Author Question: A 55-year-old patient complains of lower back pain due to heavy lifting at work yesterday. He ... (Read 125 times)

ghost! · **on:** Jun 25, 2018

A 55-year-old patient complains of lower back pain due to heavy lifting at work yesterday. He reports weakness of the left leg and paresthesias in the left foot.

On physical examination, the patient has diminished ability to dorsiflex the left ankle. Which of the following symptoms should prompt the clinician to make immediate referral to a neurosurgeon?
A. Straight leg raising sign
B. Lumbar herniated disc on x-ray
C. Loss of left sided patellar reflex
D. Urinary incontinence

Question 2

A 20-year-old male construction worker is experiencing new onset of knee pain. He complains of right knee pain when kneeling, squatting, or walking up and down stairs.

On physical examination, there is swelling and crepitus of the right knee and obvious pain with resisted range of motion of the knee. He is unable to squat due to pain. Which of the following disorders should be considered in the differential diagnosis?
A. Joint infection
B. Chondromalacia patella
C. Prepatellar bursitis
D. All of the above

mcomstock09 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
With low back pain in a patient, it is important to obtain a detailed history of the onset and progression of the pain. A thorough pain history should be completed, noting its quality, location, radiation, and intensity as well as any exacerbating and relieving factors. A thorough review of systems is necessary to identify any associated symptoms that may indicate an urgent problem. These include altered bowel and/or bladder function, fever, weight loss, and/or weakness. The physical examination should begin by noting the patient's posture and apparent level of comfort. The standing patient should be directed through a series of maneuvers to assess the back motion, including flexion, hyperextension, lateral flexion, and rotation, as the smoothness of motion, ROM, and any obvious signs of discomfort are noted. Observe the patient walking on heels and on toes, noting any signs of weakness. Next, with the patient resting supine on the examination table, the straight leg maneuver should be performed. As the patient rests supine with both legs extended, the examiner should passively elevate one leg at a time. A positive test is indicated if the patient experiences discomfort with the initial elevation rather than once the hip has been hyperflexed beyond 50 degrees. If the results indicate nerve impingement or disk injury, further radiographic testing is then indicated.

Answer to Question 2

ANS: D
Prepatellar bursitis is also called housemaid's knee, which is common to persons whose occupation requires extended periods of kneeling, such as plumbers and carpet layers. This bursitis can also be caused by an infection. The patient complains of pain in the area inferior to and over the patella, and there is swelling and inflammation of the bursa. Chondromalacia patella is seen in young active persons of either gender. The condition is also commonly called patella-femoral syndrome and runner's knee. The pain involves the anterior knee, often develops gradually, and is moderate in intensity. Pain can be reproduced by pressing the patella against the femoral condyles, and there is tenderness around the patella. Other maneuvers that reproduce the pain include applying pressure against the patella as the patient extends the lower leg, flexing the quadriceps, and moving the patella from side to side. Crepitus and effusion are often present.