| Ernest Mboto, aged 66, farmer. Problem: Persistent dull low lumbar back pain for ten weeks, worse at night and steadily becoming more intense. |
| History of injury: | No |
| Site and Radiation: | Central
lower lumbo-sacral, radiation into both buttocks when severe. |
| Type of Pain: | Boring
deep ache, unrelenting and continuous. |
| Onset: | Insidious |
| Aggravation: | Movement
and activities such as lifting and gardening. |
| Relief: | None apart from analgesia. |
| Associated Features: | Malaise,
fatigue, muscular weakness, recent weight loss 2kg. |
| Urinary symptoms: | Increasing
frequency, difficulty starting and stopping micturition. |
| Physical examination | |
| Inspection: | Gait
and movement: Limited with protective movements. |
| Posture: | Flattened lumbar lordosis. |
| Palpation: | Mild
tenderness to deep palpation over L4 and L5. |
| Movement: | All
movements (flexion, extension and lateral flexion), restricted and protective. |
| General: | Patient
appears unwell.
No neurological abnormalities. Examination of chest, CVS, abdomen and urine normal. |