Author: Spencer Jones, DO
Co Author #1: Wade Rankin, DO
Co Author #2: James Joyner, MD

Patient Presentation:
A 24-year-old male presented to a Family Medicine Clinic for evaluation of 3 months of low back pain. He had been seen before at an outside hospital when the pain first started and diagnosed with muscle spasm, which did not respond to NSAIDs or muscle relaxants. The pain was acute in onset without acute injury. He described it as constant, sharp, piercing, with 9/10 in severity. Initially the pain was concentrated in right lower back but had recently migrated to the left side near the thoracolumbar junction with an associated “knot� in the same area. Pain was exacerbated by both spinal flexion and extension and with activity in general. No pain at rest. He denied numbness, tingling, incontinence, radiculopathy. He had been experiencing nightly dull headaches over the past month and low-grade fevers (101) for the past week. Otherwise review of symptoms was negative, with no night sweats or weight loss.

History:
Past medical history was unremarkable, with no previous hospitalizations, surgeries, or medications.

He was born in Cameroon and immigrated to the USA 11 months prior to visit. Immigration labs including tuberculin skin test were normal per patient. He denied any history of illicit drug use, smoking, or heavy alcohol use. He was physically active prior to the onset of pain, mainly recreational soccer. He was sexually active with consistent protection. He was enrolled in a nurse-assistant training program in Cameroon, and had planned on starting stockroom work in the USA soon. He lives with one female from Cameroon who is well.

Physical Exam:
BP: 115/68 Pulse: 82 Temp: 98.2° BMI: 22.9
Gen: healthy appearing adult male in NAD.
HEENT: Normocephalic, PERRL, no scleral icterus. Fundocopic and otoscopic exams normal.
Neck: No lymphadenopathy
CV: RRR, no murmur, rub, or gallop
Resp: CTAB
Derm: No visible rashes or cyanosis. No open lesions.
Neuro: CNII-XII intact, strength/sensation 5/5 globally, 2+ reflexes throughout
MSK: Tender to palpation over L2 spinous process. Normal active and passive spinal ROM with mild pain. No pain with Hip ROM or squatting
Skin: Freely mobile fluctuant minimally tender nodule over the T12-L1 vertebral junction extending over the left paraspinal muscles. Mass approximately 6cm diameter with 2cm central fluctuance without surrounding erythema. Additional mobile nontender 2cm nodule near T11-T12.

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