In Search of the Best Pain Clinic in Los Angeles: Clinical Presentation

By | November 7, 2012

People would come from all over the medical center to listen to the case presentations and test their diagnostic skills.

I remember being told over and over again in medical school, that the history was the most important part of the diagnostic process and that if you didn’t have a list of reasonable diagnostic possibilities in mind by the time you were starting the physical exam and before ordering any lab tests, you were in trouble. Bianca (not her real name) is an elegant 79-year-old Brazilian woman who was sent to the Burbank offices of Schlesinger Pain Centers for bilateral L4-5 facet blocks. Being a contrary and generally disagreeable character I insisted on making a diagnosis before proceeding with treatment. The patient complained of mid-back pain and left flank pain of about a year’s duration. She had seen a number of physicians, all of whom were unable to make a diagnosis, although a genito-urinary cause for her pain had been ruled on multiple occasions. She had been treated with anti-inflammatory agents and oral opiates without much improvement. Epidural steroids were likewise reported to be without salutary effect. Upon further questioning the patient states that the pain began relatively suddenly and that there had been a small nondescript rash in her mid-back at about the same time. Physical exam was unrevealing except for what looked like a burnt out vesicular rash centered on the area of her pain. Bianca was also exquisitely tender in that area and upon careful palpation this tenderness extended for about ten inches along the inferior border of the last rib, a finding which was confirmed, by repeat examination under fluoroscopy. Imaging studies showed a minimal anterolisthesis of L4 on L5 associated with mild arthritis of those facet joints. In the next blog we will examine the meaning of the various pieces of data outlined above and how they lead to a diagnosis.

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