Mr. Y’s history of a specific precipitant and diffuse back pain is consistent with nonspecific mechanical back pain, which is the cause of 95% of the back pain seen in a primary care practice. History and physical exam should focus on looking for neurologic signs and symptoms that would suggest a specific musculoskeletal cause, such as a herniated disk, and for signs and symptoms that would suggest the presence of a systemic disease. Signs and symptoms of neurologic or systemic disease are pivotal points in the assessment of back pain. It is necessary to further explore the differential by looking for findings listed in Tables 7-1 and 7-2. Table 7-2 lists the differential diagnosis.
The clinical clues (sometimes called “red flags”) listed in Table 7-1 should be assessed in all patients with back pain.
Mr. Y has no history of other illnesses. He has had no trauma, weight loss, fever, chills, or recent infections. He takes no medications and does not smoke, drink, or use injection drugs. The back pain does not radiate to his legs. On physical exam, he has mild tenderness across his lower back; lower extremity strength, sensation, and reflexes are normal. Straight leg raise test is negative.
Is the clinical information sufficient to make a diagnosis? If not, what other information do you need?
The exploration does not undercover new findings suggestive of specific or serious causes of back pain, limiting the differential at this point to nonspecific, mechanical low back pain.