For Professionals

• Injecting oral formulations
• Crushing Oral formulations

• Taking drugs from family or friends
• Buying prescription medications from the street
• Multiple-doctoring

• Recurrent prescription losses
• Ongoing complaints about need to increase dose
• Asking for specific medication

• Dysphoria
• Myalgias
• Diarrhea
• Cravings
• Sweating
• Goosebumps

• Alcohol dependence
• Stimulant abuse
• Cannabinoids abuse
• Mood disorders resistant to treatment
• Anxiety disorders resistant to treatment

• Family and relationship problems
• Job loss and unemployment
• Concerns expressed by family or friends

• Resistance to dose reduction
• Reporting severe withdrawal symptoms with minor dose reduction
• Denying dependence

There are two types of low back pain

1. Acute: lower back pain for less than 3 months
2. Chronic: lower back pain that has been present for more than 3 months

Drugs/medications:

• Steroid use > 3 months
• Hypertension medications?

Infection/Inflammations:

• Osteomyelitis
• Spinal TB
• Urinary tract infection (sign of urinary retention)
• Reiters disease if patient is a young guy with symptoms of STI
• Inflammatory (seroneg/spondyloarthropathies)
• Ankylosing Spondylitis
  • If young (20-30), no radiation, and pain is worst at movement and better with rest
• Morning stiffness relieved by activity.

• Joint pain,
• Uveitis (inflammation of the uveal tract: iris, ciliary body, and choroids)

Medical/Metabolic:

• Osteoporotic
• Osteomalacia
• Paget’s

Structural:

• Spondylolisthesis: Forward displacement of a lumbar vertebra
• Disc herniation:
  • Sciatica:
    • Pain due to entrapment of sciatic nerve
    • Patient complains of pain, burning or aching in buttocks radiating down posterior thigh to the posterolateral aspect of calf
    • Pain worse with sneezing, laughing or straining during bowel movement
  • Cauda equina syndrome:
    • Leg weakness
    • Lax anus
    • Impotence,
    • Urinary retention
    • Fecal incontinence
    • Is surgical emergency

• Spinal stenosis:
  • is characterized by worsening of symptoms with standing and walking, with relief on bending and setting (a typical history of leaning on and bending over the shopping cart for relief of pain while shopping is suggestive of spinal stenosis).
  • Nerve root entrapment in lumbar spinal stenosis is caused by narrowing of the spinal canal (congenital or acquired), nerve root canals, or intervertebral foramina
  • This narrowing is usually caused by bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum. Disc bulging and spondylolisthesis may contribute.
  • Symptoms of significant lumbar spinal stenosis include back pain, transient tingling in the legs, and ambulation-induced pain localized to the calf and distal lower extremity, resolving with rest.
  • This pain with walking, referred to as “pseudoclaudication” or “neurogenic claudication”, is clinically distinguished from vascular claudication by the presence of normal arterial pulses
• Pancreatitis
• Aortic aneurysm
• PUD
• Kidney stone
• Pyelonephritis
• Prostatitis
• Endometriosis
• PID

• Pain lower back with or without radiation to thighs or legs
• Fever may be present in case of infection
• Limping

Pain:

• Location (worse in leg or back? Radiates to shoulder?)
• Onset
• Duration
• Type of pain: Deep dull pain, sharp pain,
• Severity
• Triggering event
• Pattern, changes with position
• Progression
• Alleviating: rest, warmth
• Aggravating Factors: lifting, walking, sitting, bending

Associated symptoms:

• Previous illness
• Past trauma
• Constitutional (fever, fatigue, night sweats, wt loss, chills)
• Eye syndromes
• Heart diseases
• GU (retention, frequency, overflow incontinence, hesitancy, erectile)
• Bowel (incontinence, perianal sensory loss)
• Other neuro: Saddle anesthesia, loss of sensation, weakness in arms / legs

Consequences:

• Ask about emotional consequences of the injury, the goals of treatment and the visit, patients concerns
• Occupational impact
• Limitation in usual activities
• Social / recreation / sleep
• How long can pt sit / stand / walk
• How much weight can lift

• Previous hx of back pain / treatment / surgery
• Recent infection (UTI)
• Hospitalizations for back injuries
• HIV
• IVDU
• Corticosteroid use
• Vascular disease
• Autoimmune disease
• Supplement use (no use vs. too much use)
• Depression or other mental conditions
• Past history of trauma or injuries
• Previous history of cancer

Vital Signs:

• Temperature
• BP
• PR
• Weight (loss)

