I-HUMAN WEEK #9 HIGH-YIELD QUESTION
EXAM FOR A 69-YEAR-OLD PATIENT WITH
BACK PAIN EXAM QUESTIONS AND ANSWERS
WITH RATIONALES LATEST UPDATE
• Each question is rationaled and correctly answered
• The questions cover history, physical exam, differential diagnosis, diagnostics (X-ray, ECG,
labs), and management—tailored to the outpatient clinic setting with the stated capabilities.
History & Review of Systems (Questions 1–25)
1.He reports morning stiffness lasting >1 hour. This points to:
• A) Mechanical back pain
• B) Inflammatory back pain (e.g., ankylosing spondylitis)
• C) Fibromyalgia
• D) Degenerative disc disease
Rationale: Prolonged morning stiffness is characteristic of inflammatory
spondyloarthropathies.
Answer: B
2. He takes no blood thinners. This is relevant because:
,• A) NSAIDs would be safer
• B) Epidural hematoma risk is lower
• C) He can safely have a spinal injection
• D) He does not need an INR check before X-ray
Rationale: In anticoagulated patients, spontaneous spinal epidural hematoma is a rare but
serious cause of back pain.
Answer: B
3. He has a history of osteoporosis. Most likely acute pathology:
• A) Disc herniation
• B) Vertebral compression fracture
• C) Spinal stenosis
• D) Muscle spasm
Rationale: Osteoporosis + back pain (even without trauma) = high risk for insufficiency fracture.
Answer: B
4. He denies IV drug use. This reduces suspicion for:
, A) Spinal metastasis
• B) Spinal epidural abscess
• C) Osteoporotic fracture
• D) Scheuermann’s disease
Rationale: IV drug use is a major risk factor for spinal epidural abscess (often
Staphylococcus aureus). Answer: B
5. Pain is midline lumbar rather than paraspinal. This suggests:
• A) Myofascial pain
• B) Vertebral body pathology
• C) Renal colic
• D) Sacroiliac joint pain
Rationale: Midline bony tenderness suggests vertebral body lesion (fracture, tumor, infection).
Answer: B
6. He reports recent corticosteroid use for COPD exacerbation. This increases risk for:
• A) Lumbar strain
• B) Avascular necrosis of spine (rare)
• C) Vertebral fracture
• D) Spinal stenosis
Rationale: Chronic/exogenous steroid use accelerates osteoporosis and fracture risk. Answer:
C
7.Pain is not relieved by lying down. This is concerning for:
• A) Mechanical cause
• B) Malignancy or infection
• C) Muscular strain
• D) Disc bulge
Rationale: Pain that persists recumbent is a red flag for neoplasm or infection. Answer: B
, 8.He reports fever of 101°F for 3 days. Most likely:
• A) Viral syndrome with back pain
• B) Vertebral osteomyelitis
• C) Polymyalgia rheumatica
• D) Degenerative disc disease
Rationale: Fever + back pain = infection (discitis/osteomyelitis) until proven. Answer: B
9. He has a history of multiple myeloma in a sibling. This increases risk for:
• A) Spinal stenosis
• B) Multiple myeloma (primary)
• C) Ankylosing spondylitis
• D) Paget’s disease
Rationale: Family history of multiple myeloma increases relative risk, though most cases are
sporadic. Answer: B
10.He reports pain radiating below the knee to the foot. This suggests:
• A) Lumbar radiculopathy
• B) Sacroiliac joint pain
• C) Greater trochanteric pain
• D) Facet arthropathy
Rationale: Pain radiating below knee (dermatomal pattern) = nerve root involvement. Answer:
A
11.He has no leg weakness but has reduced ankle reflex. Which nerve root?
• A) L3
• B) L4
• C) S1
• D) L5
Rationale: Ankle reflex (Achilles) is mediated by S1 nerve root.
EXAM FOR A 69-YEAR-OLD PATIENT WITH
BACK PAIN EXAM QUESTIONS AND ANSWERS
WITH RATIONALES LATEST UPDATE
• Each question is rationaled and correctly answered
• The questions cover history, physical exam, differential diagnosis, diagnostics (X-ray, ECG,
labs), and management—tailored to the outpatient clinic setting with the stated capabilities.
History & Review of Systems (Questions 1–25)
1.He reports morning stiffness lasting >1 hour. This points to:
• A) Mechanical back pain
• B) Inflammatory back pain (e.g., ankylosing spondylitis)
• C) Fibromyalgia
• D) Degenerative disc disease
Rationale: Prolonged morning stiffness is characteristic of inflammatory
spondyloarthropathies.
Answer: B
2. He takes no blood thinners. This is relevant because:
,• A) NSAIDs would be safer
• B) Epidural hematoma risk is lower
• C) He can safely have a spinal injection
• D) He does not need an INR check before X-ray
Rationale: In anticoagulated patients, spontaneous spinal epidural hematoma is a rare but
serious cause of back pain.
Answer: B
3. He has a history of osteoporosis. Most likely acute pathology:
• A) Disc herniation
• B) Vertebral compression fracture
• C) Spinal stenosis
• D) Muscle spasm
Rationale: Osteoporosis + back pain (even without trauma) = high risk for insufficiency fracture.
Answer: B
4. He denies IV drug use. This reduces suspicion for:
, A) Spinal metastasis
• B) Spinal epidural abscess
• C) Osteoporotic fracture
• D) Scheuermann’s disease
Rationale: IV drug use is a major risk factor for spinal epidural abscess (often
Staphylococcus aureus). Answer: B
5. Pain is midline lumbar rather than paraspinal. This suggests:
• A) Myofascial pain
• B) Vertebral body pathology
• C) Renal colic
• D) Sacroiliac joint pain
Rationale: Midline bony tenderness suggests vertebral body lesion (fracture, tumor, infection).
Answer: B
6. He reports recent corticosteroid use for COPD exacerbation. This increases risk for:
• A) Lumbar strain
• B) Avascular necrosis of spine (rare)
• C) Vertebral fracture
• D) Spinal stenosis
Rationale: Chronic/exogenous steroid use accelerates osteoporosis and fracture risk. Answer:
C
7.Pain is not relieved by lying down. This is concerning for:
• A) Mechanical cause
• B) Malignancy or infection
• C) Muscular strain
• D) Disc bulge
Rationale: Pain that persists recumbent is a red flag for neoplasm or infection. Answer: B
, 8.He reports fever of 101°F for 3 days. Most likely:
• A) Viral syndrome with back pain
• B) Vertebral osteomyelitis
• C) Polymyalgia rheumatica
• D) Degenerative disc disease
Rationale: Fever + back pain = infection (discitis/osteomyelitis) until proven. Answer: B
9. He has a history of multiple myeloma in a sibling. This increases risk for:
• A) Spinal stenosis
• B) Multiple myeloma (primary)
• C) Ankylosing spondylitis
• D) Paget’s disease
Rationale: Family history of multiple myeloma increases relative risk, though most cases are
sporadic. Answer: B
10.He reports pain radiating below the knee to the foot. This suggests:
• A) Lumbar radiculopathy
• B) Sacroiliac joint pain
• C) Greater trochanteric pain
• D) Facet arthropathy
Rationale: Pain radiating below knee (dermatomal pattern) = nerve root involvement. Answer:
A
11.He has no leg weakness but has reduced ankle reflex. Which nerve root?
• A) L3
• B) L4
• C) S1
• D) L5
Rationale: Ankle reflex (Achilles) is mediated by S1 nerve root.
