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A 32-year-old male presents with constant low back pain that radiates to the left or right upper buttock region. The symptoms have been constant for about two weeks. The patient works as a manual laborer and has a history of low back pain although the pain has always been localized to the low back. When questioned about the symptoms, the patient reported that he injured himself at work and that the pain radiates to the left buttock then to the thigh and calf posteriorly and he experiences a ‘tingling’ sensation in the left heel. Sometimes, albeit less frequently, he experiences pain radiating into the posterior aspect of the right thigh as far as the knee. There is no night pain except when changing position, and coughing or sneezing aggravate his symptoms, as do arising from the seated position, and walking upstairs. The patient, who is a non-smoker, has had no imaging studies and his past medical and surgical history is unremarkable.

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Do you have a working hypothesis at this stage?

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This history is classic for a herniated lumbar disk. If this was not your chosen working hypothesis, review the history again and list all of the reports that suggest neurologic compromise. The larger issue that now remains is to determine the type of herniation and whether the patient will benefit from physical therapy.

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Does this patient warrant a lower quarter scanning examination?

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This patient certainly warrants a lower quarter screening examination.

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What is your differential diagnosis at this stage?

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The differential diagnosis should include, however unlikely, any condition that can cause a similar distribution of symptoms, including but not limited to piriformis syndrome, sacroiliitis, a vascular disorder, and lumbar spine neoplasm.

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The physical examination revealed the following findings:

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  • No obvious pelvic obliquity or scoliosis in the standing position.
  • Deep palpation of the paraspinal muscles elicited pain at the L5-S1 level.
  • The sacroiliac joint tests were negative.
  • Deep tendon reflexes in the upper and lower extremities were normal.
  • Lumbar spine active range of motion testing revealed the following:
    • Lumbar flexion -- 66% and limited by increasing low back pain. The patient experienced difficulty in straightening his spine following the flexion due to an increase in low back pain.
    • Lumbar extension was limited by approximately 10% due to low back pain.
    • Side bending to the right and left were normal.
  • Strength testing and pinprick sensation were normal.
  • The slump test was positive for low back pain with the addition of left straight leg raising (40°) and right straight leg raising (50°).
  • The supine straight leg raise test was limited to 60° on the right due to right leg pain posteriorly and 55° on the left due to left thigh and calf pain posteriorly. The ...

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