Some of the diagnoses you should consider include, lumbar and sacroiliac joint intersegmental dysfunction (restriction), lumbar spine sprain/strain, sacroiliac joint sprain/strain, lumbar facet syndrome. For the secondary complaint diagnoses should include; acute hepatitis, chronic hepatitis, autoimmune hepatitis, cirrhosis, Gilbert’s syndrome, and Najjar syndrome.

Physical Examination Findings:                       

• Ht: 5’3”                            
• Wt: 145 lbs
• Blood pressure: 140/80 mmHg bilaterally
• Heart rate: 106 beats per minute
• Respiration rate: 22 cpm
• Temp: 98.1 F

Physical Findings: Patient is pale in appearance with a yellow cast to her skin and sclera, and mild generalized petechiae on her trunk. Palpation documented an enlarged liver and spleen with mild tenderness on palpation. No fricition rubs were heard through auscultation over the liver and spleen. Tachycardia and tachypnea were noted, without any laborious breathing.

Lumbar spine active range of motion (ROM) – Mild decrease in flexion with mild pain on the right, extension was mildly decreased with mild to moderate pain on the right, and right rotation produced mild pain on the right at the right sacroiliac joint. There was no referral into the lower extremities. Belt test decreased pain, standing Kemps test produced pain on the right at the right sacroiliac joint, Yeoman’s was positive on the right. Hibb’s and SLR were both negative.

Neurological testsing: Babinski (aka extensor upgoing toe sign) was absent.  Muscle tests, reflexes, and dermatomal exam were within normal limits for the lower extremities. This testing included the nerve root levels from L1-S1. Upper extremity neurological examination was not performed.

Question: What is your working diagnoses at this point?   What imaging, or laboratory testing would you order?