PDA

View Full Version : Team Sergeant with Low Back Pain


ender18d
12-04-2013, 07:45
Scenario:
You and your team are deployed to train a special operations element of a friendly host nation in CQB techniques. Your team picked up this mission at the last minute, and there was something of a rush to get everything and everyone ready for deployment. The only other US medical asset in country is a family medicine physician at the embassy 3-4 hours away by truck. The host nation medical system is… not providing a standard of care with which you feel comfortable.

You’ve been in country for about a week when your team sergeant pulls you aside and asks you for some “Motrin.” Being a good medic, you ask him why he wants the ibuprofen, and he tells you that he has some “low back pain.”

I will give you the following:

The patient WDWN 45 y/o steely-eyed barrel-chested team sergeant in moderate distress.

C/C: “Low back pain”
O: “It’s been kinda funky for the past few days but it’s really pissing me off now.”
P: “No, nothing seems to help. Running around in full kit hurts.”
Q: “Sharp”
R: “The pain doesn’t seem to go anywhere else but my back.”
S: “Its pretty f’ing bad or I wouldn’t be asking you for meds.”
T: “It hurts pretty constantly.”

What other questions do you want to be sure to ask this patient as part of the history? What “red flags” in the history would differentiate a typical lumbago from something more serious? (physical exam will come after we discuss history)

PedOncoDoc
12-04-2013, 08:25
Any numbness/tingling/weakness in the legs?

Change in bowel and urinary frequency (both increased and decreased)? Any bowel or bladder incontinence?

ender18d
12-04-2013, 08:28
Any numbness/tingling/weakness in the legs?

Change in bowel and urinary frequency (both increased and decreased)? Any bowel or bladder incontinence?

Patient denies all of the above.

sinjefe
12-04-2013, 08:32
Tell him to stop experimenting with autofellatio.:D

ender18d
12-04-2013, 08:41
Tell him to stop experimenting with autofellatio.:D

Patient denies adventurous solo sexual activity.

:D

ender18d
12-04-2013, 08:52
At first glance, he's 45 y.o., for pete's sake. Spinal joints are beginning a normal process of degeneration, especially after a lifetime of heavy duty physical stuff.


This is of course the most likely etiology for low back pain in this demographic. Part of the reason for the scenario is that this is a common thing medics see all the time, but there are some things you don't want to miss....



But...

Has this ever happened before?


The patient has had lower back pain before. "he's 45 y.o., for pete's sake." ;) But now that you mention it this seems different....


Is there any position or action that makes the pain worse?


Flexion is more painful than extension, but no position brings total relief.


Any trouble urinating (blood in urine, painful micturition)?

Negative.

PedOncoDoc
12-04-2013, 09:12
Did he first notice this pain during/after any particular activity (or trauma)?

Where on his back does it hurt?

Is the pain constant or intermittent (crampy/colicky)?

Dusty
12-04-2013, 09:12
Happened to me.

Turned out, I had a Pars defect in the L5, subjugal and degenerative arthritis, spondylolithesis at the sacral plane, and my coccyx was broken off and just dangling there.

Subsequent irradiation discovered a cervical fracture.

My first soap reads: "SM snivelling about sharp lower back pain", or something like that. :D

tonyz
12-04-2013, 09:16
...and my coccyx was broken off and just dangling there.

I love it when you talk dirty. :D

Dusty
12-04-2013, 09:17
I love it when you talk dirty. :D

lol Kiss my coccyx (if you can find it). :D

ender18d
12-04-2013, 09:19
Did he first notice this pain during/after any particular activity (or trauma)?

There is no particular incident that stands out in the patient's mind, although you have been training hard for the past few days.

Where on his back does it hurt?

When asked, the patient points to an area you approximate as L3/L4. (more details will be available when we get to physical, but I want to cover history thoroughly first).

Is the pain constant or intermittent (crampy/colicky)?

The pain is constant.

ender18d
12-04-2013, 09:23
Happened to me.

Turned out, I had a Pars defect in the L5, subjugal and degenerative arthritis, spondylolithesis at the sacral plane, and my coccyx was broken off and just dangling there.

Subsequent irradiation discovered a cervical fracture.

My first soap reads: "SM snivelling about sharp lower back pain", or something like that. :D

OUCH.

I wrote the scenario because most of the time, LBP is just LBP, except when it isn't.

PedOncoDoc
12-04-2013, 09:30
Any increased/unusual bruising, nosebleeds or other abnormal bleeding? Any pallor, decreased exercise intolerance/dyspnea on exertion?

ender18d
12-04-2013, 09:33
Any increased/unusual bruising,

Negative

nosebleeds or other abnormal bleeding?

Negative

Any pallor, decreased exercise intolerance/dyspnea on exertion?

The patient does appear slightly pale, and admits that he's been feeling like he's "lost a step" the past few days during training, not entirely due to the pain.

PedOncoDoc
12-04-2013, 09:36
Any fevers or night sweats?

What medications is he taking (including antimalarials/prophylactic medications deemed necessary for the AO)?

ender18d
12-04-2013, 09:46
Any fevers or night sweats?

The patient admits that he has felt a bit hot and woken up in sweaty sheets, but attributed it to the "God-forsaken climate in this @#$hole of a country."

What medications is he taking (including antimalarials/prophylactic medications deemed necessary for the AO)?

Current Meds:
Lisinopril
Atovaquone/Proguanil
Various nutritional supplements for weight-lifting

ender18d
12-04-2013, 09:54
Also curious about his medications. Looking for any kind of blood thinner...

Covered above.


What does his low back physically look like? Any visible rubor/calor/tumor? Blisters or rash?

Alright, lets start the physical exam. Your visual examination of the lower back is unremarkable.

Any family history of this kind of LBP, or disease that causes joint pain?

"Dad always had lower back pain, and mom had RA."

ender18d
12-04-2013, 10:02
Hyperkalemia is a genuine concern in "older" male users. Has he noticed any irregularities in his heartbeat?

No.

PedOncoDoc
12-04-2013, 10:16
Has urine been darker?

If you're moving into exam - CVA tenderness? Distribution of tenderness on palpation of the back (over the spine, paraspinous muscles, etc?)

Can we look at the shoulders for evidence of petechiae/bruising?

ender18d
12-04-2013, 10:39
Has urine been darker?

If you're moving into exam - CVA tenderness? Distribution of tenderness on palpation of the back (over the spine, paraspinous muscles, etc?)

Can we look at the shoulders for evidence of petechiae/bruising?

No CVA tenderness.
The patient is exquisitely tender on the vertebral prominence of L3 & L4 with a conspicuous absence of tenderness in the paraspinous muscles. Shoulder exam unremarkable.

May as well begin at the beginning...

Agree with Ped's palpation of the affected area and shoulders check.

BP, HR

Valsalva's, SLR tests

See above.

BP 130/85
HR 90

What exactly are you checking with valsalva? There are a number of possible PE techniques with valsalva. Are you checking volume status?

Straight leg raise results in mild bilateral hamstring pain w/o paresthesias radiating below the knee.

x SF med
12-04-2013, 10:44
I noticed that the Hx kind of bypassed the time frame for this attack (onset, severity increase over time, and loss of mobility over time, what helps what aggravates), and the timing/severity of other similar attacks for the Pt... Are the attacks consistent, when was the first remarkable attack he can remember, excluding 'normal' training pain. Have there been any remarkable changes in activity, medication, hydration. Has the Pt been at depth or altitude for long periods in the recent past? Do altitude or depth change the symptomology? We know the big green tick or armor will change things / aggravate symptomology, but.... to what degree has this changed, and does it scale the pain or refer it to other areas. What are the postural locations that aggravate or relieve symptomology, in any degree.

Ok, those are my add ons to the Pt Hx questionnaire and where I'd go with the phys exam...

(Is this going to be a Rocky Farr question... with an answer like "He's been eating a 1/4 lb of black licorice a day for the last week?"... huh Ender? If it is, I know where to find you... and this time it won't be pleasant...:eek:)

ender18d
12-04-2013, 10:56
Good call on fleshing out the history!

