This patient presents with acute low back pain following a specific inciting event, which is a common presentation. However, the mild scleral icterus and hepatomegaly are findings that warrant further investigation and could indicate a more complex picture than just musculoskeletal back pain. Let’s address your questions:

1. What other subjective data would you obtain?

   Beyond the information provided, I would want to delve deeper into several areas:

   • Detailed Pain History:
     • Radiation of pain: Ask him to describe the exact path of the leg pain. Does it go below the knee? Is it in a dermatomal pattern?
     • Aggravating and relieving factors: Besides rest and Motrin/heat, what else makes the pain worse (e.g., coughing, sneezing, prolonged sitting, standing)? What else provides relief?
     • Timing of pain: Is it constant or intermittent? Are there specific times of day it’s worse?
     • Previous episodes of back pain: Has he had back pain before? If so, how was it treated and what was the outcome?
     • Impact on daily life: How is this pain affecting his ability to work, sleep, and perform daily activities?
   • Gastrointestinal Symptoms:
     • Any nausea, vomiting, abdominal pain, changes in appetite, or weight loss? (Given the hepatomegaly and scleral icterus)
     • Changes in stool color or consistency? (Could indicate biliary issues)
   • Urinary Symptoms (more specific):
     • Any difficulty initiating or stopping urination? Frequency, urgency, or pain with urination? (While he denies changes, more specific questions are helpful)
   • Systemic Symptoms:
     • Fever, chills, night sweats, unexplained weight loss, or fatigue? (Could suggest infection or other systemic illness)
   • Work History:
     • Specific tasks involved in his painting job? Does it involve repetitive bending, twisting, or heavy lifting?
     • Any recent changes in his work routine?
   • Social History:
     • Alcohol or tobacco use? (Can impact liver health and overall healing)
   • Medication History (more detailed):
     • Any other over-the-counter medications, supplements, or herbal remedies he takes?
   • Past Medical History (beyond family):
     • Any history of liver disease, jaundice, arthritis, inflammatory conditions, or recent infections?

2. What other objective findings would you look for?

   Building on the initial physical exam, I would perform a more detailed musculoskeletal and abdominal assessment:

   • Musculoskeletal:
     • Posture and Gait: Observe his posture while standing and sitting. Note any asymmetry or guarding. Re-assess his gait, specifically looking for any subtle antalgic (pain-avoiding) gait that might have been missed initially.
     • Palpation: Carefully palpate the paraspinal muscles for localized tenderness, trigger points, and muscle spasms in the lumbar region and potentially the gluteal muscles.
     • Range of Motion (ROM): Quantify the degrees of limitation in flexion, extension, lateral bending, and rotation of the lumbar spine. Assess for pain with specific movements.
     • Straight Leg Raise (SLR) Test: Perform bilaterally to assess for radicular pain, which could indicate nerve root irritation. Note the angle at which pain occurs and any associated symptoms (e.g., foot dorsiflexion causing increased pain).
     • Crossed Straight Leg Raise Test: Perform on the unaffected leg to see if it reproduces pain in the affected leg, which is more specific for disc herniation.
     • Femoral Nerve Stretch Test: Assess for upper lumbar nerve root irritation (L2-L4).
     • Reflexes: Re-assess deep tendon reflexes (patellar and Achilles) bilaterally and compare for any asymmetry.
     • Sensory Examination: Perform a more thorough sensory examination in the lower extremities to light touch, pinprick, and vibration to identify any subtle dermatomal deficits.
     • Motor Strength Testing: Assess strength in key muscle groups of the lower extremities (e.g., dorsiflexion, plantarflexion, inversion, eversion, knee flexion and extension, hip flexion and extension, abduction and adduction) and compare bilaterally.
   • Abdominal:
     • Repeat Palpation: Gently but firmly palpate the abdomen, paying close attention to the liver size and consistency. Assess for any tenderness in the right upper quadrant or elsewhere.
     • Percussion: Percuss the liver span to confirm the size noted on palpation. Assess for any fluid wave or shifting dullness if ascites is suspected (though less likely with mild hepatomegaly).
     • Auscultation: Re-auscultate bowel sounds to ensure they are normoactive. Listen for any bruits over the liver or abdominal aorta (though less likely to be significant in this context).
     • Murphy’s Sign: Assess for right upper quadrant tenderness and inspiratory arrest, which could suggest cholecystitis (though less directly related to back pain).
   • Skin and Sclera: Re-examine the sclera under good lighting to confirm the mild icterus. Note the color and distribution. Examine the skin for any signs of jaundice.

3. What diagnostic exams do you want to order?

   Given the acute back pain and the concerning findings of mild scleral icterus and hepatomegaly, my initial diagnostic workup would likely include:

   • For the Back Pain:
     • Plain Lumbar Spine X-rays (AP and Lateral views): To rule out fracture, gross instability, spondylolisthesis, or significant degenerative changes as immediate causes of the acute pain, although soft tissue injury is more likely.
   • For the Potential Liver Issues:
     • Liver Function Tests (LFTs): This panel would include:
       • Alanine aminotransferase (ALT)
       • Aspartate aminotransferase (AST)
       • Alkaline phosphatase (ALP)
       • Total and direct bilirubin
       • Albumin
       • Total protein
     • Complete Blood Count (CBC) with differential: To assess for signs of infection, anemia, or other hematological abnormalities that could be associated with liver disease.
     • Hepatitis Viral Panel (Hepatitis A, B, and C serologies): To screen for common viral causes of liver inflammation.
     • Right Upper Quadrant Ultrasound: To visualize the liver, gallbladder, and biliary ducts to assess for structural abnormalities, masses, or obstruction. This would help further evaluate the hepatomegaly and potential cause of the mild icterus.
   • Other Considerations (depending on initial results and further history):
     • Sedimentation Rate (ESR) and C-reactive protein (CRP): Non-specific markers of inflammation that could be elevated in various conditions, including inflammatory back conditions or liver disease.
     • Urinalysis: To rule out urinary tract infection as a cause of referred back pain, although his specific symptoms don’t strongly suggest this.
     • MRI of the Lumbar Spine: If his back pain does not improve with conservative management or if there are neurological deficits (which he currently denies but could develop), an MRI would be indicated to evaluate for disc herniation, nerve root compression, or other soft tissue abnormalities. However, given the acute onset and lack of significant neurological signs initially, I would likely hold off on this pending the initial workup and his response to conservative treatment.

4. Name 3 differential diagnoses based on this patient presenting symptoms?

   Considering both the musculoskeletal complaint and the other findings, my top 3 differential diagnoses would be:

   1. Lumbar Strain/Sprain with Concurrent Incidental Liver Abnormality: This is the most straightforward explanation for the acute back pain directly related to the lifting incident. The pain characteristics and limited ROM are consistent with a musculoskeletal injury. The mild scleral icterus and hepatomegaly could be due to a pre-existing, possibly asymptomatic, liver condition unrelated to the back pain, which is now being incidentally discovered.