Table of Contents
Common Questions
Chat with CodyMD
Cody's Chat with Patient
Cody's AI Summary
Top 3 AI Diagnosis List
Review by Dr Albert DiPiero
Dr. DiPiero Video Guide to this Case Study
Resource Center
Testimonials
Share this Case Study
Case Study
Meet your host
Albert DiPiero, MD MPH FACP
I am a co-founder and the Chief Medical Officer at CodyMD and your host for this edition of Cody Grand Rounds. I have been a practicing physician and faculty member at medical schools for over 26 years.
About The AI Doctor Case Study
CodyMD is a partnership between Human Doctors and AI Doctors. Cody is an AI Doctor who helps thousands of people every day. At each Cody Grand Rounds, I select a real case and review it with Cody, the AI Doctor.
Each case is based on a real patient but has been modified to maintain privacy and to emphasize certain teaching points.
Common Questions
What are common causes of sudden onset low back pain?
How does an AI doctor diagnose back pain?
What treatments are effective for lumbar muscle strains?
Can lifting heavy objects cause back pain?
When should you see a doctor for back pain?
What preventive measures can help avoid low back pain?
Chat with CodyMD
Click the button below to initiate a conversation with CodyMD, your AI Doctor.
Cody's Chat with Patient
Below is a conversation transcript between the patient and our AI Doctor CodyMd.
Cody, the AI Doctor
Hello! I'm Cody, your AI doctor. I see you're here for back pain today. Is that correct?
Patient
Yes, that's right.
Cody, the AI Doctor
Great! My goal is to provide you with an accurate assessment and plan. Let's dive into your symptoms regarding your low back pain. When did your back pain start?
Patient
It started about three days ago.
Cody, the AI Doctor
Thank you. Did the pain come on gradually or was it sudden?
Patient
It was quite sudden.
Cody, the AI Doctor
Understood. Can you recall any specific activity or event that might have triggered the pain?
Patient
Yes, I was helping a friend move some heavy furniture when it started.
Cody, the AI Doctor
That sounds like it could be related. On a scale of 1 to 10, with 1 being no pain and 10 being the worst possible pain, how would you rate your current pain?
Patient
I would rate it as a 9 out of 10. It's very severe.
Cody, the AI Doctor
I'm sorry to hear that. Have you had any previous episodes of back pain before this?
Patient
Yes, I had a similar episode a few years ago, but not as severe.
Cody, the AI Doctor
Thank you for letting me know. Do you have any chronic illnesses or underlying conditions?
Patient
No, I don't have any chronic illnesses.
Cody, the AI Doctor
That's good to hear. Are you currently taking any medications?
Patient
No medications at all.
Cody, the AI Doctor
Have you ever had any surgeries or operations?
Patient
No, I haven't had any surgeries.
Cody, the AI Doctor
Can you describe exactly where the pain is located? Is it in a specific spot on your lower back or spread out?
Patient
The pain is across my low back, right at the belt line.
Cody, the AI Doctor
Any pain, numbness, tingling, or weakness extending into your legs?
Patient
No, there's no pain, numbness, tingling, or weakness in my legs.
Cody, the AI Doctor
Any recent trauma or falls?
Patient
No recent trauma or falls.
Cody, the AI Doctor
Thank you for providing that information. Based on your history, I have a few more questions before I summarize and propose my top conditions. Have you tried any treatments or remedies so far, like rest, ice, or over-the-counter pain relief?
Patient
Yes, I've been resting and using ice packs, but it hasn't made much of a difference.
Cody, the AI Doctor
Has the pain affected your ability to perform daily activities or your work?
Patient
Yes, it's making it very hard to focus on work, and I can't really do much around the house either.
Cody, the AI Doctor
I appreciate the detailed responses. I'm now close to forming a list of the top three most likely conditions. Would you like to proceed, or do you have any other details to add?
Patient
No, that's everything. Please proceed.
Cody's AI Summary
- You are a 30-year-old man experiencing sudden onset severe low back pain for three days, rated at 9 out of 10 in severity.
- The pain began while helping a friend move furniture.
- There is a history of one prior, less severe episode of back pain a few years ago. You have no chronic illnesses, take no medications, and have had no surgeries.
- The pain is localized across the low back at the belt line with no radiating pain, numbness, tingling, or weakness in the legs.
- There has been no recent trauma, and current treatments such as rest and ice have not provided significant relief.
Top 3 AI Diagnosis List
Based on the information and conversations with Cody, we have prepared a top 3 AI Diagnosis List.
1. Lumbar Muscle Strain( 60% probability)
Most likely due to the sudden onset associated with lifting heavy furniture, localized pain without radiating symptoms, and lack of significant improvement with rest and ice.
2. Herniated or Bulging Discs(25 % probability)
Possible due to the history of heavy lifting, but less likely without symptoms extending into the legs (numbness, tingling, or weakness).
3. Sacroiliac Joint Dysfunction(15 % probability)
A possibility given the location of pain, though less likely without any trauma or specific movement provoking the pain more significantly.
Review by Dr Albert DiPiero
Dr. Albert DiPiero
In reviewing the patient’s history and symptoms, I agree that lumbar muscle strain remains the most probable condition.
1. Lumbar Muscle Strain(70% probability)
Lumbar muscle strain is the most probable diagnosis, with a probability adjustment to 70%. The sudden onset of severe low back pain following heavy lifting is a strong indicator of a muscle strain. The patient’s pain is localized to the lower back and does not radiate into the legs, which further supports this diagnosis. Additionally, the lack of improvement with rest and ice is expected in muscle strains of this severity. There are no chronic illnesses or medications that complicate the picture, making this diagnosis highly likely.
2. Herniated or Bulging Discs(20% probability)
This remains a plausible diagnosis given the context of lifting heavy furniture, which can cause disc pathology. However, the absence of radiating pain, numbness, tingling, or weakness in the legs makes this less likely. Typically, herniated discs present with these additional symptoms due to nerve root involvement, but it can occasionally present with localized pain only. Therefore, this remains a valid consideration but secondary to the primary diagnosis of muscle strain.
3. Sacroiliac Joint Dysfunction(10% probability)
Sacroiliac joint dysfunction is assigned a 10% probability. While it can cause localized pain in the lower back, it is often associated with specific trauma or movements that exacerbate the pain, which the patient did not report. The location of the pain near the belt line could potentially indicate SI joint involvement, but without a clear mechanism or exacerbating factors, it remains the least likely of the top three diagnoses.
Next Steps for Evaluation
Physical Examination: Focusing on palpation of the lower back muscles, range of motion tests, and specific maneuvers to provoke disc or SI joint pain and well as assessment of the sensory and motor function in the legs.
Imaging Studies: An X-ray or MRI are usually not indicated unless there is significant history of trauma or of symptoms persist longer than 6 weeks, or if there is any worsening of symptoms, especially signs of neurologic compromise such as new weakness in the legs or a change in bowel or bladder function.
Physical Therapy Assessment: A thorough evaluation by a physical therapist can provide additional insights into the functional aspects of the injury and guide treatment.
Potential Treatment Modalities
For Lumbar Muscle Strain: Rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, and physical therapy focusing on strengthening and flexibility exercises are the foundation of treatment.
For Herniated Discs: Initially conservative management including NSAIDs, physical therapy, and possibly epidural steroid injections. Surgery is considered if conservative measures fail.
For Sacroiliac Joint Dysfunction: NSAIDs, physical therapy, SI joint injections, and lifestyle modifications to reduce strain on the joint.
Dr. DiPiero Video Guide to this Case Study
Resource Center
Lower Back Pain Resources
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