A 53-Year-Old Waitress With a Cough and Constant Back Pain

Avan Armaghani, MD


March 22, 2022

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 that you would like to suggest for a future Case Challenge, please contact us.


A 53-year-old postmenopausal woman has had worsening low back pain for the past 2 months. The pain is in the mid to lower back region and does not radiate. She describes it as a constant dull ache that worsens when she stands for long periods. Over-the-counter analgesics initially relieved the pain; however, over the past 2 months, these medications have become ineffective in alleviating her symptoms.

She has no loss of bladder or bowel function, and she reports no numbness or tingling sensation in her legs. She is able to ambulate without difficulty, but she experiences the back pain when she walks. The patient has never had back pain before. She has not sustained any recent injury. She does not recall experiencing fever, chills, dizziness, changes in vision, nausea, vomiting, diarrhea, constipation, or chest pain. She has an occasional dry cough that has been ongoing for about 6 months. The cough does not produce any sputum or blood.

The patient's past medical history is significant for hypertension, for which she takes a beta-blocker once daily. She also has hyperlipidemia, for which she takes a statin once daily.

The patient had a mammogram 2 years earlier, which did not reveal any abnormalities. Her most recent Pap test was 2 years ago, and the results were normal. She has never had a colonoscopy.

The patient is a current smoker; she has smoked one pack per day for the past 31 years. She drinks one glass of wine a week and does not use any illicit drugs. She currently works full-time as a server at a local restaurant.

Her family history is significant for the death of her father from lung cancer at the age of 62 years. Her mother was diagnosed with colon cancer at the age of 52 years; she received treatment and is still living. The patient has a younger sister, aged 50 years, who is healthy.


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