I noticed that the Hx kind of bypassed the time frame for this attack (onset, severity increase over time, and loss of mobility over time, what helps what aggravates),

As noted, there was no clear precipitating incident, and the onset was gradual over a few days. The pain has continued to increase, and this morning it was the worst its been. The patient is clearly in discomfort, exacerbated by movement, especially flexion.

and the timing/severity of other similar attacks for the Pt... Are the attacks consistent, when was the first remarkable attack he can remember, excluding 'normal' training pain.

The patient has had sporadic lower back pain in the past, typically associated with heavy leg days. However, this feels "different." As noted, he first noticed this pain a few days ago. You are one week in country.

Have there been any remarkable changes in activity, medication, hydration. Has the Pt been at depth or altitude for long periods in the recent past? Do altitude or depth change the symptomology? We know the big green tick or armor will change things / aggravate symptomology, but.... to what degree has this changed, and does it scale the pain or refer it to other areas. What are the postural locations that aggravate or relieve symptomology, in any degree.

The patient had been in "normal" SF pre-mission training (lets say various vendor schools and other team training). Now, the team is out at ranges all day every day training the LNs. No significant depth or altitude exposures (team flew commercial FWIW). PT admits he hasn't been drinking enough water. Medications as noted.

Wearing body armor or carrying gear is particularly unpleasant. No ruck training, but he has been wearing body armor for much of the range training. He prefers sitting with a fairly straight posture. As noted, all movement exacerbates the pain, but flexion most of all.

Ok, those are my add ons to the Pt Hx questionnaire and where I'd go with the phys exam...

(Is this going to be a Rocky Farr question... with an answer like "He's been eating a 1/4 lb of black licorice a day for the last week?"... huh Ender? If it is, I know where to find you... and this time it won't be pleasant...:eek:)

I promise this won't be a complete Zebra. :D

Trapper John
12-04-2013, 10:58
(Is this going to be a Rocky Farr question... with an answer like "He's been eating a 1/4 lb of black licorice a day for the last week?"... huh Ender? If it is, I know where to find you... and this time it won't be pleasant...:eek:)

LMAOROF :D Now that's funny rat there! :D :D

ender18d
12-04-2013, 11:04
SOL, volume status. I've personally seen cases of the following start out febrile and with LBP:

- Malaria
- Meningitis
- Extradural primary spinal cancer
- Conus Medullaris Syndrome after intradural disc herniation

These are zebras, but clinical experience with similar S/S, nonetheless.

Got it. Just wanted to make sure I gave you correct feedback for what you were asking.

Normal CV response to valsalva and no increase in pain is noted.

PedOncoDoc
12-04-2013, 11:05
SOL, volume status. I've personally seen cases of the following start out febrile and with unremitting LBP:

- Malaria
- Meningitis
- Extradural primary spinal cancer
- Conus Medullaris Syndrome after intradural disc herniation

These are zebras, but clinical experience with similar S/S, nonetheless.

Acute leukemia and mutliple myeloma may also present in a similar fashion.

x SF med
12-04-2013, 11:08
Pfff.... kidney stones seem to be the least zebra Dx right know... Lisinopril, recurring but increasing severity, palpation or striking causes increase in pain, and increased activity causes pain.... reduced hydration has reduced volume, 'bad' water increases mineralization coupled with the lisinopril and the attendant hyperkalemia...

Tell Top he needs to drink more water dammit, especially with lisinopril and heavy physical activity.

the other Dx option is gouty arthritis in combination with arthroarthritis in the lumbosacral joint (multiple damage does not r/o this area even though it is not an initial joint for attacks in most cases) - same reasons as above - need to get the diff on them and run a couple of blood panels... K levels and Uric acid levels will be key in the r/o on this... but it's gonna suck with no lithotripsy available for relief if it is a stone....

Trapper John
12-04-2013, 11:09
I'd like to go back to the Hx for a minute. Patient said he does weight lifting. Deadlifts? When was the last time he was at the gym? What was the routine? Weight? Did he increase the weight during the last workout? Did he notice any back pain during the workout? Immediately after?

Did the patient do clean-and-jerk or standing overhead presses in the last workout?

ender18d
12-04-2013, 11:22
I'd like to go back to the Hx for a minute. Patient said he does weight lifting. Deadlifts? When was the last time he was at the gym? What was the routine? Weight? Did he increase the weight during the last workout? Did he notice any back pain during the workout? Immediately after?

Did the patient do clean-and-jerk or standing overhead presses in the last workout?

Last gym trip was a few days before deployment. He did dead lifts and squats as is normal for him, without any unusual increases in weight. He did not notice any pain during or immediately following the workout, and a number of days passed before he first noticed any symptoms (based on our hypothetical timeline, you've been in theater a week, and he noticed symptoms a few days in.)

Trapper John
12-04-2013, 11:23
This is turning into a "Get on the next truck running back to the hospital, sit upright, get a cushioned seat. I've radio'ed ahead but don't lose this order script" situation, isn't it? :D

Yeah, DDx - Stone.... maaaaybe posterior disc herniation pressing on ALL.

Yep, if I were the Team Medic I would evac him to a facility that can take a peak (X-ray/MRI). I'm thinking herniated disc, vertebral process avulsion fracture, R/O kidney stones.

ender18d
12-04-2013, 11:25
Before we start trying to nail our differential, I think it would help to complete our history and physical exams, and maybe do a problem list.

Yep, if I were the Team Medic I would evac him to a facility that can take a peak (X-ray/MRI). I'm thinking herniated disc, vertebral process avulsion fracture, R/O kidney stones.

Nearest facility is a few hours away, and the trip will seriously disrupt training. Still wanna go?

x SF med
12-04-2013, 11:25
LMAOROF :D Now that's funny rat there! :D :D

300F-1, San Antonio, The 2005 reclass.... CPT Rocky Farr.... "We're going to work on your ability to get a good Hx, and diagnose to a diff Dx level wit h4 options.... 30y/o white male in good health (soldier) and normal vitals presents c/o black tarry stools x 1 wk.... Start asking, raise your hands...." every zebra in the world came running.... but I learned how to hit the easy hx questions early, and start with easy Dx for r/o...:rolleyes:

ender18d
12-04-2013, 11:27
No CVA tenderness.
The patient is exquisitely tender on the vertebral prominence of L3 & L4 with a conspicuous absence of tenderness in the paraspinous muscles. Shoulder exam unremarkable.

Just throwing that out there as a reminder.

PedOncoDoc
12-04-2013, 11:27
Did the patient do clean-and-jerk or standing overhead presses in the last workout?

Advise him to avoid 200+ pound snatch. :D

Trapper John
12-04-2013, 11:33
300F-1, San Antonio, The 2005 reclass.... CPT Rocky Farr.... "We're going to work on your ability to get a good Hx, and diagnose to a diff Dx level wit h4 options.... 30y/o white male in good health (soldier) and normal vitals presents c/o black tarry stools x 1 wk.... Start asking, raise your hands...." every zebra in the world came running.... but I learned how to hit the easy hx questions early, and start with easy Dx for r/o...:rolleyes:

We are thinking the same, Bro. ;)

x SF med
12-04-2013, 11:33
Advise him to avoid 200+ pound snatch. :D

nah, not making the flour comment.....;)

Trapper John
12-04-2013, 11:38
Before we start trying to nail our differential, I think it would help to complete our history and physical exams, and maybe do a problem list.



Nearest facility is a few hours away, and the trip will seriously disrupt training. Still wanna go?

Yep ;)

ender18d
12-04-2013, 11:39
Full Vitals: (not yet asked... you only asked for BP and HR)
HR: 90, BP 130/85, RR 14, T 101.5deg

PMH (also not yet asked):
The patient's past medical history is significant for HTN. The patient had all routine immunizations and started malaria prophylaxis just prior to deployment. The patient was dental cat3 and had to have some significant work done to get off the "non-deployable" list before you left. No surgeries.

Trapper John
12-04-2013, 11:40
Advise him to avoid 200+ pound snatch. :D

Oweee! Now that's a visual image I did not need. Thanks a lot Doc. :D

ender18d
12-04-2013, 11:44
This stuck out for 'interspinous or ligamentum flavum tear,' which usually doesn't present symptoms for a few days, and has all of the positive ortho finding mentioned, but we have to be good boys and avoid the painfully obvious here.

But what the hell. When he lies supine and both legs are raised together, is the pain exacerbated?

