These are the blue sheet, physical exam, diagnostic studies and differential diagnosis needed for a back pain case in the USMLE Step 2 CS exam:
BLUE SHEET BACK PAIN:
Write just the initial letters on your blue sheet, then make notes depending on the information given by the SP (standardized patient).
COLD STERUM
Cold: Exposure (Raynaud’s)
S: Signs of inflammation (swelling, erythema, warmth, pain)
S: Stiffness (morning stiffness)
T: Tingling, numbness, weakness (usually you may ask them together)
T: Trauma (to the back)
E: Eye infections (reactive arthritis has conjunctivitis)
R: Rash – tick bite (Lyme’s disease)
R: ROM
U: Urinary symptoms (urethritis in reactive arthritis)
U: Ulcers in the mouth (SLE)
M: Menopause/HRT (risk for osteoporosis and pathologic fractures)
1. Back:
Inspection of the back for lesions or erythema
Palpation: Paraspinal muscle tenderness or vertebral column tenderness
2. Extremities:
Inspection
Peripheral pulses
ROM (lower limbs mostly)
3. Neurologic:
Motor
DTR’s
Sensory
Straight leg raise test (SLT)
Babisnky
Gait
- Genital and rectal exam (saddle area sensory testing).
- X-ray of the lumbar spine.
- MRI of the lumbar spine.
- PSA.
- Bone scan.
- Serum protein electrophoresis (multiple myeloma).
- CBC, ESR or CRP (if signs of infection present).
- Lumbar muscle strain.
- Disk herniation (+ SLT).
- Lumbar spinal stenosis.
- Compression fracture.
- Osteomyelitis.
- Epidural abscess.
- Metastatic cancer.
- Multiple myeloma.
- Malingering.
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