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Back Pain Quiz


Back Pain Quiz

A quick quiz about one of the most common medical complaints you will be facing in your career life

Enjoy

(والمؤمنون والمؤمنات بعضهم أولياء بعض يأمرون بالمعروف وينهون عن المنكر ويقيمون الصلاة ويؤتون الزكاة ويطيعون الله و رسوله أولئك سيرحمهم الله إن الله عزيز حكيم)

Al Durra's picture
by
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1) A 21-year-old college tennis player presents with symptoms of back discomfort that have been progressing throughout the season. She describes alternating buttock discomfort as well as persistent heel pain. With inactivity she describes more prolonged stiffness and discomfort. This presentation is most typical of:
a). Epidural abscess
b). Overuse with muscular strain
c). Spondyloarthritis
d). Spinal stenosis

2) A 72-year-old presents with complaint of back discomfort with walking. You suspect spinal stenosis. Which of one of the following symptoms would be typically seen in this condition?
a). Pain radiating to the anterior thighs
b). Improvement of pain with bending forward
c). Progressive weight loss
d). Worsening of pain upon sitting down

3) Jane S. is a 62-year-old with a history of progressive low back pain over the past eight weeks. The patient noted discomfort in the lumbar area that persisted through the day and was worse with activity and lying down. Over the past two weeks the pain has been more intense and the patient has noted difficulty standing up from a chair as well as bilateral paresthesias in the legs and urinary incontinence. This patient's presentation is most consistent with the development of:
a). Cauda equina syndrome
b). Polymyalgia rheumatica
c). Spinal stenosis
d). Herniated intervertebral disk

4) A 53-year-old man presents with the acute onset of low back pain which developed after an overnight trip to his son's college. He did no heavy lifting, but did bring a carry-on bag with toiletries and a change of clothing inside. Past history is notable for alcoholism, in remission for the past year, as well as hypertension, treated with HCTZ. On physical exam, he is afebrile, and blood pressure is controlled. There is point-tenderness at the L2 level, but neurologic testing is normal. Appropriate management at this point would be:
a). Obtain plain films of the lumbosacral spine
b). Obtain an MRI of the lumbosacral spine
c). Obtain an ESR
d). Reassure and treat with NSAIDs

5) A 52-year-old man complains of low back pain for the past 2 months. He has never had this type of back pain before in his life. Pain waxes and wanes, but is worsened by lying down and when he goes to bed at night. He denies fever or chills. Symptoms do not radiate. Symptoms improve when he gets up out of bed, and are not bad in the morning. Past medical history is otherwise unremarkable. Among the following potential causes of low back pain in this individual, which one is most likely?
a). Ankylosing spondylitis
b). Vertebral osteomyelitis
c). Vertebral metastases
d). Psoriatic arthritis

6) A 76-year-old woman with mild hypertension, who has recently been enrolled in a clinical trial for the treatment of osteoporosis, presents with acute back pain after attempting to open a painted shut window on her second floor. Her physical examination shows no focal deficits. What should be done for further evaluation?
a). Simply observe the patient with full expectation of relief of pain in 2-3 days.
b). Obtain a DEXA scan to fully assess the degree of her osteoporosis.
c). Plain radiographs of the L-S spine should be done to evaluate for a compression fracture.
d). An MRI should be done to evaluate for a herniated disk.

7) A 58-year-old man presents with a three-day history of increasing low back pain ten days after undergoing cystoscopy. On exam, he is febrile to 38.3 and has focal spinal tenderness at the L4 level. He denies any trauma. In this setting, the most appropriate diagnostic study would be:
a). Urinalysis with culture
b). CBC, ESR and CRP
c). Plain radiograph of LS spine
d). MRI of LS spine

-END-

Al Durra's picture
Al Durra
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up!
Al Durra's picture
Al Durra
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شوية تخبيص:
1b
2. b
3. a
4. d
5. c
6. b or c
but i'll go with c bcoz of the incidence of acut pain after an exercise
7. a
Rolling Eyes

lonely
طبيب مقيم

good job lonely, you got 4/7 answers correct!

who can beat that?

Al Durra's picture
Al Durra
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Quote:
you got 4/7 answers correct!

that is really disappointing Sad
would you phease define the numbers of wrong answers

lonely
طبيب مقيم

Quote:
that is really disappointing
would you phease define the numbers of wrong answers

no it is not
I will be releasing the correct answers along with explanations soon but I prefer to wait for a couple of days just in case someone else wants to participate

Al Durra's picture
Al Durra
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I will give it a shot
1-c
2-b
3-a
4-a
5-c
6-c
7-a). Urinalysis with culture

mbs2380's picture
mbs2380
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excellent man, you got 6/7

Al Durra's picture
Al Durra
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C - 1
B - 2
A - 3
B - 4
D - 5
C - 6
A - 7
I DON'T Care about the right answer ... i just enjoyed ... thanx

Tariq1987's picture
Tariq1987
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good job man, you got 4/7

