3-7
(800 mg tid with food) and progressive range of motion exercises and trunk strengthening. Bed rest is not
indicated unless absolutely essential, as it merely causes deconditioning. Epidural steroids are sometimes
used; oral steroids are not recommended. Cauda equina syndrome, a rare complication where there
is compression of the cauda equina in the spinal column causing neurological impairment, may become
permanent if not surgically repaired in 12-24 hours. Suspected fractures should be immobilized on a spine
board or the nearest eld equivalent and evacuated to the nearest appropriate facility that can perform
appropriate radiological studies and surgery if necessary.
Patient Education
General: Most low back pain is self-limited and will resolve in 4-6 weeks in most people.
Activity: Gradually resume activity. Avoid bedrest if possible - it only weakens the back muscles.
Diet: Normal
Medications: Anti-inammatory medicine may cause bleeding ulcers, kidney and liver problems with chronic
use.
Prevention and Hygiene: Use proper mechanics when lifting – bend at the knees not the waist
No Improvement/Deterioration: Loss of bowel or bladder control warrants immediate referral.
Follow-up Actions
Return evaluation: Worrisome signs for further referral for imaging (such as x-ray and MRI) and evaluation
include fever, night pain, unexplained weight loss, persistent pain (greater than 4-6 weeks)
Evacuation/Consultation Criteria: Loss of bowel or bladder control, and/or urinary retention warrants
immediate evacuation. Obtain delayed evacuation for imaging and evaluation, if fever, night pain, unexplained
weight loss, persistent pain (greater than 4-6 weeks)
Symptom: Breast Problems: Mastitis
MAJ Ann Friedmann, MC, USAIntroduction: Mastitis is inflammation of the breast most commonly presenting as a cellulitis of the
subcutaneous tissues in a lactating breast (1-3% of breastfeeding women). The causative organisms, S.
Aureus, E. Coli and streptococcus (rarely), are easily treated with antibiotics. Tuberculosis mastitis is very rare
(1% of cases) even where TB is endemic. One of the risk factors for mastitis is plugging or obstruction of one
of the milk ducts which drain to the nipple. Obstruction can be secondary to delayed infant feedings, which
can lead to engorgement, and tight clothing (poorly fitting brassieres and underwires that dig in). Other risk
factors include cracked nipples, maternal stress and fatigue. Do not let mastitis interrupt breastfeeding.
The infected breast will worsen if the baby does not empty it, and the infection cannot be transmitted to the
infant through the milk. Untreated or delayed and inappropriate treatment can lead to breast abscesses and
stop lactation in the affected breast, which deprives the infant of its food source. This may be devastating,
particularly in developing countries.
Subjective: Symptoms
Localized pain, redness, swelling, warmth in one breast; fever; chills; body aches; fatigue; headache;
occasionally nausea and vomiting.
Objective: Signs
Using Basic Tools: Fever - often greater than 101°F
Inspection: Pink, wedge-shaped area on the breast. Patient appears in mild to moderate distress.
Palpation: Tender, occasionally indurated, warm area. There SHOULD NOT be a palpable, fluctuant
mass - that is a sign of abscess.
Assessment:
Differential Diagnosis:
Plugged Duct - Tender lump in the breast of a mother who is otherwise well. Caused by partial obstruction