Problem Solving study
Group 3 Presentation
• Mr. Wong, a 32 year old salesman,
recently married for 1 year, consults you
for recurrent low back pain and frequent
urination. Physical exam and urinalysis are
normal. He had a history of jaundice at age
18. His Hepatitis B anti surface antibody is
positive.
What are the possible causes of
his problems and the reasons
for his visit to the doctor?
Problem analysis
• C/O:
– Recurrent low back pain
– Frequent urination
• Physical exam: normal
• Investigation: urinalysis normal
• PMH:
– jaundice at 18 y.o.
– now Anti-HBs+
• SH:
• salesman
• recently married for 1 yr
DDx for
recurrent low back pain
1. Probability:
─ Vertebral dysfunction e.g.degenerative OA
2. Gravity:
Cardiovascular
Ruptured aortic aneurysm
Retroperitoneal haemorrhage (Hx of anticoagulants?)
Neoplasia
Myeloma
Metastasis (prostate, thyroid, kidney, lung)
Severe infections
Osteomyelitits
Tuberculosis
Cauda equina compression (neurological changes?)
3. Pitfalls (often missed)
• Spondyloarthropathies
– Ankylosing spondylitiis
– Reiter’s disease
– Psoriatic arthropathy
– Bowel inflammation
• Sacroiliac dysfunction
• Spondylolisthesis
• Claudication (Vascular or neurogenic)
• Prostatitis
4. Masquerades
- Depression
- Spinal Dysfunction/ Spondylogenic pain
- Urinary tract infection
DDx for
frequent urination(frequency)
1. Probability:
– Urinary tract infection e.g.Cystitis
2. Gravity:
– Neoplasia
– Severe infections
• Gonorrhoea
• NSU
• Genital herpes
– Reiter’s disease
– Calculi
3. Pitfalls
– prostatitis
– foreign bodies in lower urinary tract
– acidic urine
– interstitial cystitis
– bladder diverticuli
– obstruction e.g. urethral stricture, BPH
4. Masquerades:
– Depression
– Diabetes
– Drugs
– UTI
Bored?!
BUT…
Anything missed?
• inconclusive physical examination and
investigation
• any need for more sophisticated
investigation?(given stable conditions, no
associated S&S, no significant PMH…)
Is the patient trying to tell me
something?(why did he find doctor?)
Time to dig in the psychosocial aspects
of the patients!
Consider lifestyle, stress, work problems
for low back pain
Consider psychosexual problems for
frequency
Possible causes:
1. Family:
--new wedding !
Unaccustomed to bridal life
Stress e.g. interpersonal conflicts
Depression—symptoms?
2. Work problems:
--stress from heavy workload?
--anxiety for fear of unemployment?
3. Psychosexual problems:
--Unsatisfactory sex life
Sexual dysfunction (husband? Wife?)
STD?
4. Fear of malignancy
Conclusion
• Always consider psychosocial aspects of
the patient with inconclusive findings
• Achieved by good rapport and effective
communication skill e.g.
– refined wordings to avoid embarrassment
– good questioning technique and active
listening to ‘entice’ the patient to tell the true
worry