Any motion that particularly manipulates the vertebral joints results in pain, so yeah, there's some pain when the straight leg raise is high enough to put motion into the back.... But the straight leg raise does not result in radiating sciatic pain that is the classic finding for that test.

PedOncoDoc
12-04-2013, 11:57
The reproducible point tenderness points more to a vertebral injury/fracture IMO. This could be from compression, inadvertent trauma or pathologic secondary to an invasive lesion (e.g. cancer).

My questions about change in urine color (which could indicate hemolysis secondary to medication, malaria or other causes) was not answered. This could also cause back pain, but it's typically not reproducible on palpation.

ender18d
12-04-2013, 12:12
The reproducible point tenderness points more to a vertebral injury/fracture IMO. This could be from compression, inadvertent trauma or pathologic secondary to an invasive lesion (e.g. cancer).

My questions about change in urine color (which could indicate hemolysis secondary to medication, malaria or other causes) was not answered. This could also cause back pain, but it's typically not reproducible on palpation.

I'd mentioned that the urine was medium yellow. Its a little darker-ish, consistent with someone not drinking enough water... I'll even throw you a bone and say you have a dipstick that comes up with no heme.

ender18d
12-04-2013, 13:07
Summary:

Subjective:
The patient is a 45 y/o steely-eyed barrel-chested team sergeant who presents to the medic with "lower back pain" of a few days duration. He localizes the pain to the L3 L4 region. The patient denies any history of trauma or significant precipitating event. The patient admits to possible fever and night sweats. The patient denies urinary symptoms, incontinence, impotence (strongly denies this one), or neurologic findings. The patient denies history of easy/unusual bleeding or bruising. The patient admits to poor hydration habits.

O: First noticed a few days ago. Gradual in onset.
P: Nothing helps. Movement, especially lumbar flexion, hurts.
Q: “Sharp”
R: “The pain doesn’t seem to go anywhere else but my back.”
S: “Its pretty f’ing bad or I wouldn’t be asking you for meds.”
T: “It hurts pretty constantly.” The pain has been progressive.

PMH: HTN, Recent Dental Work
SHX: N/A
Medications: Lisinopril, Atovaquone/Proguanil, Various nutritional supplements for weight-lifting
Allergies: NKA
FHX: Dad always had lower back pain, and mom had RA.
Social History: Patient is a weight lifter who enjoys 200lb snatch.

Objective:
Vitals: HR: 90, BP 130/85, RR 14, T 101.5deg
The patient is a WDWN 45 y/o male who looks his stated age and presents to medic in moderate distress. He is moderately pale and his movements are constrained and provoke grimaces and profanity. Pertinent physical findings include exquisite tenderness on the vertebral prominence of L3 & L4 with a conspicuous absence of tenderness in the paraspinous muscles. Shoulder exam unremarkable. Visual examination of back unremarkable. Straight leg raise does not provoke sciatic pain. Valsalva unremarkable. Urine dipstick test all WNL.

I will also give you: Targeted neuro exam unremarkable

Problem list:
Vertebral Pain
Fever
Night Sweats
Pallor
Recent Dental Work


Give me your differentials!

ender18d
12-04-2013, 13:31
1. Osteomyelitis (dental techs and their filthy hands!)
2. Prostatitis
3. Subclinical vertebral fracture that's turned clinical

Again, though, these are quite obvious.

I did not see anyone mention osteomyelitis yet, so it can't be THAT obvious. :p

Lets imagine now that you're the 1/1 million 18D who not only brought the lab kit on deployment, but remembers where it is AND how to use it. You find a leukocytosis with a left shift.

So what are we gonna do with this guy?

Santo Tomas
12-04-2013, 14:20
I did not see anyone mention osteomyelitis yet, so it can't be THAT obvious. :p

Lets imagine now that you're the 1/1 million 18D who not only brought the lab kit on deployment, but remembers where it is AND how to use it. You find a leukocytosis with a left shift.

So what are we gonna do with this guy?

Speak English please and get to the diagnosis. This scenario is exactly what I am going through now except 1) pain is worse on left side of my spine and 2) right butt cheek goes numb at times.

x SF med
12-04-2013, 14:33
Speak English please and get to the diagnosis. This scenario is exactly what I am going through now except 1) pain is worse on left side of my spine and 2) right butt cheek goes numb at times.

Thomas, you will kindly STFU, and not get friggin snarky with our fellow QP/18D turning doctor... an apology for the tone and tenor of your post is not expected, but demanded. Ender is a fully qualified 18D and is currently in Med School, we have a couple of PAs and couple of Doctors and a few 18Ds stretching their minds on this, it's not about you.

...and for your edification, this is Medical English, with a little Latin (a medical convention) thrown in - basic medical terminology.

We do not perform internet diagnosis on PS, go see your doctor and get the traditional work ups done by a certified physician on your own dime... this is a training and gut check scenario for the medically inclined on the board.

If an apology is not forthcoming, a moderator will take over.

Santo Tomas
12-04-2013, 14:39
Thomas, you will kindly STFU, and not get friggin snarky with our fellow QP/18D turning doctor... an apology for the tone and tenor of your post is not expected, but demanded. Ender is a fully qualified 18D and is currently in Med School, we have a couple of PAs and couple of Doctors and a few 18Ds stretching their minds on this, it's not about you.

...and for your edification, this is Medical English, with a little Latin (a medical convention) thrown in - basic medical terminology.

We do not perform internet diagnosis on PS, go see your doctor and get the traditional work ups done by a certified physician on your own dime... this is a training and gut check scenario for the medically inclined on the board.

If an apology is not forthcoming, a moderator will take over.

I PM'd Ender

Red Flag 1
12-04-2013, 14:52
Acute leukemia and mutliple myeloma may also present in a similar fashion.

Quite true, and not something I ever thought of when my brother called me from the ER. His presenting complaint was the worse back pain he had ever had. It had been there for some time, but never responded to the usual PT, only pain meds were of any value. In the end, it was, and still is, multiple myeloma. The pain was from vertebral fractures. Multiple myeloma is worth considering in your diagnosis, particularly with no other findings. I do like the line of thinking our Troll has regarding Lisinopril.

RF 1

PedOncoDoc
12-04-2013, 16:22
Problem list:
Vertebral Pain
Fever
Night Sweats
Pallor
Recent Dental Work


Give me your differentials!

1. Osteomyelitis - one should also evaluate for endocarditis given recent dental work - does he have a murmur, any splinter hemorrhages until his fingernails?

2. New onset acute leukemia (also should consider lymphoblastic lymphoma or other malignancy).

3. Vertebral fracture and concomitant (and unrelated) random infection.

swatsurgeon
12-04-2013, 17:11
Has anyone done a thorough physical exam? Was he shot and didn't know it? Did a camel spider make him a host nation to its young?

Come on people......

Brush Okie
12-04-2013, 17:16
Question on Hx.

Any Nausea and vomiting?

Does the pain get worse after meals especially fatty meals?

Any abd pain or tenderness?

Does he have a fever?

What is the malaria possibility in the region or has he been in a malaria region recently?

Any stiff neck or Sx of flu other than feels like shit and night sweats?

Sdiver
12-04-2013, 17:20
Ender,
GREAT scenario.
Nice to have someone else throw in one of these for a change. :D

Couple of questions I have that I don't recall seeing asked/answered ....

1) What country are you, is this pt. in?
2) Pt. states that father had Hx of Lower back pain. Was there any diagnosis on what caused his dad's back pain.
3) Can you in anyway, or is there any way to preform a spinal tap?
4) Does he c/o of a headache, head tilt to chin pain, bright lights bother him? (Going down the r/o Spinal Meningitis route here.)

I've noticed that you've brought up quite repeatedly about the pt. having dental work done. Where was this work done at? In a regular DDS's office or some other place. I ask because if done in a regular DDS office, I know those chairs they use do NOT supply or support the Lumbar area. So this could have exasperated an underlying condition.

5) What procedure was done in the DDS office? Was he put under with anesthetic for a surgical procedure or was it just a regular cleaning of his choppers?

