Ivan is a 44-year-old man who presents with ongoing back pain for the past six weeks. He works in the local abattoir as a forklift driver, which involves loading 50 kg pallets onto a truck. The back pain started when he twisted his back trying to load a pallet on his own.
Communication and consultation skills
How would you empathically assess the impact of Ivan’s back pain on his day-to-day life?
How would your approach differ if Ivan were an Aboriginal or Torres Strait Islander?
Empathic Assessment:
To empathically assess the impact of Ivan’s back pain on his day-to-day life, I would:
- Show empathy and concern: Start with a warm greeting and an open-ended question like, “Ivan, I understand you’ve been dealing with back pain for a while now. How has this been affecting your daily activities and overall well-being?”
- Active listening: Pay close attention to Ivan’s response, nodding and making eye contact to show you are engaged.
- Acknowledge his struggles: Respond with statements like, “That sounds really challenging. It must be difficult to manage your job with this pain.”
- Explore specific impacts: Ask about specific aspects of his life, such as sleep, work, and recreational activities. “How has the pain affected your work at the abattoir and your ability to do tasks at home?”
Approach for Aboriginal or Torres Strait Islander Patients:
If Ivan were an Aboriginal or Torres Strait Islander, I would:
- Cultural sensitivity: Show respect for his cultural background and ask if he would like a family member or community liaison present.
- Holistic approach: Consider the broader social and community context and how his cultural background might impact his perception and management of pain.
- Use appropriate language: Ensure clear communication, possibly involving an interpreter if needed.
- Build rapport: Spend extra time to build trust and rapport, understanding that cultural factors may influence his health behaviors and beliefs.
Clinical information gathering and interpretation
What red flag symptoms would you look for?
What information do you want to gather about Ivan’s back pain?
How would you explore the biopsychosocial aspects of Ivan’s back pain?
What other information would you need to clarify the aetiology of his back pain?
Red Flag Symptoms:
- Unexplained weight loss
- Fever or night sweats
- History of malignancy
- Neurological deficits (e.g., weakness, numbness, bladder/bowel dysfunction)
- Severe, unrelenting pain or pain that wakes him at night
Information to Gather:
- Onset, duration, and character of the pain
- Aggravating and relieving factors
- Any associated symptoms (e.g., leg pain, numbness, weakness)
- History of similar episodes
- Occupational and ergonomic factors
- Impact on daily activities and mental health
- Current medications and treatments tried
Biopsychosocial Aspects:
- Biological: Detailed medical history, physical examination, imaging studies if indicated.
- Psychological: Assess for anxiety, depression, and coping mechanisms.
- Social: Work environment, support systems, and any stressors.
Clarifying Aetiology:
- Detailed history and physical examination
- Imaging (e.g., X-ray, MRI) if indicated by red flags
- Laboratory tests (e.g., inflammatory markers if infection or malignancy is suspected)
Making a diagnosis, decision making and reasoning
What differential diagnosis would you consider for Ivan?
If Ivan were a 70 year old with a history of prostate cancer, what would be your approach?
What if there were no history of injury?
