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Morning Report

Morning Report. 7/7/1999 Victor Ghobrial, MD William Fink, MD. HPI. 91 F presented to the hospital with 2 days Hx of cough, scanty yellowish sputum production and elevated temp. Also C/O low back pain which has been going on for the past three years but has been worse lately.

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Morning Report

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  1. Morning Report 7/7/1999 Victor Ghobrial, MD William Fink, MD

  2. HPI • 91 F presented to the hospital with 2 days Hx of cough, scanty yellowish sputum production and elevated temp. • Also C/O low back pain which has been going on for the past three years but has been worse lately. • She denied CP, N/V or other symptoms.

  3. PMH • HTN • DJD • No DM, CAD or cancer

  4. H&P • NKDA • Tylenol daily • SH: No smoking or alcohol abuse • Family Hx: non- contributory

  5. Physical Exam • Elderly female in no distress • T 102 BP 160/80 P 94 RR 24 Pox 97% RA • HEENT : PERRBL, No ear or nose D/C • Neck : Supple without JVD • Ht : RRR S1 S2 audible without murmurs • Lungs : Bibasilar crackles no wheezes or rhonchi

  6. H&P • Abdomen : Soft not tender with positive BS and without organomegally • Ex : No E, C, C. +1 PP • Neuro : Disoriented to time. No focal deficits or CN palsies

  7. Labs • Na K Co2 Cl BUN Cr 142 3.2 22 100 9 0.6 • Glucose 120 • CXR

  8. Hospital Course • Pt was admitted for 3 days, treated with Abx for community acquired pneumonia • Back pain continued and spinal films revealed compression fx of lumbar vertebrae with Rt scoliosis • Pt was prescribed vit D with Ca and percocet PRN

  9. Low Back Pain • Structure of the back : vertebrae and discs are supported by ligaments and paravertebral ms, discs consist of gelatinous nucleus pulposus and surrounding annulus fibrosus • Sinovertebral n. arises from corresponding spinal n. and carries sensation

  10. Etiology • Trauma : bone, joints or ligaments • Mechanical : pregnancy, obesity or scoliosis • Degenerative : osteoarthritis • Infections : osteomyelitis, TB, meningitis • Metabolic : osteoporosis, osteomalicia

  11. Etiology • Neoplastic : myeloma, Hodgkin’s, pancreatic Ca, breast mets, prostate, lung • GI : ulcers, pancreatitis, cholelithiasis, IBD • Renal : hydronephrosis, calculus, neoplasm, renal infarcts, pyelo-nephritis • Hematological : sickle cell crisis, hemolysis

  12. Etiology • Vascular : leaking aortic anurysm, subarachnoid or spinal he • Gynecologic : tumors of uterus, ovary, dysmenorrhea, uterine prolapse • Inflammatory : ankylosing spondylitis, arthritis, Reiter’s syndrome, strain • Psycogenic : malinger, anxiety, hysteria

  13. evaluation • Differentiate between two main types: Mechanical xxx Medical • Most of the time it is self-limited; about 50% will improve in 1st week, 51-86% in 1st month and 92% in 2 months • Identify pts with Cancer, Infection, Neuro deficits, Inflammatory dis & Leaking AAA

  14. Standing Position 1- Kyphosis, lordosis and scoliosis 2- Localize tenderness 3- Schober test: 10cm line at LSJ & above should extend > 15cm Sitting & Supine 1- Reflexes: Knee(L4) Ankle(S1) 2- SLR: + if elevated 60*or less, spes 40%, sens 95%. 3- Crossed Straight Leg 90&25% exam

  15. labs • CBC & ESR :Inflammatory&Neoplastic • Ca & Alka phos : Diffuse bone disease • Serum & Urine Electrophoresis : MM • Acid phos & PSA : Prostate Ca • UA : Renal disease • Occult Stool : GI diseases

  16. X-Ray • Not necessary for initial work up unless hx of trauma, infection, malignancy or inflamm • By age 50, 67% of normal population have evidence of disc disease and 2/3 of pts who have evidence of lumbar disc degeneration are asymptomatic • Should be reserved for persistant pain, tenderness, elderly and if Rx fails

  17. MRI • Highly diagnostic • Reserved for pts in whom information will change Rx • Needed urgently if suspecting Cauda equina or Epidural mass • Not needed in disc herniation

  18. Scans • CT if used instead of MRI must be with intrathecal contrast to yield high resolution • Radionuclide Bone Scanning has limited utility, useful in osteomyelitis or mets. It is normal in MM (lytic lesion)

  19. Drug Rx • 1st line NSAIDs for analgesia if failed narcotics usually not longer than 2 weeks • Muscle relaxants of no proven value but if needed should be used for no longer than 2 weeks • Corticosteroid injection of unknown value

  20. rest & exersices • Once thought as cornerstone of therapy, now are ineffective for acute pain • 2 days of bed rest gives better results than 7 days • The value of traction and corsets is doubtful • Early mobilization is the current trend

  21. Surgery • Needed urgently if evidence of evolving neurologic deficits, consistent pain syndrome that failed conservative Rx for 4:6 weeks • Percutaneous lumbar discectomy is safe and effective (75%) alternative to laminectomy

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