I think he might have some sort of bacterial infection caused by the procedure done by the Jawbreaker. Will explore a little more after above Q's are answered. :cool:

doctom54
12-04-2013, 17:35
With back pain, fever and night sweats Potts Disease is also in the differential.
Potts Disease is osteomyelitis of the spine caused by mycobacterium tuberculosis (TB) usually acquired from drinking unpasteurized milk in third world countries.
I've seen one case in an active duty soldier.

Trapper John
12-04-2013, 18:04
With back pain, fever and night sweats Potts Disease is also in the differential.
Potts Disease is osteomyelitis of the spine caused by mycobacterium tuberculosis (TB) usually acquired from drinking unpasteurized milk in third world countries.
I've seen one case in an active duty soldier.

That is a very good DDx point. The night sweats initially had me thinking about TB, but it just didn't fit the recent history. Talkin about Zebra's :cool: That fits especially with the immature neutrophils and neutrophilia (leukocytosis with left shift). I guess sometimes the hoof beats are from Zebras. ;)

So has Team Sergeant been drinking unpasteurized milk? Otherwise, I'm thinking the proximate cause for the osteomyelitis is the recent dental work.

Still holding with my original plan to ship TS out on the next thing smokin'. All of the likely possibilities are well outside my ability to adequately treat him in the field.

Dusty
12-04-2013, 18:08
Kidney stone. Tell 'im to drink a 2-qt canteen full o' water, move out and draw fire.

Brush Okie
12-04-2013, 18:38
Besides meningitis I was looking at gall bladder. I know this from personal experience it can cause back pain. I was smart enough to wait until I had gangrene before I went to the MD. Also kidney stone and or infection. Lets not forget it could also be a bulging disk or back FX.

TX is evac to nearest hosp with better facilities for blood work, xrays and MRI if needed.

Scimitar
12-04-2013, 20:51
Amateur here...do let me know if I should stand down...

Has the pt had Chickpox as a child?
Has the pt been under greater than usual stress this past 1-2 months, prior to deploy?

S

Scimitar
12-04-2013, 21:23
Also, palpation of a varicella zoster outbreak site normally causes a more regional than point pain.


Yeah I was thinking the same thing, the pain description is a little out of wack for Shingles.

Good thinking, but already covered with visual exam question - no blisters/ rash of shingles.

However, pain and fever / "out of sorts" can on occasion appear up to a few days before visual blistering.

It was a long shot, the only reason I even brought it up is lisinopril has been known to increase chance of herpes zoster.

Another question...how long has pt been on meds, the sweats / out of sorts can be the meds, taking these symptoms out of the mix.

Also, any meds during dental work?

S

ender18d
12-04-2013, 22:11
Question on Hx.

Any Nausea and vomiting?

No.


Does the pain get worse after meals especially fatty meals?

No


Any abd pain or tenderness?

Abdomen appears unremarkable, is soft and supple in 4 fields w/ no guarding or rigidity. Bowel sounds auscultated.


Does he have a fever?

See vitals.


What is the malaria possibility in the region or has he been in a malaria region recently?

The patient is in a region with chloroquine resistant malaria, and is on prophylaxis as noted. The patient claims good compliance.


Any stiff neck or Sx of flu other than feels like shit and night sweats?

No nuchal rigidity noted. Negative NVD, cough, rhinorrhea, sore throat, etc.


1) What country are you, is this pt. in?
2) Pt. states that father had Hx of Lower back pain. Was there any diagnosis on what caused his dad's back pain.
3) Can you in anyway, or is there any way to preform a spinal tap?
4) Does he c/o of a headache, head tilt to chin pain, bright lights bother him? (Going down the r/o Spinal Meningitis route here.)

1. Lets say sub-saharan Africa somewhere. I'm not picky for this scenario. Someplace hot that has malaria and a bunch of other bad things. Pick a country.
2. His dad was always complaining about his bad back that he got jumping into Market Garden, but no diagnosis that patient can recall.
3. Could you? Would you? (assuming you have the equipment to do the procedure)
4. Negative nuchal rigidity, photophobia.


I've noticed that you've brought up quite repeatedly about the pt. having dental work done. Where was this work done at? In a regular DDS's office or some other place. I ask because if done in a regular DDS office, I know those chairs they use do NOT supply or support the Lumbar area. So this could have exasperated an underlying condition.

Work was done at a military dental facility.

5) What procedure was done in the DDS office? Was he put under with anesthetic for a surgical procedure or was it just a regular cleaning of his choppers?

He says his mouth was a real cesspool according to the dentist, but he has trouble remembering any particular words. When you say "root abscess," he seems to think that rings a bell. Local anesthetic was used.


So has Team Sergeant been drinking unpasteurized milk? Otherwise, I'm thinking the proximate cause for the osteomyelitis is the recent dental work.

Negative

Amateur here...do let me know if I should stand down...

Has the pt had Chickpox as a child?
Has the pt been under greater than usual stress this past 1-2 months, prior to deploy?

S

Yes and yes. Mama ain't happy at home.



Another question...how long has pt been on meds, the sweats / out of sorts can be the meds, taking these symptoms out of the mix.


PT has been taking lisinopril since his mid 30's. He started the malaria prophylaxis a few days prior to deployment.


Also, any meds during dental work?

S

The patient does not know if the dentist used any meds other than anesthetic... he just remembers a bunch of needles. He was given a prescription for something by the dentist, but he didn't feel sick so he ignored it.

Peregrino
12-04-2013, 22:15
The patient does not know if the dentist used any meds other than anesthetic... he just remembers a bunch of needles. He was given a prescription for something by the dentist, but he didn't feel sick so he ignored it.

Now we're getting somewhere! :p (Sorry, couldn't resist; even a former Bravo knows how much sympathy to expect when you tell the medic you FTFSI.)

Brush Okie
12-04-2013, 22:26
What is he taking the lisinopril for? High BP or kidney problems?

I looked it up and found it can cause hyperkalemia. Sooo I am looking at possibly kidney issue ie kidney problems and or hyperkalemia. Any pedal edema? DC the lisinopril. He did have some darker urine correct? Possable systemic infection due to not following through with dental med working with BP med?

Sdiver
12-04-2013, 22:39
Two quick questions ...

1) how long has he been taking his Lisinopril, and most importantly the Atovaquone/Proguanil ?

2) What is his race/ethnicity ?


ETA some differential Dx's .....

Dad's back pain came from jump into Holland so we can r/o that being a genetic trait.

Mom's RA is a possible genetic trait. Which in combination with the Lisinopril could exacerbate the back pain which is a possible side effect of Lisinopril.

The back pain can also be a hypersensitivity to the Malarone (would really like to know his race/ethnicity .... I reference the M*A*S*H episode with Klinger and Goldman taking the Primaquine.) Also Black's having an acute hypersensitivity to Malaria drugs.

Also, the combination of the Mararone and the supplements he's taking may be causing an adverse reaction. The effects of some drugs can change if you take other drugs or herbal products at the same time. This can increase your risk for serious side effects or may cause your medications not to work correctly.

Also possible, a combination of all three above.

MR2
12-04-2013, 22:45
An echo of his heart would be nice. Can we get a EKG to compare against a baseline?

Lab work - Lites/UA w diff (specifically creatinine level)?

How much ibuprofen/naproxen has he been taking?

ender18d
12-05-2013, 05:24
Somewhere along the line I missed answering:
Cardiac exam demonstrates RRR, S1/S2 w/o murmurs, gallops, or rubs. PMI @ 5th ICS MCL. No splinter hemorrhages either, but great thinking on all of the above.

Now we're getting somewhere! :p (Sorry, couldn't resist; even a former Bravo knows how much sympathy to expect when you tell the medic you FTFSI.)

Indeed!

What is he taking the lisinopril for? High BP or kidney problems?

I looked it up and found it can cause hyperkalemia. Sooo I am looking at possibly kidney issue ie kidney problems and or hyperkalemia. Any pedal edema? DC the lisinopril. He did have some darker urine correct? Possable systemic infection due to not following through with dental med working with BP med?

PT has previously noted history of HTN.

No peripheral edema noted on exam.

The urine was described as mid-yellow with no heme on dipstick and I will add no proteinurea either.

Two quick questions ...

1) how long has he been taking his Lisinopril, and most importantly the Atovaquone/Proguanil ?

2) What is his race/ethnicity ?


ETA some differential Dx's .....