Inspection (cervical, thoracic, lumbar)

• Appearance, distress, sitting or standing position
• Posture
• Asymmetry
• Skin rash or redness on back or hips
• Deformity (lordosis or loss of lordosis, kyphosis, scoliosis, rib hump)
• Signs of inflammation, trauma, scars
• Gluteal muscle atrophy
• LN exams
• Uveitis
• Abdominal pain or tenderness
• Balonitis

Gait:

• Abnormal gait

Palpation

• Tenderness (spinous processes & paravertebral muscles)
• Prominence & Alignment spinous processes
• Palpate SI joints
• Spasm of muscles

Percussion

• Spinous processes
• Costovertebral Angle

Range of Motion

• Forward bending (lumbar disc herniation)
• Extension (facet joint or spinal stenosis)
• Lateral flexion
• Rotation (T12 – L1)
• Chest expansion

Trendelenbreg test

Neurological Screen

• Motor
• Ask client to Squat (L4)
• Ask client to Heel walk (L5)
• Ask client to Walk on toes (S1-2)
• Sensory
  • Medial calf (L4)
  • 1^st web space (L5)
  • Lateral foot (S1)
• Reflex
  • Knee jerk (L4)
  • Ankle jerk (L5)
  • Babinski
• Straight leg raise:
  • The test is positive if significant back pain, or radicular pain in the lower extremity is present.
  • A positive test may indicate sciatic or lumbosacral nerve root irritation, for example due to a prolapsed lumbar disc.
  • Dorsiflex the foot at 45 degree is pain it is indicative of sciatica pain.
  • If the leg pain increases but without spinal symptoms consider piriformis syndrome.
  • If positive watch for quada equine syndrome.
• Femoral stretch test (L2,3,4)
• SI joint (flex hip & knee, hyperextend opposite), sacral compression pain
• Peripheral Vascular system
  • Inspect for venous stasis or arterial insufficiency ulcers, check femoral pulses and auscultate for femoral bruits, feel popliteal, dorsalis pedis and tibialis posterior pulses.
• Rectal exam:
  • Tone
  • Hemorrhoid

• Lifestyle
• Hobbies
• Physical activity
• Diet and nutrition
• Drug and alcohol use
• Employment history
• High risk sexual disorders

• ESR if is febrile or if cancer is in DDx
• Alk Phosphatase
• PSA if suspect prostate cancer

• Lubosacral X-Ray
• CT-Scan: is the test of choice to investigate pain suspected to be from multi-segmental bony stenosis and fracture
• MRI: is the primary diagnostic tool when cauda equine or malignancy is suspected or if there is past history of cancer or history of progressive worsening radiculopathy over 4 months

• Yoga maybe beneficial
• Spinal traction not helpful
• Physical therapy
• Chiropracter manipulation may be helpful in patients with simple back pain but not on those with radiculopathy
• Start NSAIDS if no contraindications
• Opioids are no better than non-opioids
• Surgery consult if:
• Quada equine syndrome
• Persistent sciatica
• Sensory deficit
• Positive straight leg raise

Affect is described by labelling the apparent emotion conveyed by the person’s nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility.

Affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia.

The intensity of the affect may be described as normal, blunted affect, exaggerated, flat, heightened or overly dramatic.

A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorders.

Mobility refers to the extent to which affect changes during the interview: the affect may be described as mobile, constricted, fixed, immobile or labile.

The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect.

The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive.

• Reasons the patient wants to quit
• Concerns or worries about quitting
• Success the patient has achieved
• Difficulties encountered while quitting

• Any smoking/drug use (even a single puff) increases the likelihood of full relapse
• Withdrawal typically peaks within 1-3 weeks after quitting
• Withdrawal symptoms include negative mood, urges to smoke or use drugs, and difficulty concentrating

• Negative affect
• Being around other smokers
• Using other drugs
• Experiencing urges
• Being under time pressure

• Learning to anticipate and avoid temptation
• Learning cognitive strategies that will reduce negative moods
• Accomplishing lifestyle changes that reduce stress, improve quality of life, or produce pleasure
• Learning cognitive and behavioral activities to cope with smoking urges (e.g., distracting attention)

• Communicate belief in the patient’s ability to quit
• Note that effective tobacco dependence treatments are now available
• Note that half of all people who have ever smoked have now quit

• Ask how the patient feels about quitting
• Directly express concern and willingness to help
• Be open to the patient’s expression of fears of quitting, difficulties experienced, and ambivalent feelings.

