Get Answer: Adolescent Back Pain Question Guide
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Original Question
Adolescent DDA CC: Back pain and posture History of Present Illness Destiny is a 13-year-old girl is being seen for back pain and posture issues. The mum reports that she is constantly reminding her to sit up straight. The daughter states she tries to sit straight and is doing the best she can. She admits to lingering mid-back pain. The pain is a 4/10, is localized to mid-thoracic area bilaterally, does not migrate, and is described as a consistent ache, not stabbing or pulsatile. The patient takes ibuprofen 200 mg every 6 hours occasionally, but usually tries to just ignore her pain. She is not involved in any team sports; she plays violin and piano. She is active with friends and has not noted any change or limitation in interactions with them. She denies pain in her shoulders or legs. No muscle weakness in her extremities has been noted by her or her parents. Both the patient and the parent state this has been going on for a while, and they believe they noted the problem the most over the past 6 to 9 months. Review of Systems Significant for mid-thoracic bilateral 4/10 pain as described. ROS was negative for cough, SOB, chest pain, fatigue, abdominal pain, vomiting, diarrhea, dysuria, fever, muscle weakness, or dizziness. She started her menstrual period 3 months ago. Past Medical History The patient is fully vaccinated and has had no recent travel; she has no history of prior surgeries or trauma and no chronic health concerns. Her parents recall she reached developmental milestones on time. She has not seen a health care provider since age 10—that is when her parents insurance changed to one from the exchange and started having a deductible >$6500 per year. The child lives with her parents in a house built about 10 years ago. Her parents deny any significant family history of illness. She is an only child—both of the parents are without any chronic medical problems. Allergies—no known food or drug allergies. Medications—Ibuprofen 200 mg q6h PRN for pain. Physical Examination Vitals: 98.6°F; P 80; R 17; BP 116/72; WT 95 lbs., HT 60 in., BMI 18.6. General: Alert and in no distress. Skin, Hair, and Nails: Warm, dry, with no rashes noted. Capillary refill brisk. No abnormal findings with hair or nails. Head: Normocephalic and atraumatic. Neck: Supple with no adenopathy. Chest: The sternum is normal, with no pectus carinatum or excavatum noted. Lungs: Clear to auscultation throughout all fields. Aeration is symmetric. Heart: RRR, with no murmur, gallop, or rub. Abdomen: Soft, non-tender, non-distended with no masses noted. Bowel sounds equal throughout. Genital/Rectal: Tanner stage 2. Rectal exam deferred. Musculoskeletal: Obvious shoulder height discrepancy with right shoulder elevated. Right scapula is mildly elevated compared to the left. A forward bend test shows noticeable prominence to the right thoracic and ribs in the mid-thoracic range. There is also prominence to the paraspinal muscles of the left lumbar spine. A scoliometer is utilized and shows a 9° angle of rotation over the mid-thoracic spine and 7° angle of rotation over the lumbar spine. Neurologic: Cranial nerves II to XII intact. DTR symmetric in the upper and lower extremities at 2/4, and muscle strength symmetric in the upper and lower extremities at 5/5.
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