Differential Diagnosis of Back Pain in Adults
- Lumbosacral Muscle Strains and Sprains
- Etiology: Traumatic incident or repetitive overuse
- Symptoms: Pain worsens with movement, improves with rest, restricted range of motion, muscle tenderness on palpation
- Lumbar Spondylosis
- Typical Age: >40 years
- Symptoms: Hip pain, pain with lower limb extension or rotation, normal neurologic exam
- Disk Herniation
- Common Segments: L4 to S1
- Symptoms: Paresthesia, sensory changes, loss of strength or reflexes, depending on nerve root involvement
- Spondylolysis and Spondylolisthesis
- Cause: Repetitive spinal stress
- Symptoms: Back pain radiating to gluteal area and posterior thighs, neurologic deficits following L5 distribution
- Vertebral Compression Fracture
- Symptoms: Localized back pain worsening with flexion, point tenderness on palpation, acute or chronic
- Risk Factors: Steroid use, vitamin D deficiency, osteoporosis
- Spinal Stenosis
- Symptoms: Leg sensory and motor weakness relieved with rest (neurologic claudication), neurologic exam may be normal initially
- Tumor
- Symptoms: Unexplained weight loss, focal tenderness to palpation, risk factors for malignancy
- Note: 97% of spinal tumors are metastatic
- Infection
- Risk Factors: History of spinal surgery, IV drug use, immunosuppression
- Symptoms: Fever, localized pain and tenderness, potential TB if from a developing country
- Fracture
- Causes: Trauma, prolonged corticosteroid use, osteoporosis
- Symptoms: Contusions, abrasions, tenderness to palpation over spinous processes
- Common in patients >70 years
Differential Diagnosis of Back Pain in Children and Adolescents
- Tumor
- Symptoms: Fever, malaise, weight loss, nighttime pain, recent-onset scoliosis
- Common Tumor: Osteoid osteoma (relieved by NSAIDs)
- Infection
- Symptoms: Fever, malaise, weight loss, nighttime pain, recent-onset scoliosis, refusal to walk
- Common Conditions: Vertebral osteomyelitis, diskitis, septic sacroiliitis, epidural abscess, paraspinal muscle abscess
- Consider epidural abscess if neurologic deficits and radicular pain are present
- Disk Herniation and Slipped Apophysis
- Symptoms: Acute back pain, radicular pain, recent-onset scoliosis
- Physical Findings: Positive SLR test, pain on spinal forward flexion
- Spondylolysis, Spondylolisthesis, and Posterior Arch Lesion
- Symptoms: Acute-onset back pain with radicular pain, hamstring tightness
- Physical Findings: Positive SLR test, pain on spinal extension
- Vertebral Fracture
- Cause: Trauma
- Symptoms: Acute back pain, potential neurologic deficits, progressive postural changes in stress fractures
- Muscle Strain
- Symptoms: Acute back pain, muscle tenderness without radiation
- Scheuermann’s Kyphosis
- Symptoms: Chronic back pain, rigid kyphosis
- Inflammatory Spondyloarthropathies
- Symptoms: Chronic pain, morning stiffness >30 minutes, sacroiliac joint tenderness
- Psychological Disorders (e.g., Conversion and Somatization Disorder)
- Symptoms: Persistent subjective pain with normal physical findings
- Idiopathic Scoliosis
- Symptoms: Usually asymptomatic, positive Adam test, back pain may be due to another cause
Approach if Ivan were a 70-year-old with a history of prostate cancer:
- High suspicion for metastatic disease
- Urgent imaging (e.g., MRI, bone scan)
- Referral to oncology if metastasis is suspected
Approach with no history of injury:
- Consider Underlying Conditions:
- Osteoporosis:
- Risk factors: Age, gender, family history, steroid use, low calcium intake
- Assess for signs of vertebral compression fractures
- Malignancy:
- Red flags: Unexplained weight loss, night pain, personal or family history of cancer
- Consider primary tumors (e.g., multiple myeloma) or metastatic disease
- Infection:
- Risk factors: Recent infections, intravenous drug use, immunosuppression
- Symptoms: Fever, localized tenderness, systemic signs of infection
- Common conditions: Vertebral osteomyelitis, discitis, epidural abscess
- Osteoporosis:
- Further Investigations:
- Imaging:
- X-ray: Initial assessment for fractures, osteoarthritis, spondylolisthesis
- MRI: Detailed evaluation of soft tissues, discs, spinal cord, infection, or tumors
- CT scan: Detailed bone imaging if fractures or complex anatomy is suspected
- Laboratory Tests:
- Complete blood count (CBC): Assess for infection or malignancy
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): Inflammation markers for infection or malignancy
- Bone density scan (DEXA): Assess for osteoporosis
- Imaging:
Clinical management and therapeutic reasoning
How would you manage Ivan’s back pain if he were consuming alcohol at unsafe levels or if he were using recreational drugs?
Would you consider referring him to any other health professional?
How would you manage his back pain if you were working in a remote community?
