Team Sergeant with Low Back Pain

[x SF med]

Originally Posted by Trapper John

LMAOROF Now that's funny rat there!

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...

[ender18d]

Originally Posted by ender18d

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]

Originally Posted by Trapper John

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

Advise him to avoid 200+ pound snatch.

[Trapper John]

Originally Posted by x SF med

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...

We are thinking the same, Bro.

[x SF med]

Originally Posted by PedOncoDoc

Advise him to avoid 200+ pound snatch.

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

[Trapper John]

Originally Posted by ender18d

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]

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]

Originally Posted by PedOncoDoc

Advise him to avoid 200+ pound snatch.

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

[ender18d]

Originally Posted by DocIllinois

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]

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]

Originally Posted by PedOncoDoc

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]

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]

Originally Posted by DocIllinois

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.

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]

Originally Posted by ender18d

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

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]

Originally Posted by Santo Tomas

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.