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CASE #1

 

List of possible differential diagnoses.

Low back pain is a “common symptoms and not a disease condition accounting for 15% to 20% of the U.S. population, and approximately 50% of working-age adults” (Bartleson, 2001). Differential diagnoses for low back pain include back strain, acute disc herniation, osteoarthritis, ankylosing spondylitis, infection, malignancy, etc.

Evidence needed to rule in or rule out each differential.

Comprehensive general physical examination, with attention to specific areas as indicated by the history, can be helpful to rule out or rule in any differential diagnosis. However, there are some signs and symptoms that may be specific. Therefore, a detailed initial assessment of the patient that includes musculoskeletal and neurological examination to assess bones, joints, muscle strength, and flexibility must be performed to elicit diagnosis. Review of system and questions about the onset of pain (e.g., time of day, activity), location of pain (specific site, radiation of pain), type and character of pain (sharp, dull, etc.), aggravating and relieving factors is also important in diagnosing back pain. For example, “back strain has an ache or spasm pain quality that increases with activity or bending with local tenderness and limited spinal motion at the low back, buttock and posterior thigh which is different from symptoms of acute disc herniation which come with a sharp shooting or burning pain in the lower back or lower leg and paresthesia in the leg and decreases with standing and increases with bending or sitting” (Patel and Ogle, 2000). Likewise, the presentation of “ankylosis that presents with ache and morning stiffness in the sacroiliac joint or lumbar spine with decreased back motion and tenderness over these joints is different from osteoarthritis or spinal stenosis that presents with a low back to lower leg shooting pain, pin and needled like sensation which is often bilateral and increases with walking especially up an incline and decreases with sitting with mild decrease in spine extension and reflexes” (Patel and Ogle, 2000). The presenting complaint of the patient that highlights that onset, location, and quality of pain as well as aggravating or relieving factor can be helpful to make a clinical diagnosis.

Additional aspects of the history and physical examination could provide relevant information to help in the diagnosis.

Apart from the onset, location, and quality of pain as well as aggravating or relieving factor mentions above, age of the patient, work, and medical history including previous injuries or surgeries, etc. and examination of the entire spine, stance, deep tendon reflexes, sensation, posture, and gait can be an additional aspect of history and physical examination that can provide a relevant clue to the diagnosis. Also, questions about “constitutional symptoms, presence of night pain, bone pain, morning stiffness and, the occurrence of visceral pain or symptoms of claudication and neurologic symptoms such as numbness, weakness, radiating pain, and bowel and bladder dysfunction can be helpful” (Patel and Ogle, 2000).