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“Lower back pain…” Case Conclusion July 8, 2013

Posted by Andy Jagoda, MD in : Musculoskeletal Emergencies, Neurologic , add a comment

Case re-cap:

A 45-year-old man presents after 7 days of pain in his lower back. He reports that it began the day after he started at a new job site. The pain initially improved with ibuprofen, but he woke up this morning with a severe exacerbation of the pain. He denies a fall or other trauma, and he states that the pain radiates from his left buttock to his left foot. He has had intermittent back pains in the past, but he never required any imaging or interventions. Employed in the construction industry, he has a history of hypertension and is going through a divorce. He is afebrile, has a benign abdominal exam, and displays an antalgic gait. He has intact patella and Achilles reflexes, and he has a positive left straight-leg raise sign and crossed straight-leg raise sign. Strength and sensation, including the perineum, are intact and symmetrical. The patient insists that he needs an MRI but you’re not convinced that’s necessary.

Case conclusion:

You wanted to be sure your 45-year-old construction worker patient had no red flag signs or symptoms, so you specifically asked him if he had any prior history of cancer and inquired into his habits (including illicit drug use) and told him that use of intravenous drugs would alter your management. Your physical exam was consistent with a radiculopathy. You inquired about bowel or bladder abnormalities, and he reported all was good on that front. You made a diagnosis of lumbar radiculopathy, and you decided to treat with NSAIDs and a muscle relaxant. You explained that no imaging or blood testing was needed and informed him that his symptoms needed to be reassessed in 4 weeks, as more than 85% of patients are better by then. He asked for extra pain medication, and you agreed to a short course of tramadol. He will follow up with his workers’ compensation clinic, and they will determine when he can return to work.

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Lower back pain… June 24, 2013

Posted by Andy Jagoda, MD in : Musculoskeletal Emergencies, Neurologic , 10comments

A 45-year-old man presents after 7 days of pain in his lower back. He reports that it began the day after he started at a new job site. The pain initially improved with ibuprofen, but he woke up this morning with a severe exacerbation of the pain. He denies a fall or other trauma, and he states that the pain radiates from his left buttock to his left foot. He has had intermittent back pains in the past, but he never required any imaging or interventions. Employed in the construction industry, he has a history of hypertension and is going through a divorce. He is afebrile, has a benign abdominal exam, and displays an antalgic gait. He has intact patella and Achilles reflexes, and he has a positive left straight-leg raise sign and crossed straight-leg raise sign. Strength and sensation, including the perineum, are intact and symmetrical. The patient insists that he needs an MRI but you’re not convinced that’s necessary.

How would you manage this patient?

(Leave a comment to be eligible to receive a free copy of the July 2013 issue of Emergency Medicine Practice, which features this case. To do so, simply enter your response in the comments box. The deadline to enter is July 6th.)

A case of Rhabdomyolysis… March 1, 2012

Posted by Andy Jagoda, MD in : Musculoskeletal Emergencies, Renal and Genitourinary Emergencies, Trauma , 11comments

A nurse informs you of a new patient who “just doesn’t look well.” You assess the patient, a 69-year-old woman who is coughing up green sputum, saturating 89% on room air, and is febrile, tachypneic, and tachycardic with a blood pressure of 86/40 mm Hg. The patient’s daughter informs you that her mother was just released from the hospital 6 days earlier after being treated for pneumonia. You suspect septic shock and instruct the nurse to place a nonrebreather mask on the patient. You administer broad-spectrum antibiotics, draw cultures and labs (including a venous lactate and a cardiac panel), and initiate a 30-cc/kg crystalloid infusion. The blood pressure normalizes, so you breathe a sigh of relief, but soon after, the lactate returns elevated at 8 mmol/L, which confirms your suspicion for severe sepsis. The nurse places a Foley catheter and reports that there is scant and “dark” urine in the bag. The WBC count returns at 18.4, and her BUN and Cr are 32 and 5.5, respectively. You note that the BUN:Cr ratio is odd, considering her previously normal renal function; you expected an increased ratio due to prerenal azotemia from severe sepsis. You then notice that the CK level is 67,000 U/L with normal MB fraction. To confirm your hunch, you check the UA, which returns positive for “blood” but does not show any red blood cells in the sediment.

This case reminds you that rhabdomyolysis has many causes, but the treatment in all cases is based on an aggressive hydration strategy. You recall that sodium bicarbonate infusion may be indicated and wonder: when, and how should it be initiated? You also wonder, “Is there anything else I can do for this patient that would mitigate against complications from renal failure?”

What’s Your Next Step?

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