Author: Patrick Jenkins, BS
Co Author #1: Ryan Sprouse, MD
Co Author #2: Wade Rankin, DO
Co Author #3: Kelly Evans-Rankin, MD
Editor: Velyn Wu, MD
A 30 year old African American female presented with three weeks of worsening left sided low back pain and one week of gradually worsening shortness of air.
The patient’s back pain is located in the paraspinal musculature of her left low back. The pain is constant, achy, and has gradually become sharper. The back pain had a gradual onset and is worse with flexion and extension movements. She denies trauma or other injury to that area. She has tried acetaminophen, topical capsaicin cream, and massage which have slightly helped. The patient had an abscess drained on her right buttock five weeks ago. She had also presented for evaluation of her low back pain three times prior to this visit. On all three visits, history and physical examination were consistent with muscle spasm and she was treated with methocarbamol, hydrocodone, a lidocaine patch, and oral steroids at various times. She also complains of cough and pleuritic chest discomfort but denies fever or muscle weakness. She has no known active medical problems. She works as a medical assistant and denies tobacco or illicit drug use.
Vital Signs: temperature 96.8F, blood pressure 128/80, heart rate 112, respiratory rate 30, oxygen saturation 95% on room air
General: no acute distress
Chest: no chest wall tenderness
Cardiovascular: elevated rate, no murmur, pulses normal
Respiratory: poor inspiratory effort, breath sounds decreased left base, no crackles
Musculoskelatal: tenderness to paplation left lumbar paraspinal musculature. Area of palpable spasm versus induration measuring 10x10cm. Normal range of motion
Neurologic: sensation and reflexes intact, no focal deficits
Extremities: no weakness
Skin: clean, dry, intact, no erythema
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