Management if Ivan were consuming alcohol or using recreational drugs:
- Address substance use with a non-judgmental approach
- Offer support and referral for substance use counseling if needed
- Consider non-opioid pain management strategies
- Monitor for potential interactions with medications
Referral to Other Health Professionals:
- Physiotherapist for tailored exercise program
- Occupational therapist for ergonomic assessment
- Psychologist if psychological factors are significant
Management in a Remote Community:
- Utilize telehealth services for specialist consultations
- Provide education on self-management strategies
- Collaborate with local health workers for ongoing support
Preventive and population health
What advice would you give to Ivan to prevent this injury happening again?
If Ivan were an Aboriginal or Torres Strait Islander, would you consider managing him differently?
What supports would you consider for Ivan’s recovery?
Preventive Advice:
- Proper lifting techniques and use of mechanical aids
- Regular exercise to strengthen back and core muscles
- Maintain a healthy weight
- Ergonomic adjustments at work
Considerations for Aboriginal or Torres Strait Islander Patients:
- Incorporate culturally appropriate health education
- Engage with community support programs
- Collaborate with Aboriginal health workers
Supports for Recovery:
- Multidisciplinary rehabilitation program
- Support from family and community
- Gradual return-to-work plan with modifications if needed
Professionalism
Your assessment is Ivan has recovered completely. As it is the end of the year, Ivan doesn’t want to waste his sick leave. He asks you to write a certificate for a few more days’ leave. How would you manage this situation?
If your return-to-work plan and Ivan’s expectations don’t match, how would you proceed?
Managing Ivan’s Request for Additional Sick Leave:
When Ivan requests a certificate for additional sick leave despite having recovered completely, it is important to balance patient empathy with professional and ethical standards. Here is a step-by-step approach to managing this situation:
- Empathic Communication:
- Acknowledge his request: “Ivan, I understand that you don’t want to waste your sick leave, especially since it’s the end of the year.”
- Explain your position: “However, as a healthcare professional, I am bound by ethical guidelines that require me to provide honest and accurate medical certificates.”
- Discuss the Ethical Guidelines:
- Explain the importance of accuracy: “Medical certificates need to reflect your true medical condition. Issuing a certificate for time off when it is not medically necessary can have serious implications for both of us.”
- Impact on professional integrity: “My responsibility is to provide accurate information that employers can rely on to make decisions about work and health.”
- Offer Alternatives:
- Use of annual leave: “You might consider using annual leave if you need some additional time off.”
- Well-being discussion: “Let’s also discuss any other ways I can support your well-being as you transition back to work.”
- Document the Interaction:
- Record the conversation: Ensure you document Ivan’s request and your response in his medical record to maintain transparency and protect yourself from any potential disputes.
RACGP Guidelines
The Royal Australian College of General Practitioners (RACGP) provides guidelines emphasizing professional and ethical conduct in general practice. Key points relevant to issuing medical certificates include:
- Accuracy and honesty: Medical certificates must reflect the true medical condition of the patient.
- Professional integrity: GPs should not be influenced by patient requests that compromise their professional judgment.
- Patient education: Educate patients on the importance of accurate medical documentation and its implications.
AVANT Guidelines
AVANT, a leading medical indemnity provider in Australia, also provides guidance on issuing medical certificates:
- Honest assessment: Ensure that any medical certificate provided is based on a thorough and honest assessment of the patient’s condition.
- Clear documentation: Maintain clear and detailed documentation of the consultation, the patient’s request, and your clinical decision.
- Legal and ethical standards: Adhere to legal and ethical standards to avoid potential legal consequences and maintain trust in the medical profession.
Summary
To manage Ivan’s request:
- Communicate empathetically but firmly about the ethical requirements.
- Explain the importance of accurate medical documentation.
- Offer alternative solutions, such as using annual leave.
- Document the interaction thoroughly.
Addressing Mismatched Return-to-Work Plans:
- Discuss and negotiate a realistic and safe return-to-work plan
- Involve a workplace rehabilitation provider if necessary
Step 1: Open Dialogue
- Acknowledge Ivan’s Perspective:
- “Ivan, I see that you have some concerns about the return-to-work plan I’ve suggested. Let’s discuss them so I can understand your point of view better.”
