osteoarthritis hip
Doctor Information
Brooklyn James 15
PMH:
Nill
Medication:
Nill
Allergy to penicillin
PMH:
Nill
Medication:
Nill
Allergy to penicillin
Patient Information
Brooklyn James Aged 13
History: You went to a local trampolining park for your friends 14th birthday party. You landed slightly awkwardly after one of your big jumps. You've had pain since - this was now one week ago.
If asked only: You had no pain straight away, you only noticed it when you got home. It's a dull ache in your lower back, it's difficult to localise exactly, but you think its more on the left side. The pain doesn't radiate any where. There is no pain in your legs / feet. You have no problems going to the bathroom for urinating nor evacuating your bowels. There is no weakness or numbness in your legs. You have no fevers, and feel well in yourself. Neither you nor your parents have noticed any changes in your posture.
You can remember the likely triggering event - You had attempted to jump from one trampoline to another, and had an awkward landing. You remember landing in a twisted position. You didn't suffer any direct trauma to the lower spine. You've not had any other knocks nor bumps to your back, and Rugby has been injury free so far.
Social history: You don't smoke, don't drink. You play Rugby at a high level locally, and have a big match coming up in one weeks time. You're concerned as you've had to miss this weekends training session due to the pain.
Past history:
Nill
Medication:
Nill
You are allergic to penicillin
Ideas: You are worried as the pain has been ongoing for a week, and whilst it is slightly better, it's not gone away. You have looked on Google, and are worried you have Scheuermann's disease.
Concerns: Other than the concern for a more serious underlying condition, you're also concerned the effect this may have on an upcoming rugby match you have in one weeks time.
Expectation: To be told that this isn't anything serious, and hopefully been given the all clear to play next week.
History: You went to a local trampolining park for your friends 14th birthday party. You landed slightly awkwardly after one of your big jumps. You've had pain since - this was now one week ago.
If asked only: You had no pain straight away, you only noticed it when you got home. It's a dull ache in your lower back, it's difficult to localise exactly, but you think its more on the left side. The pain doesn't radiate any where. There is no pain in your legs / feet. You have no problems going to the bathroom for urinating nor evacuating your bowels. There is no weakness or numbness in your legs. You have no fevers, and feel well in yourself. Neither you nor your parents have noticed any changes in your posture.
You can remember the likely triggering event - You had attempted to jump from one trampoline to another, and had an awkward landing. You remember landing in a twisted position. You didn't suffer any direct trauma to the lower spine. You've not had any other knocks nor bumps to your back, and Rugby has been injury free so far.
Social history: You don't smoke, don't drink. You play Rugby at a high level locally, and have a big match coming up in one weeks time. You're concerned as you've had to miss this weekends training session due to the pain.
Past history:
Nill
Medication:
Nill
You are allergic to penicillin
Ideas: You are worried as the pain has been ongoing for a week, and whilst it is slightly better, it's not gone away. You have looked on Google, and are worried you have Scheuermann's disease.
Concerns: Other than the concern for a more serious underlying condition, you're also concerned the effect this may have on an upcoming rugby match you have in one weeks time.
Expectation: To be told that this isn't anything serious, and hopefully been given the all clear to play next week.
Examination Findings
Systemically well
No spinal tenderness, no bony tenderness.
You have a normal range of movement in both your lumbar and thoracic spine.
You have some tenderness over the left lower paraspinal muscles, and this is consistent with the pain you have been feeling
Lower leg neuro exam is Normal.
No spinal tenderness, no bony tenderness.
You have a normal range of movement in both your lumbar and thoracic spine.
You have some tenderness over the left lower paraspinal muscles, and this is consistent with the pain you have been feeling
Lower leg neuro exam is Normal.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Encourages improvement, rehabilitation, and, where appropriate, recovery. Encourages the patient to participate in appropriate health promotion and self-management strategies Gives realistic expectations for prognosis Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Unable to enhance patient’s health perceptions and coping strategies |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue Shows commitment to equality for all |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Inappropriately influences patient interaction through own views/values Quick to judge |
Management
Diagnosis:
In this case, it's likely that the patient has a simple muscular back pain brought on by a different activity / awkward landing. There are no red flags as per NICE for cancer / fracture / Infection / Cauda Equina. There are also no signs nor symptoms of Scheuermann's disease of the spine in this boy. If you'd like a refresher on Scheuermann's disease, you can read the article on Patient.co.uk here. A brief summary has been outlined at the end of this section.
