A 39-Year-Old Man With Debilitating Back Pain

Tami O. Tiamfook-Morgan, MD; Daniel M. Lindberg, MD


April 27, 2016

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.


A 39-year-old Guatemalan man presents to the emergency department (ED) with severe and debilitating back pain. The patient had been evaluated by his primary care provider (PCP) for back pain approximately 3 weeks ago; in addition, he was seen in the ED about 1 week ago for his back pain. The patient's pain started immediately after he caught a heavy bag of ice, and it has progressively worsened.

At both his visit to his PCP and in the ED, the patient was diagnosed with musculoskeletal back pain, and he was discharged with a therapeutic regimen that included a nonsteroidal anti-inflammatory drug (ibuprofen). He was advised to follow up with his PCP.

At today's presentation to the ED, the patient describes the pain as throbbing and diffuse throughout the lower back, with radiation to his left buttock and upper back. The pain is exacerbated by walking and relieved with rest. He denies having any associated lower-extremity numbness or paresthesias. He also denies any fever, chills, or night sweats. Review of systems is negative for loss of bowel or bladder control, difficulty urinating, or constipation.

The patient has no known chronic medical conditions. He smokes half a pack of cigarettes daily. He is currently not taking any medications other than the prescribed ibuprofen, and he denies intravenous drug abuse.


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