A 79-year-old man presents to his physician with the complaint of severe left leg pain of 2 days duration.

The patient was in good health until 5 weeks ago when he tripped and fell on his left side in the kitchen of his home. He had no immediate symptoms but about 2 weeks later he began to have mild pain on the inside of his left thigh which worsened progressively until the onset of the acute pain two days ago.

The leg pain is instantly relieved upon sitting. It is also relieved by lying, but a pillow beneath the knees is needed to prevent the recurrence of pain. When the patient attempts to get out of bed, he experiences severe pain involving the inside of the left leg to the knee. He also notes numbness in this area. Non-steroidal analgesics have not provided any relief.

Physical examination reveals a patient in marked discomfort while walking. Temperature is 97.8˚ F, Blood Pressure is 146/72 mmHg, Pulse is 84 and regular and respirations are 18/minute. Physical findings are limited to the low back and upper left leg. When walking, the patient is somewhat bent over. He finds it necessary to hold on to something and he has a shuffling gait. There is slight weakness of the thigh muscles of the left leg but lower leg and foot strength are normal. Deep tendon reflexes are normal.

There is moderate hyperesthesia of the skin over the left upper leg anteriorly. The Romberg test is negative. There is moderate tenderness when pressing over the lower lumbar spine, more so on the left. The rest of the physical examination is normal.

Laboratory tests are unrevealing. CBC, liver and renal function studies, and electrolytes are normal.

An MRI of the lumbar spine shows scoliosis, spondylolisthesis, osteoporosis, partial collapse of the L4 vertebra compression of the L4 nerve root on the left. 

Answer Options:

Metastatic cancer to bone

Partial collapse of the L4 vertebra

Compression of the L4 nerve root

Either partial collapse or compression of the L4 nerve root

Except for Hospitalists, Emergency Medicine physicians, and Interventional Cardiologists, most physicians will spend the bulk of their professional time with patients in an office setting.

Here is where finely tuned clinical skills are most important in leading to accurate diagnoses, fewer complications resulting from unnecessary tests and procedures, and lower costs. These Bedside Diagnostic Challenges reinforces the value of these clinical skills and tests users on their knowledge of them.

Bedside Diagnostic Challenge questions are issued periodically every month as a free benefit of Med-Challenger.

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Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He has served the University of Rochester School of Medicine as Chief Resident in Medicine and as Professor, Department of Medicine. He has served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine. Dr. Griner is board certified in internal medicine.