Dad's back pain came from jump into Holland so we can r/o that being a genetic trait.

Mom's RA is a possible genetic trait. Which in combination with the Lisinopril could exacerbate the back pain which is a possible side effect of Lisinopril.

The back pain can also be a hypersensitivity to the Malarone (would really like to know his race/ethnicity .... I reference the M*A*S*H episode with Klinger and Goldman taking the Primaquine.) Also Black's having an acute hypersensitivity to Malaria drugs.

Also, the combination of the Mararone and the supplements he's taking may be causing an adverse reaction. The effects of some drugs can change if you take other drugs or herbal products at the same time. This can increase your risk for serious side effects or may cause your medications not to work correctly.

Also possible, a combination of all three above.

Medication dates already noted a few posts ago.

He's Caucasian.

An echo of his heart would be nice. Can we get a EKG to compare against a baseline?

Lab work - Lites/UA w diff (specifically creatinine level)?

How much ibuprofen/naproxen has he been taking?


You already have the diff... I think chemistries stretch what one might reasonably be expected to have given the scenario.

He has not yet taken any NSAIDs.

ender18d
12-05-2013, 05:48
Any other physical findings you want to look for or history questions to ask?

I think this covers all the new information, but if I missed something please let me know. You should be honing in on your differentials at this point. Look carefully at the problem list and you should be able to stratify this differential pretty effectively. Moving on, are we going to do anything to treat this guy?

Summary Update:

Subjective:
The patient is a 45 y/o steely-eyed barrel-chested team sergeant who presents to the medic with "lower back pain" of a few days duration. He localizes the pain to the L3 L4 region. The patient denies any history of trauma or significant precipitating event. The patient admits to possible fever and night sweats. The patient denies urinary symptoms, incontinence, impotence (strongly denies this one), or neurologic findings. PT reports urine of "medium yellow" color. PT denies NVD, cough, sore throat, rhinorrhea. No pain association with meals. The patient denies history of easy/unusual bleeding or bruising. The patient admits to poor hydration habits. PT denies unusual dietary exposures such as unpasteurized milk.

O: First noticed a few days ago. Gradual in onset.
P: Nothing helps. Movement, especially lumbar flexion, hurts.
Q: “Sharp”
R: “The pain doesn’t seem to go anywhere else but my back.”
S: “Its pretty f’ing bad or I wouldn’t be asking you for meds.”
T: “It hurts pretty constantly.” The pain has been progressive.

PMH: HTN, Recent Dental Work for suspected tooth abscess. Potential poor compliance on post-procedural medication of unknown type.
SHX: N/A
Medications: Lisinopril (since mid 30's), Atovaquone/Proguanil (started about 10 days ago), Various nutritional supplements for weight-lifting
Allergies: NKA
FHX: Dad always had lower back pain, and mom had RA.
Social History: Patient is a weight lifter who enjoys 200lb snatch. PT admits to high stress levels due to marital issues, possibly related to aforementioned 200lb snatch.

Objective:
Vitals: HR: 90, BP 130/85, RR 14, T 101.5deg
The patient is a WDWN 45 y/o Caucasian male who looks his stated age and presents to medic in moderate distress. He is moderately pale and his movements are constrained and provoke grimaces and profanity. Pertinent physical findings include exquisite tenderness on the vertebral prominence of L3 & L4 with a conspicuous absence of tenderness in the paraspinous muscles. No CVAT. Shoulder exam unremarkable. Visual examination of back unremarkable. Straight leg raise does not provoke sciatic pain. Neuromuscular exam of lower extremities unremarkable with preserved reflexes, sensation, and strength. Valsalva unremarkable. Cardiac exam demonstrates RRR, S1/S2 w/o murmurs, gallops, or rubs. PMI @ 5th ICS MCL. Lungs CTA x3 bilat. No splinter hemorrhages. Abdomen shows no visible lesions and is soft and supple in 4 fields w/ no guarding or rigidity. Bowel sounds auscultated. No nuchal rigidity or photophobia noted. No peripheral edema. Urine dipstick test all WNL.

CBC: 15,000 per mm3 leukocytes w/ 12% bands

Problem list:
Focal Vertebral Pain
Fever
Night Sweats
Pallor
Recent Dental Work for possible abscess
Possible poor ABX compliance
Leukocytosis w/ left shift


**************

Some additional questions:

1. What, precisely, is a "night sweat?"

2. What does "pain greater on flexion than extension" suggest in the context of vertebral back pain? How does this fit with our differential at this point?

3. Renal pathology is absolutely a consideration for low back pain, but there are a number of findings in our history and physical at this point that make renal issues less likely in this patient. What are they?

ender18d
12-05-2013, 07:26
infective endocarditis.

What makes you think endocarditis in this case?

Brush Okie
12-05-2013, 08:23
Well I can't pin exactly what is going on except he is a dumb ass for not finishing his antibiotics. He has an infection that is probably about to go septic. His back pain may be... well just back pain from injury or it may be related to infection, no way to tell for sure. . Start him on antibiotics, Draw blood for a C&S and malaria test. Evac to nearest facility with X-ray and MRI. Chew his ass err I mean educate on the importance of finishing his antibiotics and hope he does not have resistant strain now.

What does his mouth look and fell like? Bad breath?

ender18d
12-05-2013, 08:56
Start him on antibiotics

Type, dose, route, and reasoning please.

Draw blood for a C&S and malaria test.

I like this. Lets imagine you were a smart medic and brought a few Binax kits on the trip with you since you knew you were going to a malaria zone. Just a tiny little card that can give you instant screening for Malaria (developed here at Walter Reed, FWIW). The gold standard is still thick and thin smears, but this is small, fast, light, and effective. Your PT's BinaxNOW results are negative.

ANYONE with a fever and a relevant travel history has malaria until proven otherwise. It may be malaria/AND, but you always rule out malaria.

Evac to nearest facility with X-ray and MRI. Chew his ass err I mean educate on the importance of finishing his antibiotics and hope he does not have resistant strain now.

What does his mouth look and fell like? Bad breath?

Upon oral inspection you see the results of years of chewing tobacco and poor oral hygiene, and a number of fillings that the patient confirms are recent. Moderate gingivitis and halitosis is noted.

ender18d
12-05-2013, 09:13
Once the haematogenous route starts distributing that bacteria, funky heart stuff which can be detected by auscultation or seen on a strip will not likely appear before the pyogenic infection goes symptomatic in the spine.

That's the "working" part of the diagnosis - counting on the facts of my hypothesis lining up in an expected way because of an extremely limited access to tests which confirm.

Okie's right - sepsis is a real concern with the way things are working out, and potent one.

Alright, so what you're saying is that the patient had/has bacteremia secondary to the dental procedure, and now has osteomyelitis secondary to the bacteremia. The presumptive diagnosis in that case is osteomyelitis. Endocarditis is another possible and highly concerning complication of bacteremia, and yes clinically silent endocarditis is possible. Aggressive screening for endocarditis moving forward is absolutely warranted. However, I think calling it the presumptive diagnosis is a bit of a stretch, and endocarditis is definitely not causing the osteomyelitis in this case.

Since we're talking about sepsis as a possible complication, what is it and how would we recognize it?

PedOncoDoc
12-05-2013, 09:19
Type, dose, route, and reasoning please.

This depends on what is on hand.

I doubt we have vancomycin available, and his hydration status keeps me from wanting to further stress his kidneys.

I would choose clindamycin (good coverage for oral bacteria, covers some strains of MRSA and also effective against malaria) - given the clinical scenaria I would give IV if possible/available. I would dose at 600mg IV q8hrs.

Prior to starting Abx can we draw a blood sample for culture (to be analyzed at the facility to which we are heading)? It's best to ID the bug so treatment can be tailored based upon sensitivities (if available).


The reason some of us want to rule out bacterial endocarditis is because transient bacteremia during/following dental work can lead to cardiac bacterial vegetations that shower off bacteria, may cause septic emboli and persistent bacteremia which would put him at risk of further end-organ infections.

ender18d
12-05-2013, 10:02
This depends on what is on hand.

I doubt we have vancomycin available, and his hydration status keeps me from wanting to further stress his kidneys.

