# Worsening upper back pain that wakes her at night, a 48-year-old: a case to work up

> An internal medicine case for medical students: a 48-year-old with mid-back pain that is worse and now wakes her, after normal tests months ago. Red flags, what to ask, examination, first tests and the differential.

- Internal Medicine · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/48-year-old-woman-with-worsening-upper-back-pain
- Work up this patient: https://www.medikarya.in/case-studies/48-year-old-woman-with-worsening-upper-back-pain

## How the patient presents

A 48-year-old woman comes back with mid-back pain that has become worse and now wakes her at night. A couple of months ago her X-ray and blood tests were normal and she was treated for a muscle strain.

## Why back pain that wakes her at night matters

Most back pain is mechanical and settles. Pain that keeps getting worse, wakes the patient at night or sits in the middle of the back is a warning sign for infection, cancer or fracture, and a normal X-ray early on does not rule these out.

## What to ask in the history

- Where the pain is, how it has changed, pain at rest and at night
- Any injury
- Weight loss, fever, night sweats
- Any past cancer; breast lumps
- Contact with tuberculosis
- Numbness or weakness in the legs; bladder or bowel changes
- Steroids, thinning of the bones, menopause
- Other bone pain

## Red flags

- Pain in the middle of the back, at night or getting steadily worse
- Weight loss or fever
- Past cancer
- Numbness, weakness, bladder or bowel changes
- Steroid use

## What to examine

- The spine: tenderness, shape
- A full neurological examination of the legs, and a sensory level
- Breasts, lymph nodes, abdomen
- Temperature

## First investigations

- Full blood count, ESR and CRP
- Calcium, alkaline phosphatase, kidney function
- Protein electrophoresis
- MRI of the whole spine
- Chest X-ray
- Further tests as the findings direct: tuberculosis tests, breast imaging, biopsy

## Differential diagnosis of back pain that wakes her at night

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Infection

- Tuberculosis of the spine
- Bacterial infection of the spine

### Bone

- Fracture from thin bones

### Cancer

- Spread of a cancer to bone
- Myeloma
- Lymphoma

### Pain from elsewhere

- Aorta
- Pancreas
- Kidney
- Heart

### Mechanical

- Muscle and joint strain

## Common mistakes

- Being reassured by the normal tests from months ago.
- Skipping the neurological examination.
- Not examining the breasts.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.