Author: Irfan Chhipa, MD, MPH
Editor: Mark Riederer, MD
A 30-year-old male with no past medical history presents to the office for evaluation of three months of persistent lower back pain.
The patient is a recreational athlete who plays basketball and football. He had gone to the emergency room two months prior for this same back pain. At that time, he was diagnosed with a low back strain and discharged with NSAIDs and a muscle relaxant. His low back x-ray in the emergency room was unremarkable. In the office, patient described the pain as localized to his lower back, 8/10 in severity, sharp, and non-radiating. The pain prevents him from sleeping at night. The pain is exacerbated by movement, in all directions. The pain is minimally alleviated with NSAIDs. He did have morning stiffness. He does not recall any trauma, nor any injuries during his sporting activities. He denies weakness, numbness or tingling in his lower extremities. He denies buttock pain. He denies bowel/bladder incontinence. He denies pain or swelling in any other joints or tendons. He denies any recent infections, diarrhea, urinary symptoms, urethral discharge, fever, intravenous drug abuse. He is sexually active with multiple partners, and does not use condoms.
He is a well developed, white male in distress. His cranial nerves II-XII grossly intact. There is no gait abnormality. He has no eye redness or discharge. There are no oral ulcers or skin lesions. There are no murmurs. He has no swelling or erythema in lower back, but is mildly tender to palpation. He has limited range of movement due to pain, more so on flexion. Negative straight leg test. His muscle strength 5/5 in lower extremities with normal sensations. He has no other joint swelling or erythema.
Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.