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Old 12-05-2013, 05:48   #61
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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?
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Old 12-05-2013, 07:26   #62
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Quote:
Originally Posted by DocIllinois View Post
infective endocarditis.
What makes you think endocarditis in this case?
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Old 12-05-2013, 08:56   #63
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Quote:
Originally Posted by Brush Okie View Post
Start him on antibiotics
Type, dose, route, and reasoning please.

Quote:
Originally Posted by Brush Okie View Post
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.

Quote:
Originally Posted by Brush Okie View Post
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.
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Old 12-05-2013, 09:13   #64
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Originally Posted by DocIllinois View Post
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?
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Old 12-05-2013, 09:19   #65
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Originally Posted by ender18d View Post
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.
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Old 12-05-2013, 10:02   #66
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Originally Posted by PedOncoDoc View Post
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?
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Old 12-05-2013, 10:11   #67
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Originally Posted by ender18d View Post
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.
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Old 12-05-2013, 10:20   #68
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Originally Posted by PedOncoDoc View Post
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.
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Old 12-05-2013, 10:29   #69
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Red Flags

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)
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Old 12-05-2013, 10:51   #70
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[QUOTE=DocIllinois;532354]
Quote:
Originally Posted by ender18d View Post
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.
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Old 12-05-2013, 10:56   #71
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[QUOTE=DocIllinois;532354]
Quote:
Originally Posted by ender18d View Post
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.
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Old 12-05-2013, 11:48   #72
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[QUOTE=DocIllinois;532372]
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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.
Cheers!

Perhaps I'll consider that next go.
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Old 12-05-2013, 11:58   #73
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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?
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Old 12-05-2013, 12:18   #74
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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.
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Old 12-05-2013, 12:41   #75
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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!
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