I would choose clindamycin (good coverage for oral bacteria, covers some strains of MRSA and also effective against malaria) - given the clinical scenaria I would give IV if possible/available. I would dose at 600mg IV q8hrs.

Prior to starting Abx can we draw a blood sample for culture (to be analyzed at the facility to which we are heading)? It's best to ID the bug so treatment can be tailored based upon sensitivities (if available).


The reason some of us want to rule out bacterial endocarditis is because transient bacteremia during/following dental work can lead to cardiac bacterial vegetations that shower off bacteria, may cause septic emboli and persistent bacteremia which would put him at risk of further end-organ infections.

Absolutely agree on the endocarditis! Ruling it out is crucial, and continued surveillance is also crucial. I just objected to it being the presumptive diagnosis and cause of the osteomyelitis.

I'm happy with that treatment plan. Clindamycin seems reasonable if you have it. Rocephin would also be a reasonable broad spectrum agent a medic is likely to have available. Start treating this right away!

So, treatment plan:
Start IV antibiotics immediately (agent selected based upon availability)
Pain Control?
Medevac imediately
Reassess, reassess, reassess

Unanswered questions:
1. What, precisely, is a "night sweat?"

2. What does "pain greater on flexion than extension" suggest in the context of vertebral back pain? How does this fit with our differential at this point?

3. Renal pathology is absolutely a consideration for low back pain, but there are a number of findings in our history and physical at this point that make renal issues less likely in this patient. What are they?

4. Since we're talking about sepsis as a possible complication, what is it and how would we recognize it?

PedOncoDoc
12-05-2013, 10:11
Absolutely agree on the endocarditis! Ruling it out is crucial, and continued surveillance is also crucial. I just objected to it being the presumptive diagnosis and cause of the osteomyelitis.

I'm happy with that treatment plan. Clindamycin seems reasonable if you have it. Rocephin would also be a reasonable broad spectrum agent a medic is likely to have available. Start treating this right away!

So, treatment plan:
Start IV antibiotics immediately (agent selected based upon availability)
Pain Control?
Medevac imediately
Reassess, reassess, reassess

I'd be worred that ceftriaxone doesn't cover strep viridans groups and MRSA which both can cause a nasty osteomyelitis, but you have to choose from what's available.

I would be monitoring him closely during and after the first dose of antibiotics in case he goes septic from endotoxin/toxic shock - would have IV fluids ready to run open wide for pressure support and be checking blood pressure and extremity perfusion frequently. I've seen several patients crash within 1-2 hours of the first antibiotic dose (typically gram negative bugs in those cases).

For pain control I would hold off on systemic treatment for now - motrin can affect platelet adhesion and if he starts to head down the line towards DIC I don't want to contribute to bleeding issues. For the concern of shock above I would prefer not to administer narcotics as well so I can keep an eye on mental status.

ender18d
12-05-2013, 10:20
I'd be worred that ceftriaxone doesn't cover strep viridans groups and MRSA which both can cause a nasty osteomyelitis, but you have to choose from what's available.

I would be monitoring him closely during and after the first dose of antibiotics in case he goes septic from endotoxin/toxic shock - would have IV fluids ready to run open wide for pressure support and be checking blood pressure and extremity perfusion frequently. I've seen several patients crash within 1-2 hours of the first antibiotic dose (typically gram negative bugs in those cases).

For pain control I would hold off on systemic treatment for now - motrin can affect platelet adhesion and if he starts to head down the line towards DIC I don't want to contribute to bleeding issues. For the concern of shock above I would prefer not to administer narcotics as well so I can keep an eye on mental status.

My thought is that MRSA is a lower risk given our proposed mechanism, so I wouldn't make MRSA coverage my treatment priority. Agree that a good portion of Strep Viridans is resistant to Rocephin, so it might not be an ideal agent... I'm just running over in my mind what a medic is likely to have. Someone with more current knowledge of what is in an 18D's aid bag than myself would be better to answer this definitively.

Fair call on the pain control.

ender18d
12-05-2013, 10:29
The point of this case is to illustrate an example of a "red flag." Back pain is an unbelievably common complaint, especially in the military. Most of the time, back pain is a relatively self-limiting condition requiring only some supportive treatment and the tincture of time. However, there are a number of extremely dangerous causes of back pain that can masquerade as lumbago. Obviously, we're not going to go full House MD every time a team-mate has a little back ache, so we need some screening questions to identify those back pain cases that need more thorough investigation. This list is not exhaustive, but it covers some of the most important issues to look out for.

Red Flags: Fever, Night Sweats, Unexplained Weight Loss
Why we're concerned? Infection, Rheumatologic Disease, Cancer

Red Flags: Personal History of Cancer, Constitutional Symptoms, New onset at age > 50 w/o clear mechanism
Why we're concerned? Cancer

Red Flag: Age <18
Why we're concerned? Stress fractures, infection, discitis

Red Flag: Unrelenting nocturnal pain
Why we're concerned? Cancer, osteoid osteoma

Red Flag: History of Trauma
Why we're concerned? Fracture

Red Flag: Numbness or sensation change, neuro findings on PE
Why we're concerned? Nerve root compression

Red Flag: Bowel or bladder incontinence, "saddle" sensation changes
Why we're concerned? Cauda Equina Syndrome

Red Flag: IV drug use, immunosuppressed status (IE corticosteroid use!)
Why we're concerned? Infection

(to be clear, the red flag finding does not diagnose the concern! It is just an important finding that should prompt further investigation)

ender18d
12-05-2013, 10:51
[QUOTE=ender18d;532347]
1. What, precisely, is a "night sweat?"

Hyperhidrosis during sleep, not related to the environment.

2. What does "pain greater on flexion than extension" suggest in the context of vertebral back pain? How does this fit with our differential at this point?

It can indicate a great many things; posterior ligamentous strain or tear, posterior disc herniation or sequestration pressing on ALL, lateral recess or dural attachments, muscle spasm of multifidus or other posterior rotator/ extensor

In the context of our Dx? Paraspinous infection in the form of spondylodiscitis.


3. Renal pathology is absolutely a consideration for low back pain, but there are a number of findings in our history and physical at this point that make renal issues less likely in this patient. What are they?

Assume the ballotment method was used during standard ab. quadrant exam, results negative. Outside of that, maybe a more renal-oriented doc/ medic can chime in?
4. Since we're talking about sepsis as a possible complication, what is it and how would we recognize it?

SIRS caused by the immune system's response to a severe infection, usually bacterial. Signs vary depending upon early or established sepsis. Flushed skin, decreased urination, low BP, elevated HR are common early signs.

This looks good to me. I would simplify the flexion/extension response for the sake of non-bone-benders and say that because of the physics involved, increased pain on flexion points to a problem on the anterior portion of the spine (body, discs, etc) while increased pain/symptomology on extension suggests a posterior etiology. Its an over-simplification perhaps, but a good rule-of-thumb. Osteomyelitis generally infects the vertebral body due to its vascularity.

As for the kidneys, the first thing is that the location I'm describing is pretty specific. It really only hurts when you mess with his vertebrae. The muscles are fine. No costo-vertebral tenderness. No referred pain. This is a very focal issue. We also don't have any exciting findings related to his urine. He's a little dehydrated (hence the yellow urine) like every team guy in the field ever, but no changes in urinary habits, the pain isn't associated with urination, and our dipstick revealed no heme or protein. Stones and the like also tend to be colicky pain, not continuous pain. None of this is to say that we can forget this guy's kidneys, but these findings move primary renal issues lower on our differential.




So, any last wrap up? Hopefully this has been helpful, and I welcome any of the real doctors here to chime in and correct any errors I've made.

PedOncoDoc
12-05-2013, 10:56
[QUOTE=ender18d;532347]
1. What, precisely, is a "night sweat?"

Hyperhidrosis during sleep, not related to the environment.

2. What does "pain greater on flexion than extension" suggest in the context of vertebral back pain? How does this fit with our differential at this point?

It can indicate a great many things; posterior ligamentous strain or tear, posterior disc herniation or sequestration pressing on ALL, lateral recess or dural attachments, muscle spasm of multifidus or other posterior rotator/ extensor

In the context of our Dx? Paraspinous infection in the form of spondylodiscitis.


3. Renal pathology is absolutely a consideration for low back pain, but there are a number of findings in our history and physical at this point that make renal issues less likely in this patient. What are they?

