case presentation dave choi pgy-4 emergency medicine edmonton dave choi pgy-4 emergency medicine...
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Case PresentationCase Presentation
Dave ChoiPGY-4
Emergency MedicineEdmonton
Dave ChoiPGY-4
Emergency MedicineEdmonton
Learning GoalsLearning Goals
Present an interesting case
Briefly review relevant material
Be done in 25 minutes… really.
Present an interesting case
Briefly review relevant material
Be done in 25 minutes… really.
The CaseThe Case
Day shift at the Foothills Just finished resusitating a level 1
trauma patient Feeling good about your intubation
and chest tube skills, you move to the minor side to see a patient with “low back pain”
Day shift at the Foothills Just finished resusitating a level 1
trauma patient Feeling good about your intubation
and chest tube skills, you move to the minor side to see a patient with “low back pain”
HistoryHistory
Mr G. 58 y.o. male Walked into ER c/o lower back pain x 1/12 Seen by GP last week given toradol
and percocet, also put on Flomax for BPH
Mr G. 58 y.o. male Walked into ER c/o lower back pain x 1/12 Seen by GP last week given toradol
and percocet, also put on Flomax for BPH
HistoryHistory
Noticed lower back pain at night initially No history of trauma Constant pain Mildly relieved by hot compresses, and
pain medications Activity doesn’t make it better or worse Wakes him up at night sometimes
Noticed lower back pain at night initially No history of trauma Constant pain Mildly relieved by hot compresses, and
pain medications Activity doesn’t make it better or worse Wakes him up at night sometimes
HistoryHistory
Pain has been getting bit worse Worse with coughing, straining Radiating to flank/groin x 1/52 Some voiding difficulty (hard start)
x 1/52 No bowel incontinence
Pain has been getting bit worse Worse with coughing, straining Radiating to flank/groin x 1/52 Some voiding difficulty (hard start)
x 1/52 No bowel incontinence
HistoryHistory
No fever, chills, night sweats ~5lb weight loss over last couple
months
No fever, chills, night sweats ~5lb weight loss over last couple
months
Red FlagsRed Flags
Pain not relieved by lying down Night pain Leg weakness Bowel, bladder, sexual symptoms Fever (esp. IVDU) Weight loss
Pain not relieved by lying down Night pain Leg weakness Bowel, bladder, sexual symptoms Fever (esp. IVDU) Weight loss
HistoryHistory
PmHx: ↑ cholesterol Meds: Crestor 10mg PO QD,
Percocet 1tab PO Q4H prn, Toradol 10mg PO Q6H prn
Allergies: NKDA FHx: father MI at 80 y.o.
PmHx: ↑ cholesterol Meds: Crestor 10mg PO QD,
Percocet 1tab PO Q4H prn, Toradol 10mg PO Q6H prn
Allergies: NKDA FHx: father MI at 80 y.o.
HistoryHistory
SHx- non smoker- occas. EtOH- no illegal drugs- worked as senior manager for Telus, retired
earlier this year, exercises 3x/week, going on holidays soon
ANY OTHER QUESTIONS? Ddx?
SHx- non smoker- occas. EtOH- no illegal drugs- worked as senior manager for Telus, retired
earlier this year, exercises 3x/week, going on holidays soon
ANY OTHER QUESTIONS? Ddx?
O/EO/E
Vitals: T36.8, P54, RR15, BP137/83, Sat 99% Heart S1S2, no EHS/murmurs/rubs Lungs clear, AE=AE Abd soft, normal BS, bit tender
suprapubic, no peritoneal signs/guarding
No pulsating mass, no flank tenderness
Vitals: T36.8, P54, RR15, BP137/83, Sat 99% Heart S1S2, no EHS/murmurs/rubs Lungs clear, AE=AE Abd soft, normal BS, bit tender
suprapubic, no peritoneal signs/guarding
No pulsating mass, no flank tenderness
MSK ExamMSK Exam
No erythema/warmth/swelling over back Pain is midline but not worse with
palpation No atrophy legs Normal SLR tests (Lasegue’s) Normal ROM lower back (Schober’s) Normal gait
No erythema/warmth/swelling over back Pain is midline but not worse with
palpation No atrophy legs Normal SLR tests (Lasegue’s) Normal ROM lower back (Schober’s) Normal gait
Neuro ExamNeuro Exam
Motor: 5/5 power UE, Slight decreased power L hip flexor, otherwise normal
Sensation: normal UE/LE, no saddle anesthesia, normal rectal tone, mild prostate enlargement
DTR +2 bilat UE, +1 bilat LE, no Babinski
Motor: 5/5 power UE, Slight decreased power L hip flexor, otherwise normal
Sensation: normal UE/LE, no saddle anesthesia, normal rectal tone, mild prostate enlargement
DTR +2 bilat UE, +1 bilat LE, no Babinski
InvestigationsInvestigations
Xray Lspine - mild degen changes
Hgb158 WBC5.9 Plt 243 Na140 K4.1 Cl105 bicarb27 Cr100, Urea5.5
Urine neg leuks/protein/hgb
Bladder scanned for 154ml
Xray Lspine - mild degen changes
Hgb158 WBC5.9 Plt 243 Na140 K4.1 Cl105 bicarb27 Cr100, Urea5.5
Urine neg leuks/protein/hgb
Bladder scanned for 154ml
Differential Dx Low Back Pain
Differential Dx Low Back Pain
Mechanical (>95%)- Lumbar strain (70%), degenerative process (10%), herniated disk
(4%), spinal stenosis (3%), OP compression # (4%), spondylolisthesis (2%), traumatic # (<1%), congenital disease (<1%), disc disruption
Non-mechanical spinal conditions (~1%)- Neoplasia, infection, inflammatory arthritis, Paget’s
Visceral disease (~2%)- Disease of pelvic organs, renal disease, AAA, GI
Mechanical (>95%)- Lumbar strain (70%), degenerative process (10%), herniated disk
(4%), spinal stenosis (3%), OP compression # (4%), spondylolisthesis (2%), traumatic # (<1%), congenital disease (<1%), disc disruption
Non-mechanical spinal conditions (~1%)- Neoplasia, infection, inflammatory arthritis, Paget’s
Visceral disease (~2%)- Disease of pelvic organs, renal disease, AAA, GI
PLANPLAN
D/C home?
