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A 60-year-old businessman presents with a 12-week history of gradually worsening low back, buttocks and right knee pain. The patient was evaluated by his primary care physician who prescribed NSAIDs. After several weeks, the patient was no better and was referred to spine surgeon who ordered a magnetic resonance image (MRI) scan. The MRI scan revealed three herniated disks at L3-4 on the right, L4-5 on the left, and L5-S1 on the right. The spine surgeon recommended epidural steroid injections, which were refused by the patient. Instead, the patient was administered a methylprednisolone dose pack and reported a 50% improvement of pain for approximately 1 week. However, the pain persisted in the right buttocks and radiated into the right anterior thigh and into the right knee. Feeling frustrated, the patient insisted on a prescription for physical therapy. In addition to the above reports, the physical therapy history revealed that the patient was a self-employed businessman with no significant past medical or surgical history. There were no reports of night pain unrelated to movement, unexplained weight loss, or fever.

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Based on this limited history, what is your differential diagnosis?

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The differential diagnosis for this distribution should include femoral nerve neuropathy, lumbar disk herniation, meralgia paresthetica, sacral plexopathy, or a vascular disorder.

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Of those listed in the differential diagnosis, which would be the best working hypothesis?

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Given the findings from the imaging studies and the history, a lumbar disk herniation would be the best working hypothesis, although the level(s) of involvement could not be determined at this stage.

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What will be the first test you perform to help rule in/rule out your differential diagnoses?

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A lower quarter screening examination.

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Is there anything else in the subjective history you would have asked the patient?

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Other questions to ask include, but are not limited to, whether any movements or positions affect the symptoms, whether the symptoms vary according to time of day, what has the patient found that makes his symptoms feel better or worse.

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Which dermatome is involved with this patient?

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The symptoms appear to cover the L 3 dermatome.

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The physical examination revealed the following findings:

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  • A generally well-developed, well-nourished male
  • The patient’s gait was noted to be a normal heel-to-toe pattern; however, he stooped forward and listed to the left.
  • Lumbar range of motion was difficult to assess in all directions secondary to pain.
  • Palpation revealed lumbar paraspinal tenderness bilaterally, with some tenderness in the medial facet of the patella on the right side.
  • Reflexes were as follows: 1/4 right patella, 1/4 right medial hamstrings, 0/4 right Achilles, and ...

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