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outpatient department- not in ward/ just clinic

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64-year old retired male

presented to the outpatient department

lower back pain

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64-year old retired male- senior citizen, compromised immune system, easy tired, sedentary lifestyle, suscebtible with cormobidities, muscle degeneration,atrophy, etc. Past occupational related

presented to the outpatient department- not severe enough

lower back pain - age related, fragile, due to body posture, injury, past job, common for elder

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MSK

Osteoporosis

Degenerative disc disease

ankylosing spondylitis

osteoarthritis

Gout

Muscle strain

Fracture/ trauma

Neuro causes

LMN lesion

Spinal cord compression/ lesion

Endocrine causes

Hyperparathyroidism

Malignancy

tumour

prostate cancer (can cause backpain)

osteosarcoma

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Socrates- backpain

Site- exact site of lower back/ left right/ lumbar sacral

Onset- start feeling pain/ sudden or gradually

Character- sharp pain/ dull/ throbbing/ pulsating(aneurysm)/ neuropathic (cancer, opioids taking)

Radiation - to the hips, to the front, etc

associated symptom - weakness, swelling, tingling sensation, fever, tenderness, stiffness, numbness

Time - persistent/ intermittent/ duration, on-off/ day or night/

Exacerbate / elevate factor- position/ drug (nsaid, painkiller)/ activity, exercise

Severity - pain scale 1-10, effect the lifestyle

PMH

post surgery, trauma, allergies, autoimmune disease, illness

Similar symptom

Medication (pain killers, glucocorticoids (cause osteoporosis)(eg; prednisone)

FH

History of cancer, hypertension, dyslipidemia, DM, autoimmune, etc

Similar symptom in family

SH

Diet (vitamin D, Ca), alcohol, smoke, drugs

past occupation

Family life- wife, kid

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1. been experiencing aching pain in the lower lumbar area

2. for the last few months

3. during the past three weeks, the pain became worse

4. fairly localised without radiation, exacerbated with exertion

5. did not experience any tingling, numbness or weakness.

6. The patient also added that he had weight gain up to 80 kg (increased 5 kg over one year) and he felt he might be "shrinking”

7. PMH, FH, medication and allergies : unremarkable

8. Social: smoker with a 45 pack-year history. The patient had a history of moderate alcohol consumption.

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1. been experiencing aching pain in the lower lumbar area for the last few months

chronic condition, pain become unbearable - change in lifestyle/trauma

may be degenerative disease

2. during the past three weeks, the pain became worse

progressive pain due to activity that damage spine and vertebra

3. fairly localized without radiation, exacerbated with exertion

pain is localized with no radiation, less likely to be systemic, less likely to be prostate cancer.

when doing activity - back pain become worse

4. did not experience any tingling, numbness or weakness.

normal neurologic function - no compression, demyelinating

5. The patient also added that he had weight gain up to 80 kg (increased 5 kg over one year) and he felt he might be "shrinking”

decrease in posture - the feeling of shrinking - hunching

not likely malignancy

weight gain can exacerbate mechanical strain of lower back

6. PMH, FH, medication and allergies : unremarkable

rule out trauma

less likely heart disease, HTN, DM, cancer

7. Social: smoker with a 45 pack-year history. The patient had a history of moderate alcohol consumption.

risk factor causing immunodeficiency

risk factor for bone related diseases

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MSK

Osteoporosis

Degenerative disc disease

ankylosing spondylitis

osteoarthritis

Gout

Muscle strain

Fracture

trauma

Neuro causes

LMN lesion

Spinal cord compression/ lesion

Endocrine causes

Hyperparathyroidism

Malignancy

tumour

prostate cancer (can cause backpain)

osteosarcoma

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general examination

1. vital sign (B Re He T) - BP, RR, HR, Temp

2. BMI

general inspection (LOC)

systemic

Inspection: see he's posture, scoliosis? kyphosis? gait pattern? goitre?

