A 42-Year-Old Office Assistant With Chronic Leg and Back Pain

John G. Christensen, Jr, MD

Disclosures

March 05, 2021

Physical Examination and Workup

The physical examination reveals a healthy-appearing, nonobese female. She has no axillary, cervical, or inguinal adenopathy. Her lung sounds are clear. Heart auscultation reveals regular rhythm with no murmurs. Abdominal examination findings are negative, with no tenderness or mass. No flank tenderness or mass is noted. Lower extremities are normal without edema.

Metabolic panel findings are normal, including normal creatinine levels, liver function test results, and calcium levels.

Laboratory studies reveal normal urinalysis without red blood cells or protein. A complete blood cell count reveals normal hemoglobin level, hematocrit level, and white blood cell count.

After structural issues were ruled out, a spinal MRI is eventually performed as part of the investigation into her leg and lower back pain. Findings prompt CT scanning with and without contrast. See Figures 1-2 below.

Figure 1.

Figure 2.

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