Second Nature--Linda Kratky

Linda Kratky

University of Nebraska Medical Center - College of Medicine
Omaha, Nebraska
Instructor(s): Von Essen, Susanna; Wampler, Mary
Subject area: Health / Medicine
Department: Medicine
Level: Undergraduate Medical
Duration of exercise: 3 sessions, 5 hours total
Learning objective: Develop Group Skills, Develop Individual Skills, Provide Information
Teaching style: Group Activity, In-class Activity

Please note that the copyright for this course project is retained by the instructor.

This Problem Based Learning Case is presented to medical students at the University of Nebraska College of Medicine. The students work through an actual case presentation of an environmental health problem. The instructor guides the discussion as the students work through the case. In an interactive question/discussion format, needed information is provided to the students to work through the differential diagnosis and arrive at the appropriate conclusion.

FACILITATOR'S GUIDE

Major Subject Areas

1. Anatomy of the wrist
2. Anatomy of the spine
3. Management of carpal tunnel syndrome
4. Management of a herniated lumbar disk and acute low back strain
5. Management of repetitive strain injury

Minor Subject Areas

1. Rehabilitation of the patient with lower back pain
2. Worker's compensation insurance
3. Management of hypertension
4. Management of perimenopausal symptoms
5. Ergonomics for the office worker
6. Efficacy of alternative medicine for musculoskeletal problems

NOTE: This case is based on several patients seen in the clinical practice of the authors. Any resemblance to real persons is coincidental.

NOTE: THIS CASE IS PACED SOMEWHAT SLOWLY. It is a good opportunity for the M1 students to see the components of an office visit with a new patient. I think you can explain to them that you obtain a detailed history before you perform a physical exam. YOU ARE RIGHT ... NO REAL CLINIC VISIT WILL LAST 4 HOURS.

Learning Objectives

1. Be familiar with the anatomy of the wrist. Be able to recognize important anatomical structures on axial images.
2. Describe the anatomic structures of the spine and be able to identify these structures on axil images.
3. Outline the pathophysiology of carpal tunnel syndrome, the anatomic structures involved and interventions which can be taken to prevent its occurrence or alter its course.
4. Develop a diagnostic and therapeutic plan for the patient who presents with the acute onset of radicular pain.
5. Outline a therapeutic plan for the patient who has a repetitive strain injury.
6. Be able to discuss worker's compensation insurance.
7. Discuss a plan for the management of a patient with hypertension.
8. Formulate a plan for the management of a patient with perimenopausal symptoms.
9. Outline the importance of ergonomics in the work environment.
10. Compare the efficacy of alternative medicine, medical , and surgical approaches to herniated lumbar disc and acute low back pain.

References

1. Occupational Health: Recognizing and preventing work-related Disease/(edited by)Barry Levy, David H. Wegman. -3rd ed. Pgs.455-483
2. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Rockville, Maryland, AHCPR Publication No. 95-0643, December 1994

SESSION 1

Initial Presentation

Linda Kratky is a 44 year old woman who comes to the Family Medicine clinic where you are on staff. The chief complaint recorded on the chart is "my back really hurts." Two days ago she was bending over to lift a box of paper for the copy machine when she felt a sudden, sharp pain in her lower back which radiated down her right leg.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What are the other questions about symptoms that should be asked of a patient with low back pain of sudden onset that radiates down one leg? What additional information would you like to obtain?

Of the several symptoms of disease of the back, pain is of foremost importance because of its frequency and disabling effects. Four types of pain may be differentiated: local, referred, radicular, and that arising from secondary (protective) muscular spasm. Local pain is caused by any pathologic process which impinges on or irritates nerve endings. Involvement of any structure which has no nerve endings is painless. The substance of a vertebral body can be destroyed by tumor without evoking pain whereas lesions of the periosteum, synovial membranes, annulus fibrosis, muscles, or ligaments are often exquisitely painful. Local pain is often described as constant but may be intermittent and varies with position or activity. The pain may be sharp or dull and although diffuse, is always felt in or near the affected part of the spine. Referred pain is of two types, that projected from the spine into regions lying within the lumbar and sacral dermatomes and that projected from the pelvis and abdominal viscera to the spine. Radicular (root) pain has some of the characteristics of referred pain but differs in its greater intensity, distal radiation, circumspection to the territory of a nerve root and the factors which insight it. The mechanism is distortion, stretching, irritation or compression of the spinal root. The pain is often dull or aching, various maneuvers which increase irritation of the nerve root may greatly intensify the pain. Cough, sneeze, and strain are characteristically evocative maneuvers, but since they may jar or move the spine, they may aggravate local pain as well. Pain resulting from muscle spasm is usually mentioned in relation to local pain. It can produce significant distortions of normal posture.

