RACGP KFP 2016.1.2 – Acute back pain

by | Feb 6, 2018

Wonda, a 62 year old women presents to you with acute onset of lower back pain.  She ranks the pain as an 8/10.  She was helping her daughter move house yesterday and was moving some books from a car the same day it came on.  The pain is better lying down and worse bending forwards.  This is not her first episode of acute low back pain, it happens at least twice a year. 

She has a background of hypertension, asthma that is worsened by mobic and she is overweight and putting on more.  Her medications include symbicort 200/6 bd, ventolin prn, perindopril 10mg and indapamide 1.25m and panadol regularly.   She requires courses of prednisolone on average 1-2 times a year.  She is an ex-smoker, recently quit.

What are the most likely differential diagnosis? List 3

  1. Paraspinal muscular strain
  2. Facet joint pain
  3. Lumbar vertebral disc prolapse
  4. Lumbar vertebrae crush fracture

RACGP – There were a broad range of answers provided by candidates, highlighting again the need for candidates to look at the most like differential diagnoses.  Not just listing all causes of back pain or providing answers relevant to the board clinical context. Listing causes of back pain in a male patients such as metastatic prostate cancer would obviously not have scored.

What further history do you want to know? List 4

  1. Radiation down her legs
  2. Weakness in legs
  3. Sensation changes in legs
  4. Bladder dysfunction
  5. Bowel dysfunction

GPCC – This question wasn’t explicitly mentioned as being in the Public Exam Report. Our take on answering this question was to differentiate between the broad severity categories – Category A – D as described in Murtaghs.

Case continued… Wonda reports the pain is localised in her lower back and she denies radiation, bowel or bladder changes and no neurological symptoms.  You performed an xray to check for crush fractures which was normal.  

What are the initial management steps in Wonda? List 4

  1. Movement as tolerated (2)
  2. Analgesia panadeine forte 1g/60mg qid prn (2)
  3. Referral to physiotherapy for preventative exercises (2)
  4. Bone mineral density scan (2)
  5. Heat pack (1)
  6. Review in 1-2 weeks (1)

GPCC – no marks would be given for saying panadol, as the stem already indicates she is taking this.  Likewise NSAIDs in asthma and her medication combination would not be ideal and her response to Mobic would make this a poor choice.

RACGP – In managing the condition the question asked about the next steps after investigations.  In the KFP paper candidates are requested to provide a specific number of answers, in this case there was a request for four answers. If candidates provide extra responses above this then there is a penalty for each answer above the four answers.  Answers are meant to be short, and one answer per line.  No request was made to explain, expand or justify the management steps given.  In doing any of these candidates risk being penalised for extra responses.

 

RACGP Feedback

This case revolves around a 62yr old woman with acute onset of back pain after moving some books from a car.  The case focuses on the ability to assess and manage a simple musculoskeletal injury whilst taking into consideration comorbidities of asthma and hypertension.

There were a broad range of answers provided by candidates, highlighting again the need for candidates to look at the most like differential diagnoses.  Not just listing all causes of back pain or providing answers relevant to the board clinical context. Listing causes of back pain in a male patients such as metastatic prostate cancer would obviously not have scored,  It is important exam technique to ensure you read the scenario, and identify the key information about the patient, such as age and gender.

In managing the condition the question asked about the next steps after investigations.  In the KFP paper candidates are requested to provide a specific number of answers, in this case there was a request for four answers. If candidates provide extra responses above this then there is a penalty for each answer above the four answers.  Answers are meant to be short, and one answer per line.  No request was made to explain, expand or justify the management steps given.  In doing any of these candidates risk being penalised for extra responses.  It is good exam technique to review the answers and if you have used phrases/words such as ‘for example’, ‘because’, or ‘and’ or even need to use commas then the answer is most likely to contain extra responses and therefore attract penalties.

 

GPCC Feedback

This question should be well within your studied topics, should have been encountered regularly and should be a question that scores well.

 

Further reading:

  • https://www.nps.org.au/australian-prescriber/articles/managing-low-back-pain-in-primary-care
  • eTG good
  • Murtaghs good , particularly on the categories, red flag exclusion, inclusion within the Masquerades

 

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