1. Differential Diagnosis Low Back Pain Zach Bernard William Cummins Brandon Wilbanks

2. History 74 year old Male Chief Complaint: Pt. Has been experiencing pain for sometime now time. His best guess is that it started in the last 6 months or so. There is no history of trauma. The pain is bilateral traveling from the back down both legs and into the feet. The pt. Describes it as pain that is diffuse. The patient has been experiencing leg fatigue, numbness and weakness lately. The patient says that they really notice the pain when they stand up or begin walking, but it is quickly relieved up sitting.

3. Exam Findings Decreased ROM of Lumbar spine Increased pain and paresthesia when perform Extension during ROM S.L.R. reproduces radicular pain Belt test is positive in both supported and unsupported Decrease in sensation and strength occur upon walking Severely decreased mobility and flexibility of the spine

4. Imaging Plain Film X-ray: Lumbar A-P, Lateral, and Lumbosacral spot. Show signs of degeneration of the disk and facets. CT Scan Shows hypertrophy of the lamina, pedicles and apophyseal joints, along with a thickened ligamentum flavum. Giving it the classic cloverleaf or trefoil appearance. MRI Also allows for visualization of the trefoil appearance and is currently the preferred method of diagnostic imaging for this condition.

5. Differentials Lumbar Spinal Stenosis Cauda Equina Sydrome Centrally Herniated Discs Trauma Degenerative Spondylolisthesis Metastatic Disease

6. History 55 year old Black Male, 6’2’’ and a smoker Chief Complaint: Pt. Has been experiencing pain for the last couple of months. There is no history of trauma and patient can not explain why his back would hur. Pain stays in his low back. The patient says that nothing relieves his pain. Patients diet is high in meat and animal fat with low vegetable intake. Patient has reported having trouble urinating. A slower stream when urinating and dribbling after. Recently lost about 10 lbs with no change in diet. Also reports feeling fatigues and sick randomly.

7. Exam Findings Lumbar ROM normal Ortho test unable to illicit classical response All neruo test WNL Unable to elicit or elivate pain throughout exam

8. Imaging Plain Film X-ray: Lumbar A-P, Lateral, and Lumbosacral spot. Small amount of Degeneration. CT Scan Lumbar Area Unremarkable MRI Lumbar Area Unremarkable

9. Lab Tests CBC- Normal with slight anemia PSA levels are elevated > than 4 ng/ml EPCA-2 levels are elevated as well.

10. Differentials Prostate Cancer Benign Prostatic Hypertrophy Metastatic Disease Bladder Cancer U.T.I.

11. Lumbar Degenerative Disc Disease

12. History How it presents Symptoms Provocative Palliative

13. Examination Neurological Physical Laboratory

14. Imaging Radiography Nuclear (Bone Scan) Computerized Tomography (CT) Magnetic Resonance (MR)

15. Differentials Muscle strain Ligament/tendon injury Sacroiliac joint syndrome Lower lumbar zygapophyseal joint syndrome Hip joint pain Compression fracture Stress reaction Stress fracture Spondylolysis Spondyloarthropathy Marfan syndrome Fibromyalgia Myofascial pain syndrome Diskitis Neoplastic disease

16. Facet Syndrome

17. History How it presents Symptoms Examination

18. Imaging Radiography Nuclear (Bone Scan) Computerized Tomography (CT) Magnetic Resonance (MR)

19. Differentials Lumbosacral disc injuries Lumbosacral discogenic pain syndrome Lumbosacral radiculopathy Lumbosacral spine acute bony injuries Lumbosacral sprain/strain injuries Lumbosacral spondylolisthesis Lumbosacral spondylolysis Piriformis syndrome Sacroiliac joint injury

20. History 26 year old male 5’8” 165 lbs Chief Complain: Low back pain with varying intensity. Occurs mostly at night and in the morning. It usually gets better as the day goes by and as he starts to move around. It gets worse with rest. Occasionally develops low back muscle spasms. Also flexing forward eases the pain and the spasms. This has been going on for 6 months. Has experienced an occasional low grade fever and is generally fatigued. Has a loss of appetite and has loss 5lbs in the last month with out trying to lose weight.

21. Exam Findings Paraspinal muscle pain and tenderness Decreased ROM in lumbar and thoracic regions Decreased Chest expansion Increased thoracic kyphosis and Decreased lumbar lordosis low grade fever SLR is negative Lewis Gainsleins is negative Belt test is negative Amos’s sign is positive

22. Exam cont. Forester’s Bowstring sign is positive Lewin’s supine is positve Neurology tests are within normal limits Pt. cannot lie flat on the table

23. Lab Tests CBC-normal ESR-normal RA factor-negative HLA-B27-positive C-reactive Protien-negative

24. Imaging X-Rays performed. Lumbar AP lateral and Spot views, Thoracic A-P and Lateral Findings: No signs of Lumbar DDD or Thoracic DDD. Bilateral Mild sclerosis and lateral narrowing of Sacroilliac joint space. Squaring of L1 and L2 vertebrea. Is CT or MRI necessary?

25. Differentials Lumbar Disc Degenerative Disease Infection Tuberculous spondylitis Psoriatic arthritis Osteoarthritis Ankylosis spondylitis

26. History Black Male 55 years old 6’0” tall 160 lbs. BP 130/85 HR 70/min Resp 12/min Chief Complaint: Pt. has been experiencing low back pain for 3 months. He is always tired and has almost no appetite. He has lost 20 lbs in the last 3 months with no dieting. The pain is persistent especially at night and when resting. There is no history of trauma. The pain came on gradually and is unexplained. The pt. has been having to go the restroom more frequently. Pt. is also complaining of waking up at night with numbness in the hands, wrist and forearms bilaterally. Pt. also has had 3 cases of pneumonia in the last 2 years and one case of pyelonephritis 4 months ago.

27. Exam Findings Hepatomegaly Cachexia Muscle weakness 3/5 wrist extensors bilaterally 4/5 leg extension bilaterally Phalens test is positive Tinels (wrist) is positive Foraments cone test negative

28. Imaging Plain Film X-ray: Lumbar A-P Lateral and Lumbosacral spot, Cervical Lateral A-P lower and A-P open mouth views. Findings: Generalized osteoporosis, cortical thinning of the lumbar spine, L3 vertebra planna sign present. Multiple round well circumbscribed lesions of the skull are present.

29. Lab Tests CBC-Normocytic Normochromic Anemia with Rouleau, Thrombocytopenia, BUN Serium Creatine and Serum Uric Acid are elevated Hypercalemia Reversed A/G Ratio Urinary Analysis: Bence Jones Proteins, Hyperuricemia, Amyloidosis Bone Marrow Aspiration- Plasma cell Conc. >10 %

30. Differentials Metastis Lymphoma Multiple Myeloma Amyloidosis Plasma Cell Leukemia Waldenstrom macroglobuilinemia Carpal Tunnel Syndrome