- Encourage Ivan to Express His Concerns:
- “What specifically about the plan is not working for you? Are there particular aspects that you find challenging or unfeasible?”
Step 2: Understand the Concerns
- Explore Ivan’s Expectations:
- “Can you share with me what your ideal return-to-work plan would look like?”
- Identify Underlying Issues:
- Determine if Ivan’s concerns are related to the nature of his job, financial issues, fear of re-injury, or other personal factors.
Step 3: Re-evaluate the Plan
- Review the Return-to-Work Plan Together:
- Go through the plan step-by-step to ensure that Ivan understands the rationale behind each part.
- Be Flexible Where Possible:
- “Is there any part of the plan that you feel we could adjust while still ensuring your safety and well-being?”
Step 4: Negotiate and Collaborate
- Find Common Ground:
- “Let’s see if we can find a middle ground that meets both your needs and the medical recommendations.”
- Set Clear Expectations:
- Clearly outline the goals of the return-to-work plan and any modifications made.
Step 5: Seek Additional Support
- Involve Other Health Professionals if Needed:
- “Would it help if we brought in a physiotherapist or occupational therapist to provide more tailored support?”
- Consider Workplace Modifications:
- Collaborate with Ivan’s employer to explore options for modified duties or gradual return-to-work programs.
Step 6: Document the Discussion
- Keep Detailed Records:
- Document the conversation, including Ivan’s concerns, your responses, any adjustments made to the plan, and the agreed-upon course of action.
Step 7: Monitor and Follow-Up
- Regular Check-Ins:
- Schedule follow-up appointments to monitor Ivan’s progress and address any new concerns.
- Adjust the Plan as Needed:
- Be open to further adjustments based on Ivan’s progress and feedback.
Summary
When managing discrepancies in return-to-work plans:
- Engage in an open dialogue to understand Ivan’s concerns.
- Explore and address the underlying issues.
- Review and possibly adjust the return-to-work plan collaboratively.
- Involve additional health professionals and consider workplace modifications.
- Document the entire discussion and agreed-upon plan.
- Monitor Ivan’s progress through regular follow-ups and make necessary adjustments.
General practice systems and regulatory requirement
You have started Ivan on an opioid. You are going on planned leave the next day. How would you plan continuity of care for Ivan? What plans would you put in place if you were planning to prescribe opiates for his pain?
Continuity of Care for Opioid Prescription:
- Ensure clear documentation of the treatment plan
- Arrange follow-up with another healthcare provider during your absence
- Educate Ivan on safe opioid use and potential side effects
Plans for Opiate Prescription:
- Assess and document pain severity and functional impairment
- Use the lowest effective dose for the shortest duration
- Regularly review and reassess the need for ongoing opioid therapy
Procedural skills
What exercises could you teach Ivan for the longer term to prevent future back injuries?
Exercises for Long-Term Prevention:
- Core strengthening exercises
- Flexibility exercises (e.g., hamstring stretches)
- Aerobic exercises (e.g., walking, swimming)
- Proper body mechanics and posture training
Managing uncertainty
If Ivan’s recovery does not progress as you expect, what factors would you explore?
If Ivan insists on being given a narcotic medication, how would you manage this?
If Ivan’s recovery is complicated by psychosocial factors such as depression due to his chronic pain or because he has lost his job, how would you manage the situation?
Exploring Factors if Recovery Does Not Progress:
- Reassess for any missed diagnosis or complications
- Evaluate adherence to treatment plan
- Address any psychological or social barriers
- Psychological Factors (Yellow Flags):
- Catastrophizing: Exaggerated negative thoughts about pain and its implications.
- Fear-Avoidance Beliefs: Fear that physical activity will cause further injury, leading to avoidance behaviors.
- Depression and Anxiety: Mental health conditions that can exacerbate pain perception and reduce motivation for rehabilitation.