What are your diagnostic considerations at this time?

Office Visit Continues

Linda has also been having pain in her right wrist and numbness in her right hand. These symptoms have become particularly severe in the past month. The pain is worst at night. She also has wrist pain as she is working at the computer keyboard.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What additional questions do you want to ask this patient?
What is your differential diagnosis at this time?

Additional Information

Ms. Kratky is a secretary at UNMC in one of the clinical departments. She tells you that she needs some time off work and says that you have to give her a note that she can take to her manager so that the sick leave will be authorized.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What should be asked about activities away from work that may exacerbate the symptoms in the lower back and in the right wrist and hand?
What specific questions should be asked about her job in order to better understand the wrist pain?
What are other questions about symptoms that should be asked of a patient with possible carpal tunnel syndrome?
What psychosocial factors could be involved and how would you deal with the request fro time off work?

Past Medical History

Linda had her first bout with low back pain 13 years ago. Her primary care physician told her to take 2 weeks off work for bed rest. She tried to follow this advice but found it very difficult because of her 3 children. She was told by an orthopedic surgeon to whom she was referred that she had to have surgery after a CT scan of the lower back revealed the presence of a herniated lumbar disk at L4-5. She did not follow the advice of either one.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

Is her behavior with respect to taking off 2 weeks uncommon?

What information about cause of back pain can be determined by CT?

CT can be used to image the spine in all types of pathologic processes. The most common indications for spine CT include degenerative disc disease, patients with radicular pain to rule out a herniated disc, suspected spinal tumors and trauma.

How would a herniated disk cause the symptoms she was having?

What operation would the orthopedic surgeon be recommending to her?

Office Visit Continues

Information obtained for you by the nurse:

Height: 5'1"
Weight: 110 lbs.
Pulse = 92
BP = 160/92
T = 98.4

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

Have you identified any additional problems?
What is your differential diagnosis at this point?
What physical findings will you be looking for when you do a complete physical exam?

At that time, Ms. Kratky went to a chiropractor, who performed manipulations that helped her pain. She was told to do exercises for her back which she stopped doing after a few weeks. Recently, she has been using the campus fitness facility 2-3 timer per week, where she walks on the treadmills and does resistive training on the Nautilus machines. She wants to lose weight because an interesting new physician has started working in the clinic.

STOP
END OF SESSION

How common is her lack of compliance?
What would the natural history of her back pain probably have been is she had followed the chiropractor's advice?
What is the role of a chiropractor in medical management of patients?

Wrap-up

1. Hand out summary of this session.
2. Have a student summarize the case.
3. Review and prioritize learning issues; discuss possible resources.

Review Group Process

1. Did everyone get a chance to participate?
2. Did someone dominate the discussion?
3. Did someone not contribute or participate as fully as they could have?
4. What actions contributed to effective group process?
5. How can we do a better job next time?

Tasks for Next Session

1. Summarize/review case.
2. Review and discuss learning issues.
3. List and critique resources used.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.

SESSION 2

Office Visit Continues

Linda developed right wrist pain for the first time 20 years ago, shortly before the birth of her first child. She quit her job as a secretary then and had an operation for this problem 5 months later. She has not had wrist pain again until recently.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What do you think was the cause of Lindaÿs wrist pain?
What information should be obtained to make the diagnosis?
What operation do you think she had?

Additional Information

The stress level at work has been high. The department in which she works has been reorganizing. Her workload has increased with the hiring of a new faculty member. She was recently given the assignment of doing data entry for billing purposes. She was moved to a different work station 2 months ago and states that it is not very comfortable.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

How could her job be contributing to her symptoms?
On an anatomic basis, what do you think is causing her pain?
What questions need to be asked about the work station?
How might her workstation contribute to the discomfort she is feeling?
How can this problem be addressed?

Additional Information

The stress level at home is high as well. There is frequent conflict with a rebellious teenager. She often cares for a 2 year old grandson. She helps her aging parents, who no longer drive a car, by running errands. Her favorite recreational activities include working in her large garden and making quilts. Her social history is also remarkable for smoking about 1 pack per day of cigarettes for the past 30 years. She drinks 2-3 cans of beer per day.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

Could any of these factors be contributing to her symptoms?
What lifestyle risk factors have you identified?
Could these be modified and what benefit would it be to the patient?
For what disorders does her smoking place her at risk?

