1 / 30

Management of Acute Lower Back Pain in a 63-Year-Old Woman: A Case Conference

Explore the management of acute lower back pain in a 63-year-old woman with a history of lumbar strain, hypertension, and other medical conditions. This case study delves into the patient's history, physical examination, lab results, and imaging studies, along with the initial and ongoing management strategies.

rpierson
Download Presentation

Management of Acute Lower Back Pain in a 63-Year-Old Woman: A Case Conference

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 63-Year-Old Woman with Acute Lower Back Pain Evan Atkinson Medicine-Pediatrics HO3 Medicine Case Conference LSUHSC New Orleans March 19, 2013

  2. Chief Complaint ~“My back hurts and I can’t walk for 5 days.”~

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

  4. History of Present Illness • Exacerbated by walking. • Relieved by lying on side with hips flexed. • Denies any leg weakness or paresthesia. • Denies dysfunction of bowel or bladder. • No additional trauma. • Denies subjective fever or chills.

  5. Past Medical History • PMHx: • HTN • Cerebral aneurysm (1998) • OA hands/knees (x10y) • PSHx: • Brain aneurysm clipped (1998) • C-section • Appendectomy • Allergies: • NKDA • Denies food allergies

  6. Past Medical History • Meds: • Diltiazem 240mg daily • Metoprolol succinate 50mg daily • Hydrochlorothiazide 25 mg daily • Meloxicam 7.5mg prn: pain • Tramadol 50mg prn: pain • Cyclobenzaprine 10mg prn: spasm • Acetaminophen 325mg prn: mild pain

  7. Past Medical History • Social: • Former unit clerk at Charity MICU • Lives locally with family • Social EtOH • History of ½ packs tobacco per day over 45 years • Quit 5 years ago • Denies history or current drug abuse • FamHx: • Mother deceased at 66 yo of gastric cancer • Father deceased at 67 yo of prostate cancer

  8. Past Medical History • Health Maintenance • PCP – unknown • Mammogram – 4/12 - negative • Pap – not done in several years • Colonoscopy – never done • Vaccines • Flu - denies • Pneumovax - denies • Tetanus – 4/12

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

  10. Physical Examination VS: Triage: BP 112/69, P 128, R 19 (93% RA), T 102.7°CBP 137/69, P 108, R 25 (99% RA) Gen: Moderate distress and anxious-appearing Non-toxic, lying in bed on her side, cooperative HEENT: Normocephalic/atraumatic Dentition fair but mild gingivitis OP/NT/TM clear No LAD, trachea midline

  11. Physical Examination • CV: • Tachycardia, normal S1/S2 • No murmurs, S3 or S4 • Resp: • Tachypnea, symmetric breath sounds • CTAB, No wheezes/crackles/rhonchi • GI: • Obese, non-distended; +Bowel sounds • Non-tender • No hepatosplenomegaly

  12. Physical Examination • GU: • External exam normal, no abscess • Ext: • +2 DP, no edema, nails unremarkable • Spine: • Neck supple • L4 spinous process TTP • Paraspinous muscles tense but nontender • Skin: • Nooverlying integument defect • No erythema, warmth, fluctuance, or induration above L4

  13. Physical Examination • Neuro: • +rectal tone, no saddle anesthesia • LE tone/strength/sensation normal • Neg straight leg raise • Ambulation deferred o/w unremarkable • MSK: • No effusions or erythema • No limitations in ROM but exam slightly limited due to back pain • No muscle tenderness

  14. Labs Na: 141 K: 3.1 (3.6-5.2) Cl: 104 CO2: 25 BUN: 19 Cr: 1.05 Glu: 114 (65-99) TP: 8.1 (6.0-8.0) Alb: 4.3 AST: 37 AP: 100 ALT: 31 GFR: >60 CRP: 10.36 (<0.90) ESR: 20 UA: neg with no microscopic analysis Blood cxs x 2 sets Gonorrhea and Chlamydia - neg WBC: 12.8 (4.5-11.0) Hgb: 13.4 Hct: 37.8 MCV: 83.8 Plt: 198 RDW: 13.7 N 86% Bands: 2% Lymp: 10% Mono: 2%

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

  16. Initial Management • Sepsis with unclear source: • Empiric vancomycin and piperacillin-tazobactam • Surveillance for and removal of source • Back Pain: • Neurosurgery consulted • No indication for surgical intervention • Provide hydromorphone and cyclobenzaprine for pain • HTN: • Holding BP meds and monitor closely

  17. Hospital Course: Day 2

  18. Hospital Course: Day 2 • CT of lumbar spine • No evidence of osteomyelitis/abscess • Multi-level mild degnerative disc disease within thoracic spine

  19. Hospital Course: Day 2 Blood Cultures after 28 hrs: Gram Negative Rods in 4 of 4 bottles Continued empiric GNR coverage with piperacillin-tazobactam Vancomycin discontinued Source of infection not definitively identified Back Pain: Improving with less medications Added heat packs and encourage ambulation HTN: Hemodynamically stable off BP meds

  20. Hospital Course: Day 2

  21. CDC PHIL #1602, http://phil.cdc.gov Hospital Course: Day 4

  22. Hospital Course: Day 4 Blood Cultures Eikenella corrodens identified in 4 of 4 bottles Antibiotic coverage changed to ceftriaxone Source of infection still not identified Reviewed risk factors and pursued ancillary studies Entry Site: no risk factors for E.corrodens ø dental work, ingested bones, licking needles ø instrumentation of GU or GI tracts ø IV or percutaneous drug use ø human or animal bites

  23. Searching for the Source • Back Pain • Still improving with less use of opioids • Decreased pain on exam but increased ambulation from bed to restroom with only mild pain • HTN • Resume home BP meds • Infection Locus: ancillary imaging studies • TTE/TEE • structurally normal valves, no vegetation • CT Abd • ø abdominal or pelvic abscess, large uterus

  24. Hospital Course: Day 7

  25. Gallium Scan • Faint increased uptake within the mid to lower lumbar spine slightly left of midline. • More significant osseous changes from prior CT scan • Within right L3-L4 facet joint

  26. Clinical Resolution • Day 2: mild-mod pain with ambulation only • Day 9: pain only with deep palpation of L4 • Day 32: ESR-CRP wnl • Day 60: no back pain discharged on a 3-week course of ceftriaxone IV

  27. The End ~ Thanks! ~

More Related