- Passive Coping Strategies: Reliance on rest and medication rather than active participation in rehabilitation.
- Social Factors (Yellow Flags):
- Workplace Issues: Stressful work environment, lack of support from employers or colleagues, and job dissatisfaction.
- Social Support: Lack of support from family and friends, leading to isolation and increased stress.
- Financial Stress: Concerns about medical costs, loss of income, and job security.
- Psychological Factors (Yellow Flags):
Addressing Non-Improvement
- Re-assessment and Accurate Diagnosis:
- Comprehensive Evaluation: Re-assess Ivan’s condition with a thorough history, physical examination, and appropriate imaging or laboratory tests to rule out other causes of chronic pain.
- Multidisciplinary Approach: Involve specialists such as orthopedic surgeons, neurologists, or pain management experts for a comprehensive evaluation.
- Optimizing Physical Treatment:
- Tailored Physical Therapy: Design a personalized physical therapy program focusing on strengthening, flexibility, and functional restoration.
- Pain Management: Optimize pain management strategies, including non-opioid medications, nerve blocks, or minimally invasive procedures if necessary.
- Addressing Psychological Factors (Yellow Flags):
- Cognitive Behavioral Therapy (CBT): Refer Ivan to a psychologist for CBT to address catastrophizing thoughts, fear-avoidance beliefs, and depression.
- Encourage Active Coping: Promote active participation in rehabilitation and self-management techniques, such as mindfulness and relaxation exercises.
- Educational Interventions: Educate Ivan about the nature of chronic pain, the importance of physical activity, and realistic recovery expectations.
- Improving Social Support and Work Environment:
- Workplace Interventions: Collaborate with Ivan’s employer to modify his work environment and duties to reduce physical strain and stress.
- Social Support Networks: Encourage involvement of family and friends in Ivan’s treatment plan to provide emotional and practical support.
- Financial Counseling: Provide resources for financial counseling or support services to alleviate financial stress.
Managing Requests for Narcotic Medication:
- Discuss risks and benefits of narcotics
- Explore alternative pain management strategies
- Consider referral to a pain specialist
Managing Complications from Psychosocial Factors:
- Provide holistic care, addressing both physical and mental health
- Refer to mental health services for support
- Collaborate with social services if needed
Identifying and managing the significantly ill patient
If Ivan presents with symptoms suggestive of spinal cord compression, how would you assess and manage this?
If he presented acutely unwell with back pain and fever, how would you assess and manage him?
Assessing and Managing Spinal Cord Compression:
- Immediate neurological examination
- Urgent MRI to confirm diagnosis
- Emergency referral to a neurosurgeon
ASIA IMPAIRMENT SCALE
- The American Spinal Injury Association (ASIA) Standard Neurological Classification of Spinal Cord Injury is a standard method of assessing the neurological status of a person who has sustained a spinal cord injury.
- Scale assessments can be carried out using this ASIA Impairment Scale worksheet (PDF).
- The neurological level of injury is the most caudal segment of the cord with intact sensation and antigravity (3 or more) muscle function strength, provided that there is normal (intact) sensory and motor function rostrally respectively.
| Category | Description |
|---|---|
| A = Complete | No motor or sensory function is preserved in the sacral segments S4-S5 |
| B = Incomplete | Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5 |
| C = Incomplete | Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade of less than 3 |
| D = Incomplete | Motor function is preserved below the neurological level, and at least half of the key muscles below the neurological level have a muscle grade of 3 or more |
| E = Normal | Motor and sensory function are normal |
- Loss of motor function’ means a person has no voluntary control of their muscles.
- ‘Loss of sensory function’ means a person has no sense of touch and cannot feel hot or cold, pain, or pressure. They also have no sense of where in space their limbs are (proprioception).
Assessing and Managing Acute Back Pain with Fever:
- Evaluate for signs of systemic infection (e.g., osteomyelitis, discitis)
- Perform relevant blood tests (e.g., CRP, ESR, blood cultures)
- Urgent imaging if infection is suspected
- Referral to an infectious disease specialist if necessary