Palpation: pain, position of spine, tenderness, thyroid gland

Percussion: percuss for dullness

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fingerbreadths - width of distal of two fingers

kyphosis - exaggerated forward curvature of thoracic spine resulting in hunched or rounded back (excessive forward rounding of the upper back)

rib-pelvic distance - anatomical distance between lower rib and top of pelvis (used to assess postural changes that may indicate vertebral fracture)

occiput-wall distance - test to measure distance between head and wall (for hunchback)

lumbar radiculopathy - condition where there is compression, inflammation or irritation of one or more lumbar nerve roots in lower back

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1. normal temp, HR, BP

2. borderline high RR

3. alert and well-oriented

4. BMI is 24.7 kg/m2: normal

5. prominent kyphosis of thoracic spine and occiput-wall distance more than 5cm

6. rib-pelvis distance less than two fingerbreadths

7. no gait

8. localised tenderness to palpation in lower lumbar area

9. no lumbar radiculopathy or nerve damage

10. 5.5cm shorter in height than 5 years ago

11. no regional lymphadenopathy

12. others normal

# data[].attributes.body
1. normal temp, HR, BP

no systemic symptoms

no inflammation

no shock or stress

2. borderline high RR

due to pain

due to affected airways caused by hunching

harder to breathe

3. alert and well-oriented

no neurological deficit

4. BMI is 24.7 kg/m2

normal

5. prominent kyphosis of thoracic spine and occiput-wall distance more than 5cm

hunchback

can cause compression fractures in cases of osteoporosis

6. rib-pelvis distance less than two fingerbreadths

positive finding of vertebral deformities

normal range: 2-3 fingerbreadths

7. no gait

normal walking posture

no joint pain or nerve damage

no lower limb problem (mainly spine related)

8. localised tenderness to palpation in lower lumbar area

underlying issue related to spine, muscle or surrounding structures

9. no lumbar radiculopathy or nerve damage

no compression of spinal nerves

10. 5.5cm shorter in height than 5 years ago

due to kyphosis

may be other components or structures that collapsed causing shortening

bone becomes brittle and weak leading to height reduction

11. no regional lymphadenopathy

no abnormal lymph node enlargement

no systemically involved diseases or inflammation

no infection, no malignancy

12. others normal

no systemically involved diseases or inflammation

# data[].attributes.body
MSK

Osteoporosis

Degenerative disc disease

ankylosing spondylitis

osteoarthritis

Gout

Muscle strain

Fracture

trauma

Neuro causes

LMN lesion

Spinal cord compression/ lesion

Endocrine causes

Hyperparathyroidism

Malignancy

tumour

prostate cancer (can cause backpain)

osteosarcoma

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FBC

XRay

serum plasma: calcium, vitamin D, PTH hormone, calcitonin, CRP, ESR, renal function test

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Prostatic Specific Antigen (PSA)-protein made by the prostate,used to indicate prostate cancer

Dual X-ray absorptiometry (DXA)-special imaging to check for mineral bone density

osteopenia-condition between normal and osteoporosis bon density

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normal lab result

(DXA) test results showed low bone density at the femoral neck with a T-score of -1.9 (osteopenia) and a T score of -3.5 (osteoporosis) at L3-L5

note of two vertebrae being wedge-shaped meeting the criteria for vertebral compression fracture.

osteoporosis complicated with a vertebral compression fracture.

Therapy with a bisphosphonate (alendronate) was started along with calcium and vitamin D supplementations.

Lumbar support back brace for 12 weeks was given to help alleviate

lower back pain and stabilise the injury and was prescribed non-steroidal anti-inflammatory

drugs for the pain.

Cessation of alcohol consumption and physiotherapy programme with

manual techniques, clinician-led exercises, and home exercises were recommended.

On a

follow-up appointment made after three months, serial spinal radiographs showed

progressive vertebrae union

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FINAL DIAGNOSIS-patient diagnosed with osteoporosis complicated with vertebral compression fracture

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normal lab result-normal and no systemic changes

(DXA) test results showed low bone density at the femoral neck with a T-score of -1.9 (osteopenia) and a T score of -3.5 (osteoporosis) at L3-L-risk for fracture and confirmatory result for osteoporosis(osteopenia precursor 4 osteoporosis)

note of two vertebrae being wedge-shaped meeting the criteria for vertebral compression fracture.-common in osteoporosis,causes the backpain

osteoporosis complicated with a vertebral compression fracture.-diagnosis(final)

Therapy with a bisphosphonate (alendronate) was started along with calcium and vitamin D supplementations. -inhibit osteoclats activity,less resoption,more denisty,less fracture,first line drugs

Lumbar support back brace for 12 weeks was given to help alleviate

lower back pain and stabilise the injury and was prescribed non-steroidal anti-inflammatory

drugs for the pain. -non pharmacological treatment,alleviate pain,reduce movement,faster healing

Cessation of alcohol consumption and physiotherapy programme with

manual techniques, clinician-led exercises, and home exercises were recommended. -promotes healing,because alcohol can causes bone breakdown

follow-up appointment made after three months, serial spinal radiographs showed

progressive vertebrae union-treatment for osteoporosis