Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 45-year-old adult presents for a sick visit with the chief complaint of 3-day history of low back pain. Clinical assessment is consistent with lumbar sacral strain. Which of the following represents the most appropriate next step in this person's care?
A: Advise 3 days of bed rest on a firm surface.
B: Apply ice or heat to the affected area based on clinical response.
C: Refer to neurology for further advice.
D: Order a lumbar sacral X-rays to help confirm the diagnosis.
And the correct answer is B: Apply ice or heat to the affected area based on clinical response. Where should you start with a question like this? First, determine what kind of a question it is. This is a little bit of a mixed bag.
It looks like it could be an intervention question, because we're being told a few things that we could advise this patient to do. It looks like it could be a further assessment question, but that's actually the point of the question when it's developed like this, to figure out if you have enough information to go ahead and treat the patient, or do you need to gather more information?
In this case, it ends up being an intervention question. First, some background information: the majority of adults, in the vicinity of 80% and plus, will have low back pain at some time. And the diagnosis in most of these will, in fact, be lumbar sacral strain. And that's what we're told this patient has. I appreciate that simply being told what the diagnosis is without getting a report of the history of present illness or the physical exam findings can be quite unsettling. As we are clinicians, we want information, and indeed a lot of times when you're looking at a clinical scenario like this, what you could do is envision that you are in an exam room with the patient and then think through what would be the history with lumbar sacral strain, what would be the physical exam with lumbar prostrate?
Of course, lumbar sacral strain is fairly self-defining, and it means that the muscles and ligaments of the lumbar sacral region have been overworked or excessively taxed, but there's no resulting neurological findings. In other words, this is a clinical diagnosis where no special testing is needed beyond the history and physical exam. At the same time, the history and physical exam has to approve an appropriate muscular, skeletal, and neurological evaluation.
I also want to reinforce a great history of present illness is where you start with a new-onset complaint like this. But this is background information. Let's revisit the question. Look at the choices we've been given, which are correct and which ones are incorrect. A 45-year-old adult presents for a sick visit with the chief complaint of a 3-day history of low back pain.
Clinical assessment is consistent with lumbar sacral strain. Which of the following represents the most appropriate next step in this person's care? Would it be A: Advise 3 days of bed rest on a firm surface? This is incorrect. In the past, it actually was standard to advise a number of days of bed rest to a person with low back pain, even if it was lumbar or sacral strain.
It's now recognized as actually being a quite harmful intervention, as overall deconditioning can occur quite quickly, even in a person who's only in their early 40s. But I often say to patients when they have back pain, it might hurt to move, but it's not going to damage your back more to move.
B: Apply ice or heat to the affected area based on clinical response. This is the correct answer. The term “based on clinical response” reflects on whether the patient's discomfort gets better with ice or better with heat. And a lot of times, what I will tell patients to do is alternate both of them for 15 minutes on, 15 minutes off type of a thing and give it a try.
See which one helps them more. Quite often people have never tried ice on a muscular issue, and they're quite happy with the results because they get such good pain control. Additional advice, of course, would include prescribing an NSAID or acetaminophen and likely referral to physical therapy, with the goal of learning about body mechanics and core strengthening exercise.
C: Refer to neurology for further advice. Of course, this answer is incorrect. Lumbar sacral strain is a clinical diagnosis. There are no alarming neurological findings. And what you've done with this is simply delayed the onset of what is often very helpful advice, as was mentioned in option B in what is usually a self-limiting illness. Before you go to choose any answer that talks about referring a patient to a sub-specialist or a specialist, what you always need to do is say to yourself, ‘What will that specialist do that I'm unable to do as a primary care provider?’
There's no need to refer this person to neurology. D: Order lumbar sacral X-rays to help confirm the diagnosis. This is also incorrect. X-ray imaging in lumbar sacral region is not indicated in the diagnosis of LS strain. Although you'll see it often done, it isn't best evidence. By best evidence, the findings on back X-rays in the absence of trauma, from fall or the like, are unlikely to contribute to the diagnosis or the treatment plan.
And one more adage: never do a test that doesn't contribute to your diagnosis and/or address your treatment plan. It is as complicated as that. It is as simple as that. So, no back X-rays. There was no trauma history mentioned here, and we were told that this is a 40-year-old adult with LS strain. We're going to go along with that.
Key takeaway: NP board questions will often ask how to look at next best steps to take in a patient scenario. Knowing when you need to gather more assessment information and when you need to refer to specialty, when you need to refer for specialty advice or go ahead and proceed with intervention is key to safe practice and clinical as well as NP board success.
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