Axial load - of crap!

NewFNP is fortunate to work in a practice site where there are exceedingly few patients who are drug seeking, unlike her good pal BostonFNP who has, a number of times, had to revive people who have overdosed in her clinic's bathroom. The only things that newFNP's patients are overdosing on are carbohydrates!

After a while in practice, one just gets a feeling as to who is bullshitting and who is in real distress. However, newFNP doesn't want to make the mistake of letting her gut override her intellect and thus attempts to approach each patient as though their complaint is valid. Sure, it can be a real challenge at times, but newFNP tries, people, she really does.

NewFNP's first walk-in patient of the day started with a call to the on-call phone last night. NewFNP's colleague fielded the call and let newFNP know that this patient would be coming into the clinic. The patient started out her visit by giving the front desk clerk shit when she had to fill out paperwork as she was here "with an emergency" - low back pain. Yes, a little lumbago is right up there with crushing chest pain and profuse intractable bleeding! She then proceeded to evade newFNP's questions about how she hurt her back until her shifty-eyed husband prompted her to relay her history. It didn't involve any trauma, it didn't include any radiculopathy, it was free from any form on incontinence - thank goodness!

NewFNP proceeded to the exam. Straight leg raise - negative. Deep tendon reflexes - 2+ bilaterally. Palpable spasm - absent. Axial load - positive.

For those of you unfamiliar with the axial load test, wary (astute?) clinicians use it to detect malingering. One simply applies downward pressure to the top of the head and asks if it results in pain. It shouldn't.

NewFNP always feels a tad guilty about employing it. She feels as though she is conducting a sting operation. Is the patient lying to get the good drugs? Is the patient who is experiencing true pain thinking that by replying in the affirmative, she is more likely to get the care she needs? Who knows. In newFNP's practice, patients are very prone to expressing their pain in no uncertain terms (see Ayyyyy me duele!). It's tough for newFNP to see through that manner of expression sometimes.

Honesty and trust are so crucial in the history and exam. This patient didn't seem honest with newFNP and it is likely that neither of us trusted the other. NewFNP wrote her a prescription for Ibuprofen and Cyclobenzaprine and advised gentle stretches, ice & heat and to continue modified physical activity. Return to clinic 4 weeks prn.