CASE PRESENTATION 6

SITI NUR BAITI BINTI SHAIK

KHAMARUDIN
012013100196

PROVISIONAL DIAGNOSIS
Back pain secondary to muscle strain
(mechanical back pain)
Points supporting:
Pain is localized and non-radiating.
Pain occurs on activities.
Pain is relieved by resting.
Job stress factor as psychogenic
consideration.

DIFFERENTIAL DIAGNOSIS
1) Upper urinary tract infection
(UTI)
POINTS

SUPPORTING
Flank pain
Fever (day 1
subsided)

POINTS AGAINST

No frequency /
hematuria /
urgency / dysuria
No foul smelling
urine

2) Dengue fever
POINTS
SUPPORTING
On day 1 fever

POINTS AGAINST
Living in non

subsidence (may

dengue-prone

be in afebrile /

area.

critical phase)
Abdominal pain

No
nausea/vomiting
No rashes

3)

INVESTIGATION
Urine FEME (UFEME)
AIM:
To look for evidence of
urinary tract infection:
increase white cell
count (leukocyte) and
nitrites

IMPRESSION:
Absence of
leukocytes/nitrites.
UTI is excluded.

MANAGEMENT
NON-PHARMACOLOGICAL
1. Have some rest for 1 to 2 days.
2. Practice active movements slowly.

PHARMACOLOGICAL:
1. VOLTAREN Injection

IM Diclofenac Sodium 75mg/3ml

Once in the clinic

2. T. Diclofenac

50mg TDS

3. Dermasafe ointment

Methyl Salicylate 25% w/w, Menthol 5%

w/w
Apply and massage on affected area 3-4
times daily.

DISCUSSION

INTRODUCTION
Low back pain accounts for at least 5% of
general practice presentations.
It is estimated that up to 84 percent of adults
have low back pain at some time in their lives.
For many individuals, episodes of back pain
are self-limited.
Patients who continue to have back pain
beyond the acute period (4 weeks) have
subacute back pain (lasting between 4 and 12
weeks) and may go on to develop chronic
back pain (persists for 12 weeks)

CLUES FROM PATIENTS

HISTORY

MUSCLES OF THE BACK

3 types of back muscles that help the
spine function:
The extensor muscles are attached
to the posterior (back) of the spine
and enable standing and lifting
objects. These muscles include the
large paired muscles in the lower back
(erector spinae), which help hold up
the spine, and gluteal muscles.
Back muscles and gluteal muscles.

 The flexor muscles are

attached to the anterior
(front) of the spine (which
includes the abdominal
muscles) and enable
flexing, bending forward,
lifting, and arching the
lower back.
Abdominal muscles and

The oblique muscles are

attached to the sides of the
spine and help rotate the
spine and maintain proper
posture.

2 TYPES OF COMMON
LOWER BACK PAIN
Amuscle strainhappens when the
muscle is over-stretched or torn,
resulting in damage to the muscle
fibers (also called a pulled muscle).
Alumbar sprainhappens when
ligaments are stretched too far or
torn

COMMON CAUSES
Any type of movement that puts undue
stress on the lower back.
Frequent causes include lifting a heavy
object, lifting while twisting, or a sudden
movement or fall.
Sports injuries are also a frequent cause of
a pulled back muscle, especially with
sports that involve twisting (such as golf),
or any types of sudden impact or jarring
motions.

THE SYMPTOMS
Symptoms may range from a mild ache to
sudden debilitating pain.
Typical symptoms of a lower back pulled
muscle include some combination of the
following:
The pain is usually localized in the lower back,
meaning that it doesnt radiate into the leg (as
insciatica)
The lower back may be sore upon touch
Pain usually comes on suddenly
There may be accompanying muscle spasms
The patient usually feels better when resting,
and may find standing or walking difficult.

COMPLICATION OF BACK
PAIN
If an episode of low back pain lasts for more
than two weeks, the muscles may start to
weaken.
Because using the lower back muscles is
painful, the natural tendency for most
patients is to avoid using them.
However, lack of activity leads to disuse
atrophy (muscle wasting) and subsequent
weakening, which in turn causes more low
back pain because the muscles are less able
to help hold up the spine.

BACK PAIN TREATMENT

Typical first line treatments:

Pain medication(such as
acetaminophen), to interrupt
transmission of pain signals to the
brain

Anti-inflammatory
medication(such as ibuprofen, or
possibly oral steroids), to reduce
the local inflammation that is a
cause of the pain

Muscle relaxants, which may be

prescribed on a short-term basis to
relieve severe lower back pain
associated with muscle spasms.

Massage, which can help promote

blood flow in the lower back (to
help with healing), loosen tight
lower back muscles, and release

Chiropractic. Gentle manual

manipulation is an option to help
loosen tight back muscles and
promote healing in the lower back.

Ice or cold packs. Application of

some type of cold pack can help
reduce inflammation, which is
helpful immediately following the
injury.

Heat therapy. Application of heat

to the lower back is helpful longer
term to stimulate blood flow and
healing to the injured area.

BACK PAIN EXERCISE

Some general guidelines include:

Do not start exercises for the
first time during an acute back
pain episode without first
consulting a physician or a
spine specialist.
Do not stop exercising just
because pain diminishes or an
injury appears "healed"; rather,
add back and abdominal
exercises into a daily routine.
Complete a combination of
flexion and extension exercises
to balance the trunk muscles.
In general, do exercises in sets
of 3 to 5 repetitions a
minimum of 4 times a week.
Be patient; strength building
may take 6 weeks or more to
show results.

REFERENCE
John Murtaghs General Practice 6th
Edition
Websites:
http://www.spine-health.com/conditions/
lower-back-pain/pulled-back-muscle-andlower-back-strain