Carpal tunnel syndrome is a painful condition caused by compression of a key nerve in the wrist.   It occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. Symptoms usually start gradually, with  pain, weakness, or numbness in the hand and wrist, radiating up the arm.  As symptoms worsen, people might feel tingling during the day, and decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks.  In some cases no direct cause of the syndrome can be identified.   Most likely the disorder is due to a congenital predisposition – the carpal tunnel is simply smaller in some people than in others.  The risk of developing carpal tunnel syndrome is especially common in those who preform repetitive work tasks, such as assembly line work. Carpal tunnel syndrome is also associated with pregnancy and diseases such as diabetes, thyroid disease, or rheumatoid arthritis.

Mechanical:

• Localized repetitive trauma
• Occupational
• Forced wrist flexion

Metabolic:

• Thyroid Dysfunction
• Hypothyroid
• Pregnancy
• Acromegaly
• Gout

Inflammation and/or infection:

• Infiltrative disorders such as amyloidosis
• Sarcoidosis
• Inflamatory tenosynovitis
• Soft tissue infection

• Cervical spine disease
  • OA
  • Stenosis (C6, C7)
  • Disc herniation
  • Brachial plexus neuropathy
• Median nerve compression in the arm or forearm
• Mononeuritis multiplex
• Cervical cord abnormalities
• Angina pectoris
• Thoracic outlet
• Pancoast tumor
• TIA
• Tendonitis

• Pain distal to lesion
• Burning paresthesia/dyesthesia
• Awakens at night with numbness
• Pain may radiate to shoulder
• Pain is relieved by shaking, dangling, rubbing
• Sensory loss (median nerve distribution – 1^st 3.5 fingers)
• Muscle weakness
• Muscle wasting
• Hemiparesis, dysarthria, visual changes, HA, neck pain (R/O DDx)

• Onset, progression
• Motor, sensory or autonomic dysfunction
  • Ahnydrosis
  • GI dysmotility
  • Impotence
  • Bladder
  • Pupils
• Mononeuropathy vs. polyneuropathy
• Proximal vs. distal
• Upper vs. lower extremity
• Associated disease
  • Rheumatoid
  • Diabetes
  • Hypothyroid
  • Acromegaly
  • Vasculitis
  • Amyloidosis
  • Pregnancy
  • Post-injury
  • Alcohol abuse
• Occupational History:
  • Type and nature of occupation
  • Length of time in that job
  • Total number of hours worked each in that job

• Examine c-spine & shoulder
• Examine joint above and below
• Examine forearm
• Examine wrist
• Finger exam
• Compare both sides
• Inspection
  • Muscle wasting thenar muscles (late)
  • Asymmetry
  • Fasciculations
  • Swelling
  • Erythema
• Palpation:
  • Tenderness
  • Anatomical snuffbox
  • Crepitus
• Sensory:
  • Decreased light touch in thumb, index finger or middle finger
  • Decreased 2 point discrimination (> 6 mm)
  • Vibration
  • Position
  • Temperature
• Motor:
  • ROM
  • Weakness thumb in flexion (flexor pollicis longus)
  • Weakness in extension
  • Finger movements
• Special tests:
  • Tinel’s sign (Tap of nerve on wrist ® Tingling from wrist to hand)
  • Phalen’s sign (wrist flexion 90 degrees x 1 min ® numbness, dysethesias in median distribution)
  • Carpal compression test (pressure on carpal tunnel for 30 sec elicits symptoms)

• CBC
• ESR
• Fasting Blood Suger
• Rheumatic Factor
• TSH
• Uric acid
• HbA1c
• Pregnancy test

• CXR
• NCV
• EMG

Initial treatment generally involves resting the affected hand and wrist for at least 2 weeks, avoiding activities that may worsen symptoms, and immobilizing the wrist in a splint to avoid further damage from twisting or bending. Nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, other nonprescription pain relievers, and oral steroids (prednisone) may ease pain. Steroid injections can also be used to alleviate the swelling and pressure on the median nerve. For more severe cases of carpal tunnel syndrome, open carpal tunnel release surgery or endoscopic carpal tunnel release may be recommended.

The followings can be considered in treatment  of CTS:

• Minimize wrist movement
• Improved occupational and workplace ergonomics
• Splinting:
  • Neutral wrist splint at bedtime
• NSAIDS
• Lasix
• Corticosteroid injections (50-80% effective)
• Surgery Indications:
  • refractory pain
  • +++ sensory loss
  • muscle atrophy
• Release flexor retinaculum (>90% effective)