[QUOTE=DocIllinois;532354]
Quote:
Originally Posted by ender18d
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.
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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.