Al Durra's picture
Al Durra
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1- c

2- b

3- a

4- a

5- c

6- b

7- a

prettyflower's picture
prettyflower
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1 : C
2: b
3 : a
4: d
5: b
6:c
7: D

Green Wave's picture
Green Wave

Quote:
3) Jane S. is a 62-year-old with a history of progressive low back pain over the past eight weeks. The patient noted discomfort in the lumbar area that persisted through the day and was worse with activity and lying down. Over the past two weeks the pain has been more intense and the patient has noted difficulty standing up from a chair as well as bilateral paresthesias in the legs and urinary incontinence. This patient's presentation is most consistent with the development of:
a). Cauda equina syndrome
b). Polymyalgia rheumatica
c). Spinal stenosis
d). Herniated intervertebral disk

Ummm,I am not sure but it seems that there's sth here .

I am just reading in the HY neuroanatomy that the pain in Cauda Equina syndrome is unilateral and that the incontinence and sexual functions are not marked whereas the pain is bilateral and there is incontinence and impaired sexual function in Conus medullaris syndrome
I didn't like this differentiation (like many things on step1 that I don't like either) ,cuz I checked other sources and found that cauda equina is associated with incontinence !!!!!

What do u think??

mbs2380's picture
mbs2380
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pretty & green, you both got 5/7
btw, green u r the only one who answered one of qs correct

Al Durra's picture
Al Durra
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Cool Very Happy Very Happy

Green Wave's picture
Green Wave


if you are smart enough, you should know which q was thatEye-wink

Al Durra's picture
Al Durra
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4 d

Cool

mbs2380's picture
mbs2380
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no my friend. having said that, i will give you 5/7 since u got q4 right and u just changed ur mind

just kidding

Al Durra's picture
Al Durra
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Laughing out loud Laughing out loud Laughing out loud
I am not smart enough

mbs2380's picture
mbs2380
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شكراً مناقشة حلوة

رح حاول جرب معلوماتي القديمة ضل منها شي بعد مشفى الأطفال ولا كلها تبخرت
بسم الله برأيي هيك الأجوبة

1-c
2-b
3-a
4-a
5-c
6-c
7-d

iman.j.k's picture
iman.j.k
طالب دراسات عليا


brilliant 7/7
if u r able to give a brief explanation why u chose these answers, hakeem should reward u

Al Durra's picture
Al Durra
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أسأل الله أن يكون التفسير صائب و أن لا تكون رمية من غير رامٍEye-wink

السؤال 1
ألم أسفل الظهر +آلام مرتكزات الأوتار +عمر الشباب=التهاب فقار مقسط

السؤال 2
في تضيق القناة الفقرية الانحناء للأمام يخفف الأعراض لأنه يؤدي إلى اتساع في القناة

السؤال3
ألم أسفل الظهر +أعراض عصبية في الطرفين السفليين+ سلس بولي =متلازمة ذيل الفرس

السؤال 4
سوابق المريض تشير بشدة إلى وجود هشاشة عظمية عند المريض
والأعراض الحاصلة غالباً ناجمة عن كسر انهدامي في الفقرات
والخطوة 1 للتشخيص صورة بسيطة

السؤال5
عمر المريض مناسب للخباثات وصفات الألم غير نوعية لأي شيء آخر
وبعدم وجود أعراض انتانية صريحة فالخيار الأقرب هو النقائل

السؤال6
قصة هشاشة صريحة مع ألم تالي لحركة مفاجئة أول ما نفكر به هو إمكانية حدوث كسر انهدامي

السؤال 7
في هذه الحالة كل الاختبارات الموجودة يمكن طلبها للمريض لكن الاختبار المشخص بينها(الأكثر نوعية) هو MRI

iman.j.k's picture
iman.j.k
طالب دراسات عليا

Quote:
السؤال 4
سوابق المريض تشير بشدة إلى وجود هشاشة عظمية عند المريض
والأعراض الحاصلة غالباً ناجمة عن كسر انهدامي في الفقرات
والخطوة 1 للتشخيص صورة بسيطة

شو السوابق التي تشير لهشاشة العظام بالقصة ؟؟

Green Wave's picture
Green Wave


الكحولية والستيروئيدات
ارتفاع الضغط إذا كان يأخذ أدوية مثل مدرات العروة فهي تنقص كلس الدم

iman.j.k's picture
iman.j.k
طالب دراسات عليا


عذراً يبدو أن هناك لبس ما Embarrased
HCTZ ظننت أنها تعني هيدرو كورتيزون لكن يبدو أتها تعني مدر تيازيدي
لكن وبكل حال أي ألم ظهر بدايته حادة فإن أول خطوة تشخيصية هي صورة بسيطة

iman.j.k's picture
iman.j.k
طالب دراسات عليا

ok Iman, you did a very good job explaining what u were thinking about

Discussion for Question 1
Inflammatory arthritis of the back (spondyloarthritis) typically presents with pain that worsens with inactivity and improves with activity. Degenerative arthritis typically improves with inactivity, and worsens with activity. This patient describes an inflammatory arthritis, and also describes alternating buttock discomfort, commonly seen with sacroiliitis that can be a presenting feature in spondyloarthritis. Her heel pain, which might represent Achilles tendonitis or plantar fasciitis, suggests presence of enthesitis, typically associated with spondyloarthritis.