It's not uncommon for teenagers now to google up their symptoms before presenting to the GP, so it's important to elicit this. Please see below for a list taken from the NICE CKS website on red flags in back pain:
In this case, it's likely that the patient has a simple muscular back pain brought on by a different activity / awkward landing. There are no red flags as per NICE for cancer / fracture / Infection / Cauda Equina. There are also no signs nor symptoms of Scheuermann's disease of the spine in this boy. If you'd like a refresher on Scheuermann's disease, you can read the article on Patient.co.uk here. A brief summary has been outlined at the end of this section.
It's not uncommon for teenagers now to google up their symptoms before presenting to the GP, so it's important to elicit this. Please see below for a list taken from the NICE CKS website on red flags in back pain:
Serious conditions whose signs and symptoms can cause low back pain are listed below.
- Cauda equina syndrome. Red flags include:
- Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.
- Recent-onset urinary retention (caused by bladder distension because the sensation of fullness is lost) and/or urinary incontinence (caused by loss of sensation when passing urine).
- Recent-onset faecal incontinence (due to loss of sensation of rectal fullness).
- Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia).
- Unexpected laxity of the anal sphincter.
- Spinal fracture. Red flags include:
- Sudden onset of severe central spinal pain which is relieved by lying down.
- A history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids.
- Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present.
- There may be point tenderness over a vertebral body.
- Cancer. Red flags include:
- The person being 50 years of age or more.
- Gradual onset of symptoms.
- Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain.
- Localised spinal tenderness.
- No symptomatic improvement after four to six weeks of conservative low back pain therapy.
- Unexplained weight loss.
- Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine.
- Infection (such as discitis, vertebral osteomyelitis, or spinal epidural abscess). Red flags include:
- Fever
- Tuberculosis, or recent urinary tract infection.
- Diabetes.
- History of intravenous drug use.
- HIV infection, use of immunosuppressants, or the person is otherwise immunocomprimised.
Management:
The management of simple muscular back pain is fairly straight forward, and involves: Simple self management advice (light mobilisation, no heavy lifting, the self resolving nature of most lower back pains, and the encouragement to continue with usual daily activities.) If analgesia is needed, then simple analgesia is best. NICE CKS currently recommends NSAIDS as first line, and paracetamol as an adjunct if needed. for adults you could consider a short course of muscle relaxants - obviously, this would not be appropriate to prescribe in a 13 year old.
In this case - specific advice about whether he is well enough to play rugby can be difficult. Often sports clubs have access to a sports physio, and encouraging the patient to seek their advice can be helpful. If in doubt, as he has a week before his game, you could opt to speak to him again closer to the time. Then make your decision then. Often in the CSA you can find yourself in the situation of having a patient with an upcoming event that they may not be able to complete due to their presenting complaint. The best tactic is to be empathetic and understanding towards them. This way, even if you have to inform them that they may be unable to complete the event, the patient feels as though their ideas and concerns have been listened to. It can also be helpful to explain why you don't advise completing the event, and what the sequelae might be if they did.
The management of simple muscular back pain is fairly straight forward, and involves: Simple self management advice (light mobilisation, no heavy lifting, the self resolving nature of most lower back pains, and the encouragement to continue with usual daily activities.) If analgesia is needed, then simple analgesia is best. NICE CKS currently recommends NSAIDS as first line, and paracetamol as an adjunct if needed. for adults you could consider a short course of muscle relaxants - obviously, this would not be appropriate to prescribe in a 13 year old.
In this case - specific advice about whether he is well enough to play rugby can be difficult. Often sports clubs have access to a sports physio, and encouraging the patient to seek their advice can be helpful. If in doubt, as he has a week before his game, you could opt to speak to him again closer to the time. Then make your decision then. Often in the CSA you can find yourself in the situation of having a patient with an upcoming event that they may not be able to complete due to their presenting complaint. The best tactic is to be empathetic and understanding towards them. This way, even if you have to inform them that they may be unable to complete the event, the patient feels as though their ideas and concerns have been listened to. It can also be helpful to explain why you don't advise completing the event, and what the sequelae might be if they did.
Scheuermann's Disease - a Very Brief Overview:
Defined as Osteochondrosis of the thoracic vertebral bodies which leads to wedge-shaped vertebrae. Resulting in increased kyphosis, poor posture and backache, and is the most common cause of structural kyphosis in adolescents
Affects those aged 13-16, and presents with back pain, 'poor posture' noted by parents / others, excessive kyphosis. It is diagnosed with X-rays or MRI. Management is currently controversial as the natural history of the condition is poorly understood. However conservative management with physios and lifestyle modification appears to be enough for most. You might wish to seek specialist input however.