January 2019

A 83 Year Old Woman With Back Pain After a Fall

History
A 83 year old female presents to the urgent care facility after a ground-level mechanical fall with axial back pain. She denies any weakness or numbness in her legs and she denies incontinence. She admits to 10/10 axial back pain.

 

Exam
Tenderness to palpation in rostral lumbar spine without step-off deformity

Cranial nerves II-XII are intact

DTRs – 2+ upper extremities, 2+ lower extremities

Strength- 5/5 upper extremities

5/5 bilateral lower extremities

No Clonus or pathological reflexes.

Normal pinprick sensation and proprioception throughout

Questions

 
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