Assume the ballotment method was used during standard ab. quadrant exam, results negative. Outside of that, maybe a more renal-oriented doc/ medic can chime in?
4. Since we're talking about sepsis as a possible complication, what is it and how would we recognize it?

SIRS caused by the immune system's response to a severe infection, usually bacterial. Signs vary depending upon early or established sepsis. Flushed skin, decreased urination, low BP, elevated HR are common early signs.

Night sweat - for it to be concerning (from an oncologic standpoint) should be recurring and be sufficient to require change of bedclothes/sheets.

I'll defer to others on the flexion/extension question.

For renal eval - pain tends to be colicky if worried about stones (not constant such as in this case). Most commonly docs will pound on the costovertebral angle to check for kidney-associated pain (such as in pyelonephritis). Since kindeys are retroperitoneal the abdominal examination is less helpful (unless there is a large kidney mass - this will be picked up on abdominal exam). Other things associated with a renal cause - hematuria, cloudy/foul smelling urine (UTI progressing to pyelonephritis), other urinary symptoms (hesitancy, frequency, dysuria).

Sepsis is a lecture unto itself - different causes (hypovolemic, spine trauma, sepsis, cardiogenic, etc.) - compensated versus not, one could go on for a long time and I'm admittedly a bit rusty on the specific pathophysiology in these different scenarios.

ender18d
12-05-2013, 11:48
[QUOTE=PedOncoDoc;532361]

If anybody here should require guidance on that stuff, PM me. If mechanical causes are suspect, a Dx flowchart would look more complex than a COIN dynamics graph.

For wrap up, I'd say supplying an outline of your medical tools before presenting the scenario would be a good thing to do. Maybe that would take away some of the cat and mouse fun of this stuff, though. :D

Cheers!

Perhaps I'll consider that next go.

ender18d
12-05-2013, 11:58
Actually, I've got one more good question about my red flags, based on a discussion with one of our EM faculty this morning:

1. How will the incontinence of cauda equina syndrome typically present first?

MR2
12-05-2013, 12:18
Actually, I've got one more good question about my red flags, based on a discussion with one of our EM faculty this morning:

1. How will the incontinence of cauda equina syndrome typically present first?

What's the speed of sound for $100 Alex.

ender18d
12-05-2013, 12:41
What's the speed of sound for $100 Alex.

LOL, alright, I certainly didn't get this one when he asked me, so I'm not going to play "what am I thinking" too much.

There are many different kinds of incontinence, and cauda equina syndrome often starts with overflow incontinence: an inability to urinate causing bladder distention and subsequent leakage due to the buildup of pressure.

This means that the first sign of a cauda equina syndrome may not be obvious leakage, but actually lower abdominal distention and inability to urinate. A worthwhile tidbit to keep in the back of your mind (or so I thought).

OK, now I'm really done. Thanks for participating everyone!

Trapper John
12-05-2013, 12:52
Ender-

This was really very, very good and a valuable exercise - for me anyway. I learned a lot from everyone who posted here.

THANK YOU ALL :lifter

Brush Okie
12-05-2013, 19:45
Mrs. Okie come up with this one. Is it SIRS? If so he is in deep shit.

EDIT-She also says he needs to be checked for VD no matter what.

ender18d
12-06-2013, 03:34
Mrs. Okie come up with this one. Is it SIRS? If so he is in deep shit.

EDIT-She also says he needs to be checked for VD no matter what.

Yes, this case meets the criteria for SIRS (Systemic Inflammatory Response Syndrome), which are two or more of the following:

> 38oC or < 36oC, heart rate
> 90 beats/minute, respiratory rate
> 20 breaths/minute or PaCO2 < 32
white blood cell count > 12,000 or < 4,000, or > 10% band forms.

SIRS isn't the diagnosis by itself, but an extremely important indicator of severity. Yes, this patient is seriously sick and hence the importance of starting treatment immediately in addition to evacuating him.

I think VD is a very good thought here as well, for two different reasons. First, bugs like neisseria gonorrhoeae can go systemic (usually going for joints rather than bone), and also immunocompromise would predispose the PT to development of an osteomyelitis via this mechanism.

frostfire
12-06-2013, 23:08
Yes, this case meets the criteria for SIRS (Systemic Inflammatory Response Syndrome), which are two or more of the following:

> 38oC or < 36oC, heart rate
> 90 beats/minute, respiratory rate
> 20 breaths/minute or PaCO2 < 32
white blood cell count > 12,000 or < 4,000, or > 10% band forms.

SIRS isn't the diagnosis by itself, but an extremely important indicator of severity. Yes, this patient is seriously sick and hence the importance of starting treatment immediately in addition to evacuating him.

I think VD is a very good thought here as well, for two different reasons. First, bugs like neisseria gonorrhoeae can go systemic (usually going for joints rather than bone), and also immunocompromise would predispose the PT to development of an osteomyelitis via this mechanism.


Vitals: HR: 90, BP 130/85, RR 14, T 101.5deg


I was thinking SIRS all along with that vitals you posted. In the land of Airborne and SOF, I've noted that every single barrel-chested freedom fighter presented with bradycardia! Well, that's just their baseline of course. So when these types (just like our Team Sergeant pt here) presented with HR of 90, that's tachy for sure. Granted he's in pain, but still.

Toughness or stubborness (take your pick) can be problematic in the steely-eyed community. I remember treating this salty CWO4 SF who kept apologizing for showing up in the ER. He had long term steroid therapy for a previous condition, and ended up with pilonidal cyst that got to the point of both inner cheeks dripping with pus! It was the worst case I ever saw, thanks to 5 weeks wait from getting help.

Trapper John
12-07-2013, 08:51
You brought up a very good point Frostfire. As a Team Medical Sergeant I made it a point to really know the baseline vitals and medical Hx of the team members. A HR of 90 in the Team Daddy that had a baseline resting HR of 50 would be cause for concern to be sure. Couple that with the low-grade fever and neutrophilia with immature bands - voila! A Dx of sepsis is at the top of the list.

I did not initially consider this as part of the DDx :( but focusing on the back pain and RO simple causes that were field treatable it was clear that TS needed Medevac ASAP.

One other point, in my day (now I sound like an ol' geezer :eek:) we did not have field portable kits for doing a WBC. If I did and saw the neutrophilia with bands that would be reason for immediate Medevac. Now to the question of starting TS on antibiotics - probably contraindicated IMO. I don't know what the 18Ds carry these days, but I think the choice of antibiotic would be better left to the attending at a primary care facility.

Maybe some of you Docs and AD 18Ds could discuss this point (pros and cons) a bit more. I would be interested to read what you all think.

swatsurgeon
12-07-2013, 13:08
Start with fever....as mentioned, have to know a baseline to determine if the temp is elevated. Also about 75% of all fevers are inflammatory, not infection Ina hospital so how that correlated with the field I'm not sure.
An elevated WBC is too non specific and certainly not a sensitive indicator of a big problem. One of the studies I read years ago took SF warriors and checked their cortisol levels after stress, they were rarely if ever demonstrating adrenal insufficiency when significantly wounded and in an ICu..... Not the norm at all so WBC and neutrophil counts are an indicator of the immune functional and response so you SF guys mess all of that up!!!
I would go by other signs and sx's to figure out an infectious/inflammatory response.
ss

ender18d
12-09-2013, 10:11
Now to the question of starting TS on antibiotics - probably contraindicated IMO. I don't know what the 18Ds carry these days, but I think the choice of antibiotic would be better left to the attending at a primary care facility.

Maybe some of you Docs and AD 18Ds could discuss this point (pros and cons) a bit more. I would be interested to read what you all think.

I double checked this with one of our EM faculty, and he agreed that an empiric antibiotic, even if its not perfect, should be administered immediately. Studies show that even if the ABX isn't the perfect choice, early administration in serious cases like this makes a real difference in outcomes. He also mentioned that while something like Rocephin might not cover all the possible bugs, it would cover most of the ones that would produce a rapid sepsis in a patient such as this. (again, not arguing its the perfect drug... just something I'm pretty sure 18D's still have around.)

