Case 1 A 35-year-old, healthy White male is complaining of right-sided, low back pain for 1 day. The pain began suddenly after lifting a box weighting 35 lbs. at work. The pain radiates down the back

Case 1

A 35-year-old, healthy White male is complaining of right-sided, low back pain for 1 day. The pain began suddenly after lifting a box weighting 35 lbs. at work. The pain radiates down the back of his leg to his right ankle. He has tried ibuprofen and ice without relief. His pain is an 8 out of 10 (with 0 being no pain and 10 being the worst pain). He denies bowel or bladder dysfunction, paresthesia, motor weakness, or fever.  

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  • Past medical/surgical history: no major medical illnesses; no surgical history; no previous hospitalizations.
  • Social history: has smoked 1 pack of cigarettes a day for 15 years.
  • Medications: none.
  • Allergies: no known drug allergies.
  • Vital signs: temperature 98.7°F; pulse 90 beats per minute; respirations 18 per minute; blood pressure 126/78 mmHg; pulse oximeter 100%.

Physical examination revealed a well-nourished adult male without any acute distress. Significant right paraspinal tenderness at L4–L5 was present with no midline tenderness. Straight leg raise was positive at 30° to the right lower extremity. Straight leg raise was negative to the left lower extremity. The remainder of musculoskeletal examination was unremarkable (e.g., deep tendon reflexes, strength, and sensation). Other systems examinations were unremarkable (e.g., heart, lungs, etc.). 

Answer the following questions based on the Case 1. 

1. What are your differential diagnoses? What are subjective and objective findings consistent with the various differentials for low back pain?
2. Would you consider imaging for this patient? If so, what imaging would be recommended and why?
3. What are the red flags of low back pain?
4. What are treatment strategies for this patient? What education would be provided to the patient?
5. When should you refer this patient to a specialist?

Case 2

A 13-year-old male is complaining of mild recurrent bilateral anterior knee pain without fever, joint swelling, erythema, or limitation of ambulation for the past 3 months. He is accompanied by his mother. 

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  • Prenatal and birth history: unremarkable.
  • Developmental history: mother reports normal development.
  • Past medical/surgical history: no major medical illnesses; no surgical history; no previous hospitalizations.
  • Social history: actively involved on his school’s soccer team for 2 years.
  • Family and environmental risks: none.
  • Immunization history: up to date.
  • Medications: none.
  • Allergies: no known drug allergies.
  • Vital signs: temperature 98.7°F; pulse 72 beats per minute; respirations 18 per minute; blood pressure 120/70 mmHg; pulse oximeter 100%.

Physical examination revealed a well-nourished adolescent male without any acute distress. Significant bilateral tenderness was noted when palpating the tibial tubercles, and extending his knees against resistance reproduced pain. The remainder of the musculoskeletal examination was unremarkable (e.g., deep tendon reflexes, strength, and sensation). Other systems examinations were unremarkable (e.g., heart, lungs, etc.). 

Answer the following questions based on Case 2. 

1. What is the most likely diagnosis for this patient?
2. What is the pathogenesis of this disorder?
3. What additional information assists in making the diagnosis?
4. What are treatment strategies for this patient?
5. What education would the provided to the patient and mother?