79-Year-Old Man Presents with Complaint of Severe Left Leg Pain of Two Days Duration - Bedside Diagnosis Challenge
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.
On the basis of these findings, what do you consider the most likely reason for this patient's leg pain?
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
See the Answer:
More from Med-ChallengerThe Leader in Online Board Review, CME Courses, and Medical Education
Did you like this?
Get more free medical Q&A and informative CME articles.
Subscribe to the Medical Education Blog
More from Med-Challenger's Medical Education Blog
Thromboembolic Disease Board Review Questions, Free CME Quiz – Earn AMA and ANCC Credits FreeJune 29, 2022
Overuse Syndrome or Septic Joint? – Clinical Patient Case of the WeekJune 21, 2022
June 2022 CME Updates, News, and Offers from Med-ChallengerJune 17, 2022
Board Review & CME Offers
Med-Challenger provides online medical education, top-rated board review courses, annual MOC and CME credit solutions for physicians, nurses, PAs and students. Take advantage of our current offers.
About The Bedside Diagnostics Blog Series:
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.
Subscribe to the Med-Challenger blog for more Diagnostic Challenge blogs and other free clinical content from Med-Challenger.
About the Author:
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.