Case 4 – Worsening Back Pain

You are seeing Mr. Del Negro, an active 82 year old male in a walk-in clinic. He told your nurse that his back pain has recently become unbearable. Please take a focused history and perform a focused physical examination.


  • Onset of back pain
  • Location, and if pain is unilateral/bilateral
  • Quality of pain (dull)
  • Radiation of pain (none)
  • Alleviating and aggravating factors
  • Medications/therapies that have been attempted/are successful to relieve the pain
  • Associated trauma or overuse injury
  • Sensory loss (none)
  • Parasthesia (none)
  • Motor deficits (none)
  • Fever, weight loss, or other systemic symptoms (none)
  • Bladder or bowel incontinence
  • Past history of back pain
  • Personal history of peripheral vascular disease
  • Smoking history (quantity in pack-years)
  • Dyslipidemia
  • Personal history of malignancy
  • Effect on daily activities

Physical Examination


  • Comments on shape of spine – kyphosis, scoliosis, as well as posture
  • Comments on any asymmetry of the back, including swelling, scars, or bruising

Range of Motion/Gait

  • Observes all active ranges of motion for the back
  • Assesses patient’s gait


  • Palpates along spinous processes and paraspinal muscles of the back for tenderness
  • Performs straight leg raise on both sides, with and without ankle dorsiflexion (negative)
  • Palpates peripheral pulses (present)
  • States that an abdominal exam should be performed to rule out an abdominal aortic aneurysm

Neurological exam

  • Tests foot sensation (L4, L5, S1)
  • Tests for saddle anesthesia (S3, S4, S5)
  • Tests knee (L4) and ankle reflex (S1)
  • Tests Babinski response
  • Tests power of big toe and foot dorsiflexion, as well as foot plantarflexion (S1)
  • Assesses for hip abduction (L5); states that full hip examination should be performed
  • States that rectal tone should be assessed
Case 4 – Worsening Back Pain