Level 3: Back Pain – Contrasting Case #2: Patient Information

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

What is your diagnostic explanation?

As compared to the long case, this patient is an 80 year old woman who is brought to the clinic by her daughter, who is concerned about changes in her mother’s posture as well as her recent mentions of lower back pain.

HPI: The patient describes the pain as midline in her lower back, non-radiating, aching in nature, and is rated as 3/10 severity. She is uncertain of the onset or duration of her back pain, and states that it does not usually bother her. No history of falls or preceding injury.

PMH is unremarkable, and her only medication is a daily multivitamin.

SH: She resides at a local assisted living facility, where she occasionally walks for exercise. She does not consume alcohol and has never used tobacco.

FMH: Unremarkable.

ROS: Noncontributory

PE: Mild tenderness to percussion/deep palpation over L5. Mild kyphosis is noted, but gait is otherwise normal. Straight leg test is negative. Rectal exam is not performed.”