Team Sergeant with Low Back Pain

[ender18d]

Any other physical findings you want to look for or history questions to ask?

I think this covers all the new information, but if I missed something please let me know. You should be honing in on your differentials at this point. Look carefully at the problem list and you should be able to stratify this differential pretty effectively. Moving on, are we going to do anything to treat this guy?

Summary Update:

Subjective:
The patient is a 45 y/o steely-eyed barrel-chested team sergeant who presents to the medic with "lower back pain" of a few days duration. He localizes the pain to the L3 L4 region. The patient denies any history of trauma or significant precipitating event. The patient admits to possible fever and night sweats. The patient denies urinary symptoms, incontinence, impotence (strongly denies this one), or neurologic findings. PT reports urine of "medium yellow" color. PT denies NVD, cough, sore throat, rhinorrhea. No pain association with meals. The patient denies history of easy/unusual bleeding or bruising. The patient admits to poor hydration habits. PT denies unusual dietary exposures such as unpasteurized milk.

O: First noticed a few days ago. Gradual in onset.
P: Nothing helps. Movement, especially lumbar flexion, hurts.
Q: “Sharp”
R: “The pain doesn’t seem to go anywhere else but my back.”
S: “Its pretty f’ing bad or I wouldn’t be asking you for meds.”
T: “It hurts pretty constantly.” The pain has been progressive.

PMH: HTN, Recent Dental Work for suspected tooth abscess. Potential poor compliance on post-procedural medication of unknown type.
SHX: N/A
Medications: Lisinopril (since mid 30's), Atovaquone/Proguanil (started about 10 days ago), Various nutritional supplements for weight-lifting
Allergies: NKA
FHX: Dad always had lower back pain, and mom had RA.
Social History: Patient is a weight lifter who enjoys 200lb snatch. PT admits to high stress levels due to marital issues, possibly related to aforementioned 200lb snatch.

Objective:
Vitals: HR: 90, BP 130/85, RR 14, T 101.5deg
The patient is a WDWN 45 y/o Caucasian male who looks his stated age and presents to medic in moderate distress. He is moderately pale and his movements are constrained and provoke grimaces and profanity. Pertinent physical findings include exquisite tenderness on the vertebral prominence of L3 & L4 with a conspicuous absence of tenderness in the paraspinous muscles. No CVAT. Shoulder exam unremarkable. Visual examination of back unremarkable. Straight leg raise does not provoke sciatic pain. Neuromuscular exam of lower extremities unremarkable with preserved reflexes, sensation, and strength. Valsalva unremarkable. Cardiac exam demonstrates RRR, S1/S2 w/o murmurs, gallops, or rubs. PMI @ 5th ICS MCL. Lungs CTA x3 bilat. No splinter hemorrhages. Abdomen shows no visible lesions and is soft and supple in 4 fields w/ no guarding or rigidity. Bowel sounds auscultated. No nuchal rigidity or photophobia noted. No peripheral edema. Urine dipstick test all WNL.

CBC: 15,000 per mm3 leukocytes w/ 12% bands

Problem list:
Focal Vertebral Pain
Fever
Night Sweats
Pallor
Recent Dental Work for possible abscess
Possible poor ABX compliance
Leukocytosis w/ left shift


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Some additional questions:

1. What, precisely, is a "night sweat?"

2. What does "pain greater on flexion than extension" suggest in the context of vertebral back pain? How does this fit with our differential at this point?

3. Renal pathology is absolutely a consideration for low back pain, but there are a number of findings in our history and physical at this point that make renal issues less likely in this patient. What are they?