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Back Pain

Back pain requires skillful evaluation and management, as well as patient education. There is considerable data on test utility, including expensive spinal imaging, which facilitates teaching rational, cost-effective test ordering.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with BACK PAIN can include:

Medical Knowledge Learning Topics related to BACK PAIN

1. Signs and symptoms that define and categorize back pain.
2. Clinical features that help to differentiate one etiology from another.
3. Use of neuroimaging studies in the evaluation of back pain, including their indications, limitations, and cost.
4. Natural history of important causes of back pain, especially those which require urgent attention (e.g., cauda equina syndrome, epidural abscess, spinal metastasis) and those which do not (e.g., strain, minor disc herniation).
5. Effectiveness of different therapies for various etiologies.
6. Approaches to limit disability and chronicity.

Diagnostic Evaluation Learning Topics related to BACK PAIN:

1. Age-appropriate medical history taking, documentation, and presentation that differentiates etiologies of disease, such as:

  • elicitation of key elements of the history helpful in establishing etiology
  • exclusion of “must-not-miss” causes
  • determination of level of disability

2. Physical examination to establish the diagnosis and severity of disease, including detailed lower extremity neurologic exam.
3. Mental status examination.
4. Recommendation for and interpretation of diagnostic laboratory and imaging studies, both prior to and after initiating treatment, based on the differential diagnosis.
5. Differential diagnosis with recognition of specific history and physical exam findings of back pain.
6. Identification of the patient’s specific problem among others in the differential diagnosis through a combination of medical knowledge, information obtained in the clinical encounter and collective experience with similar patients.

Management Plan Learning Topics related to BACK PAIN

1. Patient education about preventive measures (e.g., proper use of bed rest and exercise) and the mechanics of lifting, standing, and sitting.
2. Treatment measures (e.g., appropriate prescribing of analgesics and muscle relaxants).
3. Appropriate use of consultants and referral to specialists.
4. Psychological support.
5. Use of appropriate information systems to ascertain information about health system and community resources.
6. Follow-up planning.
7. Prognostication for the patient with back pain and communication in a caring and compassionate manner.
8. Cost-effectiveness of the management plan.

Potential Differential Diagnosis Topics Include:

  • muscle strain
  • lumbar disc herniation
  • pyelonephritis
  • nephrolithiasis
  • vertebral compression fracture
  • spinal metastasis
  • spinal epidural abscess
  • osteomyelitis
  • aortic aneurysm
  • cauda equina syndrome
  • ankylosis spondylitis