Any fevers or night sweats?

What medications is he taking (including antimalarials/prophylactic medications deemed necessary for the AO)?

The patient admits that he has felt a bit hot and woken up in sweaty sheets, but attributed it to the "God-forsaken climate in this @#$hole of a country."

Current Meds:
Lisinopril
Atovaquone/Proguanil
Various nutritional supplements for weight-lifting

Covered above.

Alright, lets start the physical exam. Your visual examination of the lower back is unremarkable.

"Dad always had lower back pain, and mom had RA."

No.

Has urine been darker?

If you're moving into exam - CVA tenderness? Distribution of tenderness on palpation of the back (over the spine, paraspinous muscles, etc?)

Can we look at the shoulders for evidence of petechiae/bruising?

No CVA tenderness.
The patient is exquisitely tender on the vertebral prominence of L3 & L4 with a conspicuous absence of tenderness in the paraspinous muscles. Shoulder exam unremarkable.

See above.

BP 130/85
HR 90

What exactly are you checking with valsalva? There are a number of possible PE techniques with valsalva. Are you checking volume status?

Straight leg raise results in mild bilateral hamstring pain w/o paresthesias radiating below the knee.

I noticed that the Hx kind of bypassed the time frame for this attack (onset, severity increase over time, and loss of mobility over time, what helps what aggravates), and the timing/severity of other similar attacks for the Pt... Are the attacks consistent, when was the first remarkable attack he can remember, excluding 'normal' training pain. Have there been any remarkable changes in activity, medication, hydration. Has the Pt been at depth or altitude for long periods in the recent past? Do altitude or depth change the symptomology? We know the big green tick or armor will change things / aggravate symptomology, but.... to what degree has this changed, and does it scale the pain or refer it to other areas. What are the postural locations that aggravate or relieve symptomology, in any degree.

Ok, those are my add ons to the Pt Hx questionnaire and where I'd go with the phys exam...

(Is this going to be a Rocky Farr question... with an answer like "He's been eating a 1/4 lb of black licorice a day for the last week?"... huh Ender? If it is, I know where to find you... and this time it won't be pleasant...:eek:)

Good call on fleshing out the history!

As noted, there was no clear precipitating incident, and the onset was gradual over a few days. The pain has continued to increase, and this morning it was the worst its been. The patient is clearly in discomfort, exacerbated by movement, especially flexion.

The patient has had sporadic lower back pain in the past, typically associated with heavy leg days. However, this feels "different." As noted, he first noticed this pain a few days ago. You are one week in country.

The patient had been in "normal" SF pre-mission training (lets say various vendor schools and other team training). Now, the team is out at ranges all day every day training the LNs. No significant depth or altitude exposures (team flew commercial FWIW). PT admits he hasn't been drinking enough water. Medications as noted.

Wearing body armor or carrying gear is particularly unpleasant. No ruck training, but he has been wearing body armor for much of the range training. He prefers sitting with a fairly straight posture. As noted, all movement exacerbates the pain, but flexion most of all.

I promise this won't be a complete Zebra. :D

LMAOROF :D Now that's funny rat there! :D :D

Got it. Just wanted to make sure I gave you correct feedback for what you were asking.

Normal CV response to valsalva and no increase in pain is noted.

Acute leukemia and mutliple myeloma may also present in a similar fashion.