Discussion for Question 2
Spinal stenosis, more commonly seen in the elderly, typically results from degenerative changes and spondylolisthesis of the spine impinging on the spinal cord and nerve roots. Patients describe burning in their calves with walking ("pseudoclaudication"), relieved by bending forward or sitting, but worsened by standing upright. Weight loss is not characteristic of spinal stenosis. Worsening pain upon sitting is not a specific symptom related to spinal stenosis. One does not typically expect weight loss with this mainly degenerative condition as opposed to a spinal malignancy or metastatic disease.

Discussion for Question 3
In a patient with bilateral nerve root symptoms, cauda equina syndrome should be considered. Saddle anesthesia, bilateral sciatica, and even bowel or bladder dysfunction may also be present. An urgent neurosurgical consultation is required in the patient with suspect cauda equina syndrome. A high index of suspicion is required to make this diagnosis and it is most commonly due to a large disc herniation of intervertebral discs, while epidural abscesses or hematomas and tumor masses are the most frequent non-mechanical causes. MRI is the most sensitive radiographic technique for detecting these lesions. Surgery and corticosteroid administration should be considered along with the neurosurgical consult. Polymyalgia rheumatica does not commonly cause back pain, and the patient is not presenting with the typical "pseudoclaudication" pattern of pain described in Q2 above which is consistent with spinal stenosis. A broad based large intervertebral disc herniation can be a cause of the cauda equina syndrome if the disc bulge affects the mass of nerves of the cauda equina or "horse-tail" that branches off the lower end of the spinal cord and contains the nerve roots from L1-5 and S1-5.

Discussion for Question 4
In patients with back pain and risk factors for osteoporosis (such as alcoholism, as in this case), plain x-ray films of the lumbosacral spine are useful in determining the presence of compression fractures. There is no evidence to indicate that an MRI will alter management in the absence of neurologic compromise. Neither the history nor the physical exam is indicating any "red flags" for an infection or a malignancy (the two conditions where an ESR may be helpful). It would be pertinent to confirm the diagnosis of osteoporosis before empiric therapy with non-steroidal anti-inflammatory medications in order to treat the patient with anti-resorptive agents along with calcium and vitamin D.

Discussion for Question 5
This patient has the red flag symptom of new, night-time back pain in the setting of being over fifty years of age. In the absence of fever or recent invasive procedures, an infection such an epidural abscess or vertebral osteomyelitis, are unlikely. Vertebral metastatic disease in this case is more likely. He does not have morning stiffness which, if present, would raise concern for ankylosing spondylitis; a condition almost never diagnosed in men over forty years of age. Psoriatic arthritis can present before psoriasis in 10% of patients with this condition, however, axial spine involvement in the absence of peripheral arthritis or psoriasis is unlikely. An MRI and age appropriate cancer-screening is warranted to further elucidate the etiology of this back pain

Discussion for Question 6
Plain x-rays are most useful in evaluating the patient with acute trauma or suspicion of vertebral compression fractures (i.e. from osteoporosis). MRI scanning is commonly used in the evaluation of the patient with low back pain, but herniation of intervertebral disks are found commonly in those without symptoms of low back pain. Most low back pain is self-limited; in the absence of radicular symptoms, trauma, or "red flags", early MRI imaging is not indicated, and can be delayed for three weeks in the otherwise healthy patient with low back pain.

Discussion for Question 7
This clinical scenario is most concerning for a soft tissue infection (such as epidural or spinal abscess) given the acute onset, febrile state, and recent genitourinary manipulation. While it is important to obtain each of the above evaluations, in the setting of a soft tissue infection the diagnosis will most specifically be determined by MRI imaging of the affected area.

Thanks for all of you guys who participate

Al Durra's picture
Al Durra
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I really enjoy it
thank you
lonely
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شكرا الدرةVery Happy ، نتوقع منك المزيدEye-wink Very Happy
شكرا إيمان، بتضلي أستاذتنا Very Happy Eye-wink

Green Wave's picture
Green Wave


شكراً على رفع المعنويات Green Wave على الرغم من أنني متأكدة أن معلوماتكم أدق و أفضل من معلوماتيEmbarrased

شكراً Al Durra كانت الحالات مفيدة وممتعة
ولا تنسى المكافئة فأنا كالأطفال الصغار أنتظر الهدية Eye-wink

iman.j.k's picture
iman.j.k
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lonely wrote:
I really enjoy it
thank you
Tariq1987's picture
Tariq1987
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ابق على تواصل مع حكيم!
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