Level 1: Back Pain – Contrasting Case #3: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, the patient is a 54 year old obese man who is sitting uncomfortably in a chair and hesitates to move. He reports throwing a bale of hay one day prior to presentation, which involved a twisting motion of his spine, that instantly caused a painful sensation of “giving way” in his lower back. Pain is located in the right lumbar region and is associated with muscle spasms that cause referred pain to his buttock; however, the pain does not radiate distal to the knee. Pain is worse with activity and improves with rest. He iced his back after the injury which seemed to help, but only temporarily. Patient has been taking Tylenol for pain control which has helped somewhat.

Physical Exam: Pain with palpation of right paraspinal muscles in the lumbar region. Forward and lateral flexion of the spine produces pain and limits range of motion.