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SP Encounter for IPE Clinic
Back pain return to clinic
Goals of the Exercise:
To assess student history-taking and physical exam in a patient with back pain
To evaluate the use of telemedicine as part of the clinic experience
Additional teaching:
1) Ruling out dangerous medical conditions (potential cord compression or diskitis, epidural
abscess)
2) Safe prescription of narcotics
3) Counseling a patient in management of pain
The patient is a middle aged patient (preferably male) who presented to clinic 1 week ago for back
pain after moving some furniture in his house. At the time of the clinic visit, the patient described
fairly sudden onset of pain that radiated down his left leg and felt like “electric shocks.”
S/he returns to clinic today at the suggestion of clinic staff. They called the patient to followup on
how he was doing, and since his symptoms had actually worsened, he was asked to return to
clinic.
Currently, the patient has pain in his lower back which is diffuse. He rates the pain as 8/10 and it
is associated with significant nausea and sometimes sweating. The pain does not radiate as much
down his left leg as it had a week ago.
If asked (and only if asked)
The narcotics given to the patient (Percocet) helped the patient, but he ran out several days ago.
Because of the pain the patient has been taking time off work (and would like another work slip),
and laying in bed a lot.
He was given a referral for physical therapy, but he could not afford the therapy.
He does have some difficulty urinating, but this is not new, and is thought to be related to his
prostate. (strike this if female SP)
He does not have a loss of feeling in his inner thighs.
No fevers, chills, or night sweats.
Any other review of system questions that are asked can be answered with “no”
PMH:
Hypertension
Hyperlipidemia
Diabetes Mellitus
Benign prostatic hypertrophy
(previous history of depression, disclose only if asked)
Medications:
Ramipril 10mg once a day
Atoravastatin 20mg once a day
Metformin 1000mg PO (twice a day)
Lantus Insulin 20 Units QHS (at night, but injection subQ)
Social history:
Works as a independent plumber (owns own company)
Drinks fairly heavily on weekends—maybe 6-8 beers Friday, Saturday, Sunday night
Smokes 1 ppd
Family History: (male SP)
Had a father who died of liver disease from drinking, also had prostate cancer
Had a sister who abused prescription drugs (answer only if asked specifically about this)
Strong family history for prostate cancer-one brother with prostate cancer in early 50s, one uncle
with prostate cancer)
Family History (female SP):
Had a father who died of liver disease from drinking, also had prostate cancer
Mother with breast cancer, deceased
Sister with breast cancer, alive
Had a second sister who abused prescription drugs
One maternal aunt with breast cancer
(if ask and only if ask, patient also has a childhood history of being sexually abused by an uncle)
Physical Exam:
All entirely normal except:
 When the students palpate to the sides of the spine in the lower back, there is a lot of pain
(it would be great if the SP could actually tighten his back when they go to examine there).
 There is no pain along the actual spine
 There is pain with back extension
 When the student performs a straight leg raise with dorsiflexion of the foot, there is pain at
about 20 degrees
 Side of left leg and top of left foot has some numbness
 Weakness of left toe extension
 There is no Achilles reflex (or it is less---allows the SP to exaggerate reflexes on the right in
order to make the reflex on the left heel less than on the right).
There are negative Waddells signs:
 There is no nonanatomic tenderness: no skin discomfort on light palpation)
 There is no pain with axial loading (when someone pushes on your head or when they ask
you to rotate the shoulders and pelvis together
 The straight leg raise is still positive when the team tries to distract the SP
Discussion Points:
1) What is the diagnosis: should be some increased spasm with a L4 radiculopathy
2) How are you sure this isn’t something more sinister? No fevers, chills, nightsweats, no
history of trauma, no evidence of spinal cord compression
3) Why did the patient get worse: Bed rest
4) What will you counsel the patient on: stretching—go over exercises, explain why bed rest
is bad
5) Will you give a work statement: no it will make things worse!
6) Will you give narcotics: no—fails opioid screening via the opioid risk tool
Faculty will give print outs of stretching: see attached and say that after visit summary is
there.
Other Discussion points:
What are the laws around telemedicine:
 Must be fully licensed in the state in which you are practicing
 Credentialling at one hospital (Duke) is all that is needed if agreement between Duke and
the other hospital exists
What are some classic uses of telemedicine:
 In the ICU- Tele-ICU—particulary for rural locations (can be caring for patients in multiple
states at once!) (13% of ICU beds are telemedicine-results in 20% reduction in mortality
and 30% reduction in length of stay)
 To determine potential evidence of stroke- Neuro ICU
 For patients with chronic conditions (CHF, diabetes, etc)—at VA, Boston Partners—
reduced readmissions, improves medication adherence
 In dermatology—reviewing images of patients sent by referring providers
 In psychiatry- reduces inpatient admissions, LOS, 30 day OP followup and total health
charges
PIriformis Stretch
Modified Hurdlers Stretch
Back Extension
Swimmers Exercise
Leg Lifts