities. If it
is gradual pain
will be more
mild. There may
be weakness and
numbness if
nerves are
involved.

If it is a
compression
fracture then
point tenderness
may be
demonstrated
on involved
vertebrae.
11

Thorough history,
physical exam, and
neurologic
examination. Begin
with plain film x-
rays (both
anteroposterior and
lateral radiographs),
if any fracture is
noted it necessitates
radiographic
analysis of the
entire spine. CT
may be ordered for
osseus
evaluation.
10,12

Plain film x-ray
and CT scan for
osseus
structures. MRI
for soft tissue
injury.
Goal consists of
protecting neural
elements, and
prevention of
instability or
deformity. If severe,
surgery may be
needed to accomplish
these goals.
10
For non
surgical: consider
bracing along with
analgesics, along with
patient education.

If neurological
damage is seen, early
treatment with
methylprednisolone is
indicated.
9(p1289)


If compression is
severe may consider
vertebroplasty or
kyphoplasty to restore
some degree of
vertebral structure.
May send patient for a
DEXA scan to check
for osteoporotic bone
changes.
10

Instruction on
lifting techniques is
important. If pain
does not decrease,
or if neurological
symptoms develop
patient should
return to clinic.

If surgical
correction was
utilized, early
follow-up
examination to
assess wound
healing should
happen within first
few weeks, along
with radiographic
followup over the
first year.

If non operative tx
is chosen we must
monitor closely
with frequent
clinical and
radiographic follow
up, watching for
changes.
10


References:

1. Prentice WE. Essentials of Athletic Injury Management. 7
th
ed. The McGraw Hill Companies. 2010.

2. Perina DG. Mechanical Back Pain. 2012. http://emedicine.medscape.com/article/822462-overview Accessed April 20, 2013.

3. Wheeler SG, Wipf JE, Staiger TO, Deyo RA. Approach to the diagnosis and evaluation of low back pain in adults. 2013.
http://www.uptodate.com/contents/approach-to-the-diagnosis-and-evaluation-of-low-back-pain-in-adults Accessed April 20, 2013.

4. University of Minnesota Medical Center. THORACIC SPINE STRAIN. 2013.
http://www.uofmmedicalcenter.org/HealthLibrary/Article/116608EN Accessed April 20, 2013.

5. Bickley LS. Bates Guide to Physical Examination and History Taking. 10
th
ed. Lippincot Williams and Wilkins. 2009.

6. Foster MR. Herniated Nucleus Pulposus. 2012. http://emedicine.medscape.com/article/1263961-overview#aw2aab6b8 Accessed April 20, 2013

7. American College of Radiology. Appropriateness Criteria. 2013.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/SuspectedSpineTrauma.pdf Accessed April 20, 2013.

8. McPhee SJ, Papadakis MA. Current Medical Diagnosis & Treatment. 51
st
ed. The McGraw-Hill Companies, Inc; 2012

9. Porth CM, Matfin G. Pathophysiology: Concepts of Altered Health States. 8
th
ed. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009

10. Leahy M. Thoracic Spine Fractures and Dislocations. 2012. http://emedicine.medscape.com/article/1267029-overview Accessed April 20, 2013

11. Southwest Scoliosis Institute. A Patients Guide to Thoracic Compression Fractures. 2013.
http://www.consultingorthopedists.com/Compression-Fracture.php Accessed April 20, 2013

12. University of Maryland Medical Center. A Patients Guide to Thoracic Compression Fractures. 2012.
http://www.umm.edu/spinecenter/education/thoracic_compression_fractures.htm Accessed April 20, 2013

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