1: Determine etiology

What’s the cause of the pain?

As with any complaint, care should be undertaken to determine the cause of the primary complaint. A thorough history and physical exam is essential to determine the next best step in the work-up which may or may not include imaging and laboratory studies.

Take the time to decide the most likely diagnosis as well as a plausible differential diagnosis and use further work up to confirm these thoughts rather than as a “fishing expedition” as there are many situations in which a test can come back with unexpected findings that may not correlate with the patient’s symptoms and can lead to unnecessary treatment in many cases. Think, for instance, of the common findings of osteophytes or even spinal stenosis in patients with back pain: these mechanical abnormalities are commonly found in asymptomatic patients, and often mislead physicians.

Be sure to review old records for the results of previous workups if they exist, and to corroborate the patient’s history and results of prior treatment.

Per the new Indiana prescribing law, you must ask your patient to complete an objective pain assessment too,l such as the Brief Pain Inventory  to gain an objective measure. This should be done at least initially, according to the law, but periodically thereafter, ideally at each visit.


Mr. Hawkins defaultClient Case: Mr. Hawkins

On Mr. Hawkins’ exam, he is a well-groomed, obese male appearing in no physical or emotional distress. He ambulates without abnormality and is able to move to the exam table without difficulty. He has no spinal deformity or point tenderness. There is slight loss of lumbar lordosis and minimal palpable tenderness in the lumbar paraspinal muscles bilaterally. Patient has slightly limited flexion/extension/rotation of the lumbar spine. Patient can lower and rise from full squat without assistance, toe walk and heel walk. There is normal muscle tone and 5/5 motor strength in both legs. Straight leg raise and FABER tests are negative bilaterally. Patellar and Achilles deep tendon reflexes are 2+ bilaterally. Light touch & vibratory sensation are present and symmetric bilaterally.

Knowledge Check

Best practices in the care of this patient involve which of the following:

a. Prescribe a limited amount of opioid narcotics for pain management b. Refer the patient to a neurosurgeon c. Obtain an MRI to rule out dangerous pathologies such as bony metastases d. Discuss Mr. Hawkins prognosis and goals for treatment