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Matthew Donovan, a taxi driver in his 40s presents with pain at the base…
Matthew Donovan, a taxi driver in his 40s presents with pain at the base of his lower spine.
Personal life:
He is married and has a son. He mentions that he sometimes has to lift heavy weights like suitcases.
Presenting complain:
Right side back pain, sharp pain in the lower back through his leg when he lifted a suitcase on Thursday.
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Family history:
Father experienced back pain, brothers are healthy.
Physical Examination:
- All vitals within normal limits.
- Walking test: claudication
- Posture: bent forward with a lateral right tilt.
- Spine palpation: hardness of lower back muscles.
- Reduced and painful flexion, extension and lateral flexion.
- Reduced sensation in the little toe.
- Foot movements: weak eversion, cannot walk on tiptoes.
- Lasague sign positive (40 ̊)
- Wassrmann negative, Babinsky positive.
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Visit 2:
The patient says he feels better, however, is still experiencing some pain in the lower back and right leg when sitting.
Pain Severity: 3 -3.5 on the VAS.
Physical exam:
- All vital signs within normal limits.
- Walking: Claudication
- Posture: bent forward with a lateral right tilt.
- Improved spine movement.
- Recovered right ankle reflex.
- Improved Lasague sign (80 ̊)
- Babinski and Wassermann negative.
Management:
- Continue NSAID therapy.
- Follow an exercise program.