Any other investigations?
- FAST (aorta)
Follow up?
D/C home?
Any other investigations?
- FAST (aorta)
Follow up?
10 days later…10 days later…
Patient sent into ER from GP’s office for in/out cath and urinalysis
Lower abdominal discomfort Cannot sleep
Patient sent into ER from GP’s office for in/out cath and urinalysis
Lower abdominal discomfort Cannot sleep
Physical ExamPhysical Exam
Chest clear Abd: bit distended, dull to percussion,
suprapubic discomfort to palpation, symmetric fullness
Neuro exam unchanged from previous Bladder scanned for 550ml, foley
drained 500ml, foley left in
Chest clear Abd: bit distended, dull to percussion,
suprapubic discomfort to palpation, symmetric fullness
Neuro exam unchanged from previous Bladder scanned for 550ml, foley
drained 500ml, foley left in
10 days later…10 days later…
Urinalysis: 3+ leuks, many bacteria Started on Septra Discharged home with U/S pelvis
booked for next day
Urinalysis: 3+ leuks, many bacteria Started on Septra Discharged home with U/S pelvis
booked for next day
PLANPLAN
Leave catheter in Toradol 30mg IM Buscopan 10mg POPatient feels bit
better
• U/S pelvis tomorrow
Leave catheter in Toradol 30mg IM Buscopan 10mg POPatient feels bit
better
• U/S pelvis tomorrow
It’s tomorrowIt’s tomorrow
U/S abdo/pelvis – normal GB + bile ducts, liver grossly normal, pancreas, spleen, aorta normal, multiple bilateral renal cysts, but kidneys otherwise normal
Now what?
Dx = prostate hyperplasia, UTI, and mechanical back pain
U/S abdo/pelvis – normal GB + bile ducts, liver grossly normal, pancreas, spleen, aorta normal, multiple bilateral renal cysts, but kidneys otherwise normal
Now what?
Dx = prostate hyperplasia, UTI, and mechanical back pain
Case continuedCase continued
Urology consult for cystoscopy as outpatient
Urology consult for cystoscopy as outpatient
28 days later28 days later
Still c/o back pain worse at night Very tender suprapubic area Numbness / tingling feet started 1
week ago Meds: Flomax, Proscar, Flexeril,
Percocet prn, Toradol prn
Still c/o back pain worse at night Very tender suprapubic area Numbness / tingling feet started 1
week ago Meds: Flomax, Proscar, Flexeril,
Percocet prn, Toradol prn
28 days later28 days later
O/E: AVSS Neuro Exam- Motor: 4+/5 hip flexors, others 5/5- Sensation: “numb” over plantar feet
bilat, touch/pinprick ok- DTR +1 LE bilat, +2 UE bilat, no
Babinski- No saddle anesthesia- Rectal tone intact
O/E: AVSS Neuro Exam- Motor: 4+/5 hip flexors, others 5/5- Sensation: “numb” over plantar feet
bilat, touch/pinprick ok- DTR +1 LE bilat, +2 UE bilat, no
Babinski- No saddle anesthesia- Rectal tone intact
Case continuedCase continued
Working Dx = Urinary retention 2o to BPH and LBP (mechanical)
Working Dx = Urinary retention 2o to BPH and LBP (mechanical)
Hmm…Hmm…
Pt returns to ED 3 more times in the next 4 days c/o urinary retention and suprapubic discomfort
Now c/o bilateral numbness/tingling feet and lower back pain radiating to bilateral thighs
Pt returns to ED 3 more times in the next 4 days c/o urinary retention and suprapubic discomfort
Now c/o bilateral numbness/tingling feet and lower back pain radiating to bilateral thighs
InvestigationsInvestigations Pt booked for outpt MRI L-spine
for ?neurogenic claudication by GP
Cystoscopy – mildly enlarged prostate
Pt booked for outpt MRI L-spine for ?neurogenic claudication by GP
Cystoscopy – mildly enlarged prostate
2 weeks later…2 weeks later…
Returns to ED c/o gradual bilateral leg weakness L>R
Has been unable to walk independently over last 4 days (using walker)
Foley catheter in situ x 3 weeks Unable to cope at home
Returns to ED c/o gradual bilateral leg weakness L>R
Has been unable to walk independently over last 4 days (using walker)
Foley catheter in situ x 3 weeks Unable to cope at home
Recap of the EventsRecap of the Events LBP, gradual onset and worsening, night
pain, worse with valsalva x 4/12 Pain radiating to bilat thighs and groin x
