63-Year-Old Woman with Acute Lower Back Pain Evan

63-Year-Old Woman with Acute Lower Back Pain Evan

63-Year-Old Woman with Acute Lower Back Pain Evan Atkinson Medicine-Pediatrics HO3 Medicine Case Conference LSUHSC New Orleans March 19, 2013 Chief Complaint ~ My back hurts and I cant walk for 5 days.~ History of Present Illness

63-yo woman (with a past medical history of HTN) who was recovering from a mild lumbar strain after slipping and falling in a grocery store two months prior, presented to the ED with complaints of five days of crescendo lower back pain. Pain is now so severe she cannot walk. Pain is sharp, centered above her buttocks and non-radiating. History of Present Illness Exacerbated

by walking. Relieved by lying on side with hips flexed. Denies any leg weakness or paresthesia. Denies dysfunction of bowel or bladder. No additional trauma. Denies subjective fever or chills. Past Medical History PMHx: HTN Cerebral aneurysm (1998) OA hands/knees (x10y)

PSHx: Brain aneurysm clipped (1998) C-section Appendectomy Allergies: NKDA Denies food allergies

Past Medical History Meds: Diltiazem 240mg daily Metoprolol succinate 50mg daily Hydrochlorothiazide 25 mg daily

Meloxicam 7.5mg prn: pain Tramadol 50mg prn: pain Cyclobenzaprine 10mg prn: spasm Acetaminophen 325mg prn: mild pain Past Medical History Social: Former unit clerk at Charity MICU Lives locally with family Social EtOH History of packs tobacco per day over 45 years Quit 5 years ago Denies history or current drug abuse

FamHx: Mother deceased at 66 yo of gastric cancer Father deceased at 67 yo of prostate cancer Past Medical History Health

Maintenance PCP unknown Mammogram 4/12 - negative Pap not done in several years Colonoscopy never done Vaccines Flu - denies Pneumovax - denies Tetanus 4/12 Review of Systems

Gen: F/C/NS, weight changes, fatigue HEENT: sore neck, oral pain, URTI sx CV/Resp: CP/dizziness/syncope, SOB GI: pain/N/V/D, dysphagia, stools GU: vaginal discharge, dysuria Lymph: lumps in neck or under arms Skin: rash, known recent trauma Neuro: occasional H/A as per HPI

MSK: occasional hand pain as per HPI Physical Examination VS: Triage: BP 112/69, P 128, R 19 (93% RA), T 102.7C BP 137/69, P 108, R 25 (99% RA) Gen:

Moderate distress and anxious-appearing Non-toxic, lying in bed on her side, cooperative HEENT: Normocephalic/atraumatic Dentition fair but mild gingivitis OP/NT/TM clear

No LAD, trachea midline Physical Examination CV: Tachycardia, normal S1/S2 No murmurs, S3 or S4 Resp: Tachypnea, symmetric breath sounds CTAB, No wheezes/crackles/rhonchi GI:

Obese, non-distended; +Bowel sounds Non-tender No hepatosplenomegaly Physical Examination GU: External exam normal, no abscess Ext:

+2 DP, no edema, nails unremarkable Spine: Neck supple L4 spinous process TTP Paraspinous muscles tense but nontender Skin: No overlying integument defect

No erythema, warmth, fluctuance, or induration above L4 Physical Examination Neuro: +rectal tone, no saddle anesthesia LE tone/strength/sensation normal Neg straight leg raise Ambulation deferred o/w unremarkable

MSK: No effusions or erythema No limitations in ROM but exam slightly limited due to back pain No muscle tenderness Labs WBC: 12.8 (4.511.0) Hgb: 13.4 Hct: 37.8 MCV: 83.8 Plt: 198 RDW: 13.7

N 86% Bands: 2% Lymp: 10% Mono: 2% Na: K: 5.2) Cl: CO2: BUN: Cr: Glu: TP:

8.0) Alb: AST: AP: ALT: 141 3.1 (3.6104 25 19 CRP: 10.36 (<0.90) ESR: 20 UA: neg with no

microscopic analysis 1.05 114 (65-99) 8.1 (6.0Blood cxs x 2 sets 4.3 37 100 31 Gonorrhea and Chlamydia - neg Imaging Studies

L-spine: G1 anterolisthesis of L3-L4 (no pars defect), mild degenerative changes MRI: contraindicated due to cerebral aneurysm clip

CT ordered Initial Management Sepsis with unclear source: Empiric vancomycin and piperacillintazobactam Surveillance for and removal of source Back Pain: Neurosurgery consulted No indication for surgical intervention Provide hydromorphone and cyclobenzaprine for pain

HTN: Holding BP meds and monitor closely Hospital Course: Day 2 Hospital Course: Day 2 CT of lumbar spine No evidence of osteomyelitis/abscess Multi-level mild degnerative disc disease

within thoracic spine Hospital Course: Day 2 Blood Cultures after 28 hrs: Gram Negative Rods in 4 of 4 bottles Continued empiric GNR coverage with piperacillin-tazobactam Vancomycin discontinued Source of infection not definitively identified Back Pain:

Improving with less medications Added heat packs and encourage ambulation HTN: Hemodynamically stable off BP meds Hospital Course: Day 2 Hospital Course: Day 4 CDC PHIL #1602, http://phil.cdc.gov Hospital Course: Day 4

Blood Cultures Eikenella corrodens identified in 4 of 4 bottles Antibiotic coverage changed to ceftriaxone Source of infection still not identified Reviewed risk factors and pursued ancillary studies Entry Site: no risk factors for E.corrodens

dental work, ingested bones, licking needles instrumentation of GU or GI tracts IV or percutaneous drug use human or animal bites Searching for the Source Back Pain Still improving with less use of opioids

Decreased pain on exam but increased ambulation from bed to restroom with only mild pain HTN Resume home BP meds Infection Locus: ancillary imaging studies TTE/TEE structurally normal valves, no vegetation

CT Abd abdominal or pelvic abscess, large uterus Hospital Course: Day 7 Gallium Scan Faint increased uptake within the mid to lower lumbar spine slightly left of midline. More significant osseous changes from prior CT scan

Within right L3-L4 facet joint Clinical Resolution Day 2: mild-mod pain with ambulation only Day 9: pain only with deep palpation of L4 discharged on a 3week course of ceftriaxone IV

Day 32: ESR-CRP wnl Day 60: no back pain The End ~ Thanks! ~

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