doc4mindia
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A 27-year-old woman comes to the office because of a 1-day history of back pain and a "tingling and numb buttock and leg." She states that she has had periodic back pain over the past few years, but nothing as bad as this. She thinks that the pain began when she and her husband were flipping the mattress on their bed. She tells you that her best friend recently had similar back pain that was diagnosed as a "slipped disc" by an MRI. She did some "preliminary research" on the Internet before she came to this appointment and learned that an MRI or CT scan is necessary to diagnose a herniated disc. She denies any changes in bowel or bladder function. Her temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 60/min. Physical examination shows some rigidity of the lumbar spine. There is no point tenderness, but vertebral muscle spasms are present. She has normal deep tendon reflexes in her knee and ankle, and normal proprioception. She has normal and equal strength in both lower extremities. You tell her that she most likely has "mechanical low back pain (LBP)" caused by a bulging, protruding, or herniated disc that is probably "pinching a nerve" and causing the sensory loss on her buttock and posterolateral leg. You prescribe naproxen and tell her that she can stay in bed for no more than 2 to 3 days. She is completely dissatisfied with this diagnosis and treatment plan, and demands that you "at least get an x-ray." She does not understand how you can send her home without "doing anything useful." She states that it is a complete waste of time coming to the doctor because she could have treated herself with ibuprofen. She is very angry and requests a referral to an orthopedic surgeon. The most appropriate next step is to
A. arrange for her to get an MRI as soon as possible
B. explain that there is a poor relationship between most radiographic abnormalities and the symptoms of LBP,and that the findings will not alter the initial management plan
C. give her a prescription for something stronger than naproxen, like a fentanyl patch
D. give her a referral to the orthopedic surgeon
E. reassure her that most patients with back pain feel this way but maybe she would be happier seeing another primary care physician
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| dimps
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