Sacamuelas
12-19-2013, 17:18
IE was raised in the thread as it related to dental treatment. Therefore, I thought I would add to the reason that ender18D didn't focus on that possibility for the acute symptoms that this patient is experiencing based on his history.

Infective endocarditis (IE) is extremely rare in the postoperative dental patient population. In certain conditions, it is a valid concern. If at risk, the military dental clinic would have supplied Ab premedication to the TS before treatment began to prevent it. They would have also verified patient cooperation with Ab regimen before beginning treatment. Postoperative Ab therapy is not indicated to prevent IE.

When I first got out of school, the fear of postop IE dictated that we gave antibiotic prohylaxis pre and postop to patient in all sorts of widespread patient populations from MVP with or W/O regurgitation, all forms of congenitial heart defects, history of rheumatic fever, past IE episode, history of cardiac stints, valve surgeries, prosthetics, A-fib, etc. Basically, it was "if in doubt, give them antiobiotics before and after treatment. This thinking has changed as the actual scientific data has been developed.

Currently, IE is at the highest risk in patients with a history of:
1- prosthetic cardiac valve; risk 1:124,000
2- prior documented incidence of IE, risk 1:95,000
3- Heart transplant patients who develop cardiac valvulopathy
4- past rheumatic heart disease; risk 1:142,000

*** our patient in this thread has none of these in his history

The only other patient populations that are at high enough risk to warrant true concern for IE are certain congenital heart defects in the following specific groups:
1- Unrepaired cyanotic CHD, including palliative shunts and conduits
2- completely repaired CHD with prosthetic material during the first 6 months after surgery
3- repaired CHD with residual defects at the site of the prosthetic patch (inhibits endothelialization)

Since our barrel chested, freedom fighter does not fit into these parameters, it is VERY unlikely that the diagnosis is Infective endocarditis caused during a dental procedure or by his poor postoperative patient cooperation with antibiotics. Still hanging on to the likelyhood of our TS friend having IE??? What are the chances? Well, if he did in fact have mitral valve prolapse and experienced a very messy surgical procedure without the appropriate premed... his chances were still only 1:1.1 MILLION of getting IE postop to a dental visit. It is not even clear he had a heart murmor or any other even minor risk factor for IE from what I glanced at during the thread.


I promise this won't be a complete Zebra. :D
FWIW, Infective endocarditis would not only have been a Zebra, it would have been the ultra rare spotted, long neck blue throated zebra that is only found in far regions of Neverlandia. :D

BTW- there should are some simple, basic questions and tests that could help identify problems in his oral cavity and S/S of recurrent infection other than simply running a fever if the patient was septic from a dental condition/visit/treatment.

Great thread ender18D.

ender18d
12-19-2013, 17:46
IE was raised in the thread as it related to dental treatment. Therefore, I thought I would add to the reason that ender18D didn't focus on that possibility for the acute symptoms that this patient is experiencing based on his history.

Infective endocarditis (IE) is extremely rare in the postoperative dental patient population. In certain conditions, it is a valid concern. If at risk, the military dental clinic would have supplied Ab premedication to the TS before treatment began to prevent it. They would have also verified patient cooperation with Ab regimen before beginning treatment. Postoperative Ab therapy is not indicated to prevent IE.

When I first got out of school, the fear of postop IE dictated that we gave antibiotic prohylaxis pre and postop to patient in all sorts of widespread patient populations from MVP with or W/O regurgitation, all forms of congenitial heart defects, history of rheumatic fever, past IE episode, history of cardiac stints, valve surgeries, prosthetics, A-fib, etc. Basically, it was "if in doubt, give them antiobiotics before and after treatment. This thinking has changed as the actual scientific data has been developed.

Currently, IE is at the highest risk in patients with a history of:
1- prosthetic cardiac valve; risk 1:124,000
2- prior documented incidence of IE, risk 1:95,000
3- Heart transplant patients who develop cardiac valvulopathy
4- past rheumatic heart disease; risk 1:142,000

*** our patient in this thread has none of these in his history

The only other patient populations that are at high enough risk to warrant true concern for IE are certain congenital heart defects in the following specific groups:
1- Unrepaired cyanotic CHD, including palliative shunts and conduits
2- completely repaired CHD with prosthetic material during the first 6 months after surgery
3- repaired CHD with residual defects at the site of the prosthetic patch (inhibits endothelialization)

Since our barrel chested, freedom fighter does not fit into these parameters, it is VERY unlikely that the diagnosis is Infective endocarditis caused during a dental procedure or by his poor postoperative patient cooperation with antibiotics. Still hanging on to the likelyhood of our TS friend having IE??? What are the chances? Well, if he did in fact have mitral valve prolapse and experienced a very messy surgical procedure without the appropriate premed... his chances were still only 1:1.1 MILLION of getting IE postop to a dental visit. It is not even clear he had a heart murmor or any other even minor risk factor for IE from what I glanced at during the thread.

FWIW, That would not only have been a Zebra, it would have been the ultra rare spotted, long neck blue throated zebra that is only found in far regions of Neverlandia. :D

BTW- there should be some simple, basic tests that could help identify problems in his oral cavity and S/S of recurrent infection other than running a fever if the patient is septic from a dental condition/visit/treatment.

Great thread ender18D.

This is awesome and great info for me!

The funny thing is that they have run some variant of this scenario over and over again (at least 4 times I can think of), both on our written and practical exams... I've even seen board questions on it, often adding in no more information than I gave. Its to the point where as medical students the minute we hear "dental work" in a history we start thinking bacteremia... LOL

I will file this in my back pocket. That said, I would argue that even setting aside the dental history, there is a pretty short list of causes of this clinical picture, all of them are bad, and you can really only do much for one of them (infection, ABX) right now. I don't think the rarity of the particular cause I suggested here really changes the main diagnosis and treatment of this guy, although I'm open to debate on it.

MR2
12-19-2013, 17:57
My experience with boards and board type questions(not to mention briefbacks) is that a significant percentage of questions and scenarios include the near impossible improbables to the obtuse.

None-the-less, I understand the TS did in fact not fit into the parameters for IE and that it was only a blue-throated herring. ;)

Thanks! :)

Sacamuelas
12-19-2013, 18:00
I didn't say some academic won't put that on a board exam. They like to pull out wild Dx for common symptoms for standardized tests... HaHa

We had all sorts of "what ifs" drilled into us as well during school.... they are good to know when you've run through a very thorough process of ruling out the more likely causes. :cool: Just trying to give some scale to the problem so that our members knew how unlikely IE is from dental procedures. :cool:

ender18d
12-19-2013, 18:05
I didn't say some academic won't put that on a board exam. They like to pull out wild Dx for common symptoms for standardized tests... HaHa

We had all sorts of "what ifs" drilled into us as well during school.... they are good to know when you've run through a very thorough process of ruling out the more likely causes. :cool: Just trying to give some scale to the problem so that our members knew how unlikely IE is from dental procedures. :cool:

Roger that sir! This is some great real world info that may prevent me from pulling a zebra out of my back pocket on rounds one day and looking like a typical med student. :lifter

head
12-19-2013, 18:29
I am sufficiently scared for the next time I have lower back pain.

Thank you.

PS, I like these scenarios and I like the fact that board members are taking the time to post these. I read through and don't understand. I'm a "take a knee and drink water" type of guy, but it's good to know that those common maladies may kill me.

PedOncoDoc
12-20-2013, 04:37
Roger that sir! This is some great real world info that may prevent me from pulling a zebra out of my back pocket on rounds one day and looking like a typical med student. :lifter

We are often looking to see if you can keep the differential broad - we like hearing a medical student form a broad differential and a logical diagnostic plan that covers the common and most urgent causes and how to proceed from there if initial testing doesn't point to a cause.

I used to make sure that Munchausen (or Munchausen by proxy) and ingestion got on every differential in our "morning report" case exercises. :D

PedOncoDoc
12-20-2013, 10:29
This is especially true of a practice with a specific anatomical concentration.

Like recreational gynecology? :D

Brush Okie
12-20-2013, 11:53
Like recreational gynecology? :D

This post is useless with out photograph documentation. :p

PedOncoDoc
12-20-2013, 12:32
This post is useless with out photograph documentation. :p

Where do you think the camera was positioned when my avatar photo was taken? :p :D

(for the record: my avatar is from the original "Bean" movie.)