Level 3: 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, this patient is a 50 year old man presents to the clinic with back pain.

HPI: Onset was insidious and pain has slowly progressed over the past two months. The patient describes his pain as dull, constant, non-radiating and of 6/10 severity. Movement exacerbates his pain, and he has found no relieving factors. He reports some lower extremity weakness over the past month. He reports recent malaise, but denies fever/chills.

PMH: Significant for poorly controlled DM2 and recurrent cellulitis.

PE: On exam there is marked tenderness over L3-4 with concomitant paraspinal muscle spasm. Strength is 4/5 of bilateral lower extremities. Remainder of neurological exam is unremarkable. Straight leg test is negative. On rectal exam, anal sphincter tone is intact; prostate is small, symmetric and without nodules.”