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A 52-year-old female presented with constant mild to severe low back pain of approximately one year in duration. The patient reported that when the pain was severe that it sometimes radiated upwards to the mid thoracic spine and that her legs felt weak. The patient reported that there was no night pain other than the constant low back pain. The patient also reported some minor weight loss that was unexplained. A recent gynecological examination was negative. The patient reported that she smoked a packet of cigarettes a day but that she did not drink alcohol. The patient's past medical and surgical history were unremarkable. The patient works at the local supermarket as a shelf stacker that involves lifting approximately 40 kg fairly frequently. Recent lumbosacral spine radiographs showed some thinning of the L3-4 disk space with some anterior lipping at the disk-vertebral body margins. A lumbar spine CT scan taken at the same time did not show any spinal canal lesions in the L3 to S1 levels. The bone scan results were also normal.

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What other questions would you like to ask this patient?

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This is an interesting case with a mixture of information, some of which is extremely pertinent - the pain is of a long-duration and fluctuates in intensity; there is an absence of night pain but the presence of unexplained weight loss; there are also negative findings in a number of imaging studies. Because of the reported fluctuations in the severity of the pain, the clinician should determine if there are any activities or positions that have an impact on the symptoms. Questions about the quality of the pain could also prove useful.

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Is a report of constant pain more of a concern than a report with intermittent pain?

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Constant pain is usually more of a concern than intermittent pain as it tends to indicate that the condition is not improving.

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Does this patient warrant a lower quarter screening examination?

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The patient's conflicting history warrants a lower quarter screening examination.

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The lower quarter screening examination revealed the following positive findings:

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  • Tenderness of the lumbar paraspinal muscles.
  • Active range of motion of the lumbar spine reproduced the patient's low back pain in all directions.
  • The adverse neural tension tests were all negative.
  • There were no deficits with strength testing of the lower extremities.
  • The deep tendon reflexes at the knees and ankles were normal.
  • There were no deficits with sensation to pinprick.

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Following the physical examination results, do you have a working hypothesis?

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Most of the results from the screening examination were negative. Indeed, the only significant finding was pain reproduced by active range of ...

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