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Mr H
• 65 years of age• Type II Diabetes• Developed shortness of
breath when walking the dog
• Worse when he is climbing hills and better when he comes down
• Starts to develop pain in his right leg as well
• What are the main pathologies here?• Which symptoms need to asked when enquiring
about his leg pain?
• Can you explain the indications for each of the medications that are listed
• Name 3 side effects of each one
• What is the most likely cause of this mans leg pain?
• What else can cause similar pain and how do you distinguish this?
Assessment
• How would you assess this patient on clinical examination?
• Which features in the history or examination would support your diagnosis
• He is referred to hospital – which investigations might help
Management
• What are the priorities for this man’s management?
• What would you advise relating to his medication?
• Which factors need to be taken into account relating to managing this man?
MR G
• Aged 72
• Presents with aching pain in right thigh
• Pain also felt in right groin and into his knee
• Pain worse when he walks but also keeping him awake at night
Examination
• What sort of assessment would you make in this man when examining him?
• Can you explain /demonstrate the examination process to your colleagues?
• What sort of tests might help you and why might you be doing them?
Test results
• X ray hip – suggests early arthritic change in right hip ( subchondral sclerosis, loss of joint space and a few osteophytes)
• Full blood count normal
• ESR 100
• Alkaline Phosphatase raised but ALT normal
• What does the x ray report suggest?
• What are the causes of a high ESR?
• What might cause the raised ALP?
• What else might be going on here and how would you follow this up?
Mr K
• 55 fork lift truck driver
• Long history of low back pain
• Develops pain in low back which is causing early morning stiffness
• Bends down to clip toe nails and develops sudden severe pain in the leg on the left
Clinical assessment
• What is the most likely pathology here?
• How would you examine and assess this man clinically?
• Can you demonstrate the examination to you colleagues?
• What questions do you need to particularly need to ask this man ?
Tests
• Normal FBC but slightly raised ESR at 40 and CRP at 12
• X ray – Radiologists decline to perform plain film – is this correct?
• What can be seen on a plain film?
• What might be a more useful method of assessing this man?
Red flags
• What symptoms in the history might suggest that there is something more going on?
• How can you make a reasonable assessment of this?
• What actions are open to the primary care doctor when assessing a patient with low back pain
Red flag" and "yellow flag" signs Red flags are possible indicators of
serious spinal pathology
• Thoracic pain • Fever and unexplained weight loss • Bladder or bowel dysfunction • History of carcinoma • Ill health or presence of other medical illness • Progressive neurological deficit • Disturbed gait, saddle anaesthesia • Age of onset <20 years or >55 years
Yellow flags are psychosocial factors shown to be indicative of long term
chronicity and disability
• A negative attitude that back pain is harmful or potentially severely disabling
• Fear avoidance behaviour and reduced activity levels
• An expectation that passive, rather than active, treatment will be beneficial
• A tendency to depression, low morale, and social withdrawal
• Social or financial problems
Mrs F
• Develops pain initially in one then both legs when walking
• Initially buttocks and thighs then spreads to feet
• Gets better when sits and leans forward
• She gets this when walking home at the same place each night
• Worse when she goes down hill
• Last three weeks also noted that her legs get weak when she walks too far
What does this picture suggest?
Which of the following tests would you request?
• Plain lateral x ray lumbar spine
• MRI scan?
• Bone scan?
Lumbar canal stenosis
• Narrowing canal or neural foramina
• Ischaemia of cord or cauda equina
• Usually combination disc problem, osteophytes and hypertrophy ligamentum flavum
• Commonest>60s
Associated conditions
• Congenital narrowing of the spinal canal (much less common than degenerative).
• Degenerative - osteoarthritis. • Hyperparathyroidism. • Paget's disease. • Ankylosing spondylitis. • Cushing's syndrome. • Acromegaly.
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