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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?

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“Traumatic Pain Management…” Case Conclusion August 6, 2012

Posted by Andy Jagoda, MD in : Drugs & Emergency Procedures, General Emergency Medicine, Trauma , add a comment

After establishing hemodynamic stability with your motor vehicle collision patient, you considered the potential for masking serious injuries with analgesia but realized that appropriate pain control has not been shown to contribute to missing serious injuries in this context. After a dose of IV fentanyl, her heart rate normalized and her pain improved, but she still had tenderness with palpation of the left upper quadrant. A CT scan showed a grade II splenic laceration but no other emergent pathology. You consulted a trauma surgeon, who agreed with your plan for admission for observation and pain control.

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Traumatic Pain Management… July 25, 2012

Posted by Andy Jagoda, MD in : Drugs & Emergency Procedures, General Emergency Medicine, Trauma , 5comments

A 35-year-old female who was the restrained driver in a front-impact motor vehicle collision arrives. Her airbag deployed, and there was significant damage to her car. The paramedics report tachycardia to 120 beats/minute; her other vital signs are normal. Your examination reveals a young woman in pain, with a patent airway, equal breath sounds, strong distal pulses, and tenderness to palpation in her abdomen. She has a band-like ecchymosis across her chest wall and abdomen, consistent with placement of a seat belt. She is neurologically intact and is able to report that she did not hit her head or lose consciousness. She has no other tenderness or deformities. After reporting a normal fingerstick glucose and negative pregnancy test, the nurse asks you if you would like to order something for pain; the answer is yes, but you consider the risk of lowering her blood pressure or changing her exam findings, and you wonder what the safest strategy might be.

What do you do?

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