Past Medical History

Her past medical history is notable for 3 unremarkable pregnancies followed by a tubal ligation. She has been told several times by her gynecologist, whom she sees yearly, that her blood pressure is elevated. She does not want to take medication for this problem.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What additional risk factors have you identified?
How could the patient's hypertension be managed without medication?

Review of Systems

The review of systems is positive for waking up at night with sweating 1-2 times a week, which has been going on for about 6 months. Sometimes this happens at work as well. It is associated with the sensation that her heart is racing. She has not been feeling refreshed when she gets up in the morning. She has been waking too early most mornings lately, in part because of pain in her wrist and back.

STOP
END OF SESSION

What do the episodes of sweating suggest?
Could hormones have any effect on the development of carpal tunnel syndrome?
What additional information would you like to obtain?

Wrap-up

1. Hand out summary of this session.
2. Have a student summarize the case.
3. Review and prioritize learning issues; discuss possible resources.

Review Group Process

1. Did everyone get a chance to participate?
2. Did someone dominate the discussion?
3. Did someone not contribute or participate as fully as they could have?
4. What actions contributed to effective group process?
5. How can we do a better job next time?

Tasks for Next Session

1. Summarize/review case.
2. Review and discuss learning issues.
3. List and critique resources used.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.

SESSION 3

Physical Examination

You now ask Ms. Kratky to change into a dressing gown so you can perform a physical examination. Her vital signs are as previously listed.

HEENT: Normal

LUNGS: Clear to auscultation and percussion.

CARDIAC: Heart regular rate and rhythm without murmur, gallop.

ABDOMEN: Normal

EXTREMITIES: Right upper extremity: well-healed scar over the palmar aspect of the right wrist. Wasting of the thenar eminence. Decreased sensation to pinprick, palmar surface of the 4th and 5th digit. Grasp between the thumb and forefinger is weak. Pain at the base of the thumb with adduction and abduction. This pain radiates toward the elbow.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What disorder(s) does examination of the wrist suggest?
What tests would you order to determine if the median nerve is affected?
What endocrine disorder(s) could be part of the problem?

Physical Examination Continues

The patient is observed to be limping as she walks down the hall. Examination of the back reveals tenderness of the paraspinous muscles in the lumbar region. Flexion and extension of the back in the lumbar region elicits the pain she has been having. Flexion is limited to 450 and extension to 150 degrees. The straight leg raising test causes pain in the left buttock. She has slightly decreased sensation to pinprick and vibration in the right lower extremity. Her patellar reflexes are normal bilaterally but the Achilles tendon reflex is absent on the right.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What conclusions may be drawn from the examination of the lower back?
What anatomic abnormalities likely explain her symptoms?
What treatment is suitable for the back problem? For the problems with the wrist?
How should the herniated lumbar disc have been managed 18 years ago? How effective are chiropractors at treating low back pain?
Is this patient eligible for any workerÿs compensation benefits?
What is the role of regular exercise in prevention of back problems?

You review all of the information you have acquired during this lengthy clinic visit. You are concerned that Ms. Kratkyÿs herniated disc was not treated appropriately when first diagnosed. You recommend that she have an MRI of her lumbar spine and obtain the films from her previous CT scan. You are also concerned that she is having problems with repetitive strain injury to her wrist. You schedule her for an MRI of her wrist and ask her to return to see you to review the test results.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

Could you have tried conservative therapy before you sent the patient for more expensive imaging tests?

Next Clinic Visit

CT showed evidence of a herniated disc at L4-5. SEE EXHIBIT A.

MRI confirmed the presence of a herniated disc at L4-5. SEE EXHIBIT B

WRIST MRI was normal with no evidence of inflammation involving the median nerve. SEE EXHIBIT C.

STOP
END OF CASE

A wrap-up session will be held with the case writer and the patient to answer any remaining questions and to discuss the various issues raised in this case.

This document was last modified on 06/14/2000 03:08:02 PM

This resource was acquired by CEEM (Consortium for Environmental Education in Medicine), a program of Second Nature, under the auspices of a NIEHS grant to gather and disseminate environmental health educational resources over the internet in order to help medical and allied health sciences faculty identify, locate and use resources for incorporating environment and health perspectives into their curricula. CEEM has authorized the use of these materials on this website for archival purposes. Please note that the copyright for this material is retained by the instructor and/or contributing institution.