3/12 Numbness/tingling bilat feet, ascending
from feet to thigh x 1/12 Urinary retention x 1/12, indwelling
foley x 3/52 Gradual bilateral leg weakness x 2/52
LBP, gradual onset and worsening, night pain, worse with valsalva x 4/12
Pain radiating to bilat thighs and groin x 3/12
Numbness/tingling bilat feet, ascending from feet to thigh x 1/12
Urinary retention x 1/12, indwelling foley x 3/52
Gradual bilateral leg weakness x 2/52
Neuro Exam NowNeuro Exam Now
Motor: UE normal; 3/5 Hip flexors, 3+/5 Quads, 4/5 Hamstrings, 4/5 ankle dorsi/plantarflexion
Sensation: saddle anesthesia! Reflexes: no DTRs LE, no Hoffman’s, no
Babinski, normal bulbocavernosus reflex and rectal tone
Motor: UE normal; 3/5 Hip flexors, 3+/5 Quads, 4/5 Hamstrings, 4/5 ankle dorsi/plantarflexion
Sensation: saddle anesthesia! Reflexes: no DTRs LE, no Hoffman’s, no
Babinski, normal bulbocavernosus reflex and rectal tone
Case continuedCase continued
Admitted under neurosurgery MRI – syrinx vs inflammatory or
neoplastic cord disease, suggest LP by neurology to r/o viral etiology
Lumbar Puncture – WBC103 RBC96 Prot4.15 (<0.45) Glu2.6 (2.2-4.4) neg cultures
Diagnosis?
Admitted under neurosurgery MRI – syrinx vs inflammatory or
neoplastic cord disease, suggest LP by neurology to r/o viral etiology
Lumbar Puncture – WBC103 RBC96 Prot4.15 (<0.45) Glu2.6 (2.2-4.4) neg cultures
Diagnosis?
CaseCase
CT chest/abd – no aortic dissection
MRA – suspicious for dural AV fistula arising from upper lumbar region causing ischemia
OR – L2-4 laminectomy and clipping of spinal dural AV fistula
CT chest/abd – no aortic dissection
MRA – suspicious for dural AV fistula arising from upper lumbar region causing ischemia
OR – L2-4 laminectomy and clipping of spinal dural AV fistula
Dural AV fistulaDural AV fistula
a.k.a. Foix-Alajouanine Syndrome AV malformation of spinal cord vessels,
usually lower thoracic or lumbosacral Can lead to ischemic injury of the cord Male:Female 4:1 Usually >50yo Symptoms gradual onset over months
to years
a.k.a. Foix-Alajouanine Syndrome AV malformation of spinal cord vessels,
usually lower thoracic or lumbosacral Can lead to ischemic injury of the cord Male:Female 4:1 Usually >50yo Symptoms gradual onset over months
to years
Symptoms / SignsSymptoms / Signs- Weakness / numbness / tingling of LE- Gradual onset + worsening LE weakness- Urinary / fecal incontinence- lower back pain +/- radiating- Abnormal gait- Spastic or flaccid paraparesis +/-
sensory level - DTR variable; +/- Babinski- Decreased rectal tone
- Weakness / numbness / tingling of LE- Gradual onset + worsening LE weakness- Urinary / fecal incontinence- lower back pain +/- radiating- Abnormal gait- Spastic or flaccid paraparesis +/-
sensory level - DTR variable; +/- Babinski- Decreased rectal tone
Investigation / TreatmentInvestigation / Treatment
INVESTIGATION MRI Myelogram angiography
TREATMENT Embolization of AVM Laminectomy w/ obliteration of AV
shunt
INVESTIGATION MRI Myelogram angiography
TREATMENT Embolization of AVM Laminectomy w/ obliteration of AV
shunt
CaseCase Electrodiagnostic Study
- Axonal injury to leg muscles L>R
- Considerable # motor neurons still intact, prognosis for functional recovery reasonably good
Electrodiagnostic Study
- Axonal injury to leg muscles L>R
- Considerable # motor neurons still intact, prognosis for functional recovery reasonably good
Mr. G nowMr. G now
Back pain significantly reduced Unable to ambulate Self in/out catheterizations BMs ok
Still hoping to go on planned holidays to Hawaii in the future
Back pain significantly reduced Unable to ambulate Self in/out catheterizations BMs ok
Still hoping to go on planned holidays to Hawaii in the future
?
SummarySummary
Red flags for Low back pain
Multiple ER visits with same problem, do not get blinded by the “diagnosis”
Red flags for Low back pain
Multiple ER visits with same problem, do not get blinded by the “diagnosis”
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