java barcode library open source Clinical Approach to Diagnosis General History & Physical Examination in Objective-C

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1 Clinical Approach to Diagnosis General History & Physical Examination
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Low back pain is a final common pathway of many processes; the pain of vertebral osteomyelitis, for example, is not very different in quality and intensity from that due to back strain of the weekend gardener Historical factors of importance include smoking, weight loss, age over 50, and cancer, all of which are risk factors for vertebral body metastasis Osteomyelitis most frequently occurs in adults with a history of recurrent urinary tract infections and is especially common in diabetics and injection drug users A history of a cardiac murmur should raise concern about endocarditis, since back pain is not an uncommon manifestation A background of renal stones might indicate another cause of referred back pain
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History of the Back Pain
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Certain qualities of a patient s pain can indicate a specific diagnosis Low back pain radiating down the buttock and
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Table 20 6 Neurologic testing of lumbosacral nerve disorders
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Nerve Root L4 L5 S1 Motor Dorsiflexion of foot Dorsiflexion of great toe Eversion of foot Reflex Knee jerk None Ankle jerk Sensory Area Medial calf Medial forefoot Lateral foot
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tiple nerve roots suggest a cauda equina tumor or an epidural abscess, both requiring urgent evaluation and treatment Measurement of spinal motion in the patient with acute pain is rarely of diagnostic utility and usually simply confirms that pain limits motion An exception is the decreased range of motion in multiple regions of the spine (cervical, thoracic, and lumbar) in a diffuse spinal disease such as ankylosing spondylitis By the time the patient has such limits, however, the diagnosis is usually straightforward If back pain is not severe and does not itself limit motion, the modified Schober s test of lumbar motion is helpful in early diagnosis of ankylosing spondylitis To perform this test, two marks are made, one 10 cm above S1 and another 5 cm below The patient then bends forward as far as possible, and the distance between the points is measured Normally, the distance increases at least 5 cm Anything less indicates reduced lumbar motion, which in the absence of severe pain is most commonly due to ankylosing spondylitis or other seronegative spondyloarthropathies Palpation of the spine usually does not yield diagnostic information Point tenderness over a vertebral body is reported to suggest osteomyelitis, but this association is uncommon A step-off noted between the spinous process of adjacent vertebral bodies may indicate spondylolisthesis, but the sensitivity of this finding is extremely low Tenderness of the soft tissues overlying the greater trochanter of the hip is a manifestation of trochanteric bursitis Inspection of the spine is not often of value in identifying serious causes of low back pain The classic posture of ankylosing spondylitis is a late finding Scoliosis of mild degree is not associated with an increased risk of clinical back disease Cutaneous neurofibromas can identify the rare patient with nerve root encasement Examination of the hips should be part of the complete examination While hip arthritis usually produces groin pain, some patients have buttock or low back symptoms
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tion dose and are not routinely needed Radiographs can provide evidence of vertebral body osteomyelitis, cancer, fractures, or ankylosing spondylitis Degenerative changes in the lumbar spine are ubiquitous in patients over 40 and do not prove clinical disease Plain radiographs have very low sensitivity or specificity for disk disease Thus, plain radiographs are warranted promptly for patients suspected of having infection, cancer, or fractures; selected other patients who do not improve after 2 4 weeks of conservative therapy are also candidates The Agency for Health Care Policy and Research guidelines for obtaining lumbar radiographs are summarized in Table 20 7 MRI provides exquisite anatomic detail but is reserved for patients who are considering surgery or have evidence of a systemic disease For example, MRI is needed urgently for any patient in whom an epidural mass or cauda equina tumor is suspected but not for a patient believed to have a routine disk herniation, since most will improve over 4 6 weeks of conservative therapy Noncontrast CT does not image cauda equina tumors or other intradural lesions, and if used instead of MRI it must include intrathecal contrast Radionuclide bone scanning has limited usefulness It is most useful for early detection of vertebral body osteomyelitis or osteoblastic metastases The bone scan is normal in multiple myeloma because lytic lesions do not take up isotope
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