Presented by Bao Dang, MD
A 34-yo-female with PMH of DM and symptomatic L5-S1 disc herniation, presents to the ED with a chief complaint of fever and back pain. Pt states she was involved in a MVC 7 months prior that left her with a L5-S1 disc herniation with L foot drop and tingling and numbness on dorsum of L foot. Pt states she received a “back steroid injection” from a pain specialist 7 days ago. Since the injection, the pain has not subsided but instead she is experiencing worsening pain. The back pain is described as being midline of lower back. Pain is 8/10, constant even when pt is lying still, which is different from pt’s prior back pain. Pt has trouble sleeping over last few days because of pain. Pt also notes she’s been febrile with a max temperature of 102.1 taken at home. Pt has no c/o of urinary or fecal incontinence, N/V, HA, neck stiffness, photophobia, weight loss, dysurea, BM changes, weightloss, history of cancer.
Social Hx: No tobaco, Occasional Drinker, No Illicit drug use
Vitals:BP134/75, HR105, RR19, T38.9.
Generally the pt appeared uncomfortable lying in her stretcher. Pt was unable to ambulate from triage to Module.
Cardiovascular: S1 S2, no murmur, rubs or gallops
Neuro exam: Strength is 5/5 proximal and distally and FROM in bilateral upper extremities and right lower extremity. Left lower extremity showed decreased strength of dorsiflexion of L ankle, other wise strength is normal. Normal finger to nose examination. Decreased pin prick and light touch sensation was also noted over dorsum of left foot relative to right foot. Left leg raise produces sharp pain radiating down to lower leg. Palpation of lower back revealed slight tenderness of midline of lower back.
Abdominal examination: soft, nondistended, no tenderness, BS present.
Rectal: good rectal tone, guaiac negative, intact touch sensation perianally.
Lab Results: CBC:WBC(16),Hgb(13),Hct(34), Platelets(155), ESR:50(high), UA: Negative for UTI and hematuria
1. Considering the above presentation, what is the most likely diagnosis?
b. Primary or Secondary Carcinoma
c. Renal Colic
d. Spinal Epidural Abcess
e. Vertebral fracture
2. What is the diagnostic test of choice for this patient in the ED?
a. CT scan
b. Emergent MRI
c. Lumbar Puncture
e. X-ray spine
3. Which organism is the most likely cause of the above diagnosis?
b. Gram-negative bacilli
d. Staphylococcus aureus
e. The diagnosis is not due to an infection
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