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BACK PAIN - ABDOMINAL AORTIC ANEURYSMDD 1. IVDP and SCIATICA 2.AAA 3. CAUDA EQUINA 4 SECONDARIES { PROSATE} 5. MUSCLOSKELETEL BACK PAIN 6. TRAUMAQuestion:You are an FY2 doctor in the A&E department55 year old man presented with back pain since yesterday eveningYour task: Address his concerns and plan on INITIAL MANAGEMENT.Hello, I am Dr .... one of the junior doctor in the A&E Department. How can I help you ?Pt: doctor I am having back pain since yesterdayDr: I'm sorry to hear that. Are you ok to talk or do you need any medications for your painPt: I am alright doctorDr: Could you please tell me a little bit more about itPt: It started on its own since yesterday, I thought it could be some muscle painDr: Don’t worry. We will definitely help you. Can you please show me where exactly the pain is? Patient shows the middle back or lower back.Dr: What type of pain is that ? Pt:Dr: is it going anywhere else Pt: NoDr: Is it going to your legs [ sciatica]Dr: Is there any pain in you tummy? Pt: no doctor it is just thereDr: Is there anything that makes it better or worse? [ IVDP- relieved on lying down?] Pt: NoDr: Is it going to your loin area? Pt: no [RENAL PATHOLOGY]Dr: Alright. Do you feel tired? Pt: no doctorDr: Do you have any bowel or bladder problems? [ CAUDA EQUINA] Pt: no doctor Any numbness around your back passage? Pt: no doctorDr: Do you feel thirsty or do you want to pass urine more than the usual? Pt: No[secondaries]Dr: Any dribbling of urine or any urinary incontinence? [ CA prostate] Pt: no doctorDr: Did you do any physical activity more than the usual? like running, exercise, playing or lifting weight [MUSCULOSKELETEL BACK PAIN] Pt; No Dr: Any chance you may have injured your back? Any fall? Pt: no doctorDr: Do you have fever ? NoDr: Did you feel any pulsating mass in your tummy (AAA) ?Dr: have you ever had any type of scans done on your tummy ( AAA)? Dr: Did you have this type of problem before ? NoDr: Did you have any kidney problem before ? NoDr: Do you have any medical conditions? HTN ? DM ? cholesterol ? Heart problem ?MAFTOSA Any of your family members had any abnormal blood vessels in their tummy / cancer/heart disease/cholesterolSmoking [risk factor for AAA]Note: Important risk factors for AAA are 1. High blood pressure 2. Tobacco smoking 3. Atherosclerosis4. HereditaryEXAMINATIONI would like to examine your back, your back passage and your tummy is that okay?Also I need to measure your heart rate, blood pressure and oxygen levels in your body. I will have a chaperone with me and will ensure the privacy. Can you please undress from below your chest until the mid thigh? Pt: ok doctorexaminer gives NEWS chart PR: 94 BP: 120/80 SPO2 97%Examiner may say - back passage and back examination is normal.Proceed to abdominal examination MANNEQUIN kept on the tableStart examining the abdomen but examiner gives the findings :Tenderness above the umbilical region and pulsations felt all over the abdomen.Dr: Mr.... from what you have told me and after the examination, I suspect you have a condition called ABDOMINAL AORTIC ANEURYSM. Do you know anything about it?Pt: No doctor. Is it serious??Dr: I will definitely answer your question. First of all, let me tell you what AAA is.We have a large blood vessel in our tummy called Aorta which branches off and gives blood supply to organs in our tummy and our legs. Sometimes, its width increases which ends up in the thinning of the walls of this blood vessel ( A part of the Aorta becomes swollen). This can sometime result in bursting of the blood vessel and blood will start leaking, which is a life threatening condition. If that happens patient will feel dizzy, short of breath and experience severe pain the tummy or back. Are you following me? Pt: yes doctor.Dr: We need to admit you. At this moment it doesn’t look like the blood is leaking from the vessel. However, I will talk to my seniors and will arrange for an USG scan of your tummy to confirm this. We would like to run some baseline blood test and would also like to check your cholesterol, blood grouping and cross matching. Would that be okay? Pt: Okay doctor. But what will you do after the scanTreatment:Dr: We will refer you to the Vascular surgeon ( Specialist). Treatment depends on the size of the aneurysm and also whether it is leaking or not.If it is not leaking – and if the size is not too large then it does not need any immediate treatment. We will keep monitoring to check whether it grows in size or not. If the size increases and risk of rupture is there, then we have to surgically repair that. There are two types of surgeries 1. Open aneurysm repair – A graft ( artificial tbe) is placed in the Aorta through cut in your tummy.2. Endovascualr aneurysm repair. A graft is inserted through a blood vessel in the grpin and then passed up into the Aorta. The type of surgery is decided by the surgical consultants. Advise: Diet, Smoking, Exercise. Reducing weight if over weight.Medications for BP if hypertensive.If already ruptured: Immediate surgical repair to control the bleedingAbdominal aortic aneurysmMen aged 65 and over are most at risk of AAAs. This is why men are invited for screening to check for an AAA when they're 65.Symptoms?of an AAAAAAs don't usually cause any obvious symptoms, and are often only picked up during screening or tests carried out for another reason.Some people with an AAA have:a pulsing sensation in the tummy (like a heartbeat)tummy pain?that doesn't go awaylower?back pain?that doesn't go awayIf an AAA bursts, it can cause:sudden, severe?pain in?the tummy or lower backdizzinesssweaty, pale and clammy skina fast heartbeatshortness of breathfainting?or passing out The recommended treatment for an AAA depends on how big it is.Treatment isn't always?needed straight away if the risk of?an AAA bursting is low.Treatment for a:small AAA (3cm to 4.4cm across)?– ultrasound scans are recommended?every year to check if it's getting bigger; you'll be advised about healthy lifestyle changes to help stop it growingmedium AAA (4.5cm to 5.4cm)?–?ultrasound scans are recommended?every three months to check if it's getting bigger;?you'll also be advised about healthy lifestyle changeslarge AAA (5.5cm or more)?– surgery to stop it getting bigger or bursting is usually recommendedReducing?your risk of an AAAThere are several things you can do to reduce your chances of getting an AAA or help stop one getting bigger.These include:stopping smoking?– read?stop smoking advice?and find out about? HYPERLINK "" Smokefree, the NHS stop smoking serviceeating healthily?–?eat a?balanced diet?and?cut down on fatty foodexercising regularly?–?aim to do?at least 150 minutes of exercise a week; read about?how to get started with some common activitiesmaintaining a healthy weight?– use the?healthy weight calculator?to see if you might need to lose weight, and find out?how to lose weight safelycutting down on alcohol?– read?some?tips on cutting down?and general?advice about alcoholIf you have a condition that increases your risk of an AAA, such as high blood pressure, your GP may also recommend taking tablets to treat this.Screening?for AAAsIn England, screening for AAA is offered to men during the year they turn 65. This?can help spot a swelling in the aorta early on, when it can be treated. ................
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