Intern Case Report 2.2

intern-report

Presented by Bao Dang, MD

Case

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.

PMH: DM
PSH:None
Allergies: None
Social Hx: No tobaco, Occasional Drinker, No Illicit drug use
Physical Exam:

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.
HEENT: WNL
Pulmonary: CTA
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

Questions

1.  Considering the above presentation, what is the most likely diagnosis?
a.  AAA
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
d.   Ultrasound
e.   X-ray spine

3.  Which organism is the most likely cause of the above diagnosis?
a.   Anaerobes
b.   Gram-negative bacilli
c.   Mycobacterium
d.   Staphylococcus aureus
e.   The diagnosis is not due to an infection

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

16 Responses

  1. D, b, d

  2. 1. D 2.B 3. D

  3. 1. D
    2. B
    3. D.

  4. 1. D – Spinal Epidural Abscess
    2. B – Emergent MRI
    3. D – Staphylococcus aureus

  5. d b d

  6. 1. d) epidural abcess
    2. b) mri
    3. d) staph

  7. 1. D
    2. B
    3. D

  8. 1. D. Spinal Epidural Abscess
    2. B. Emergent MRI
    3. D. Staph Aureus
    Treat with Vanco 30mg/kg divided into 2 doses
    Metronidazole

  9. 1. D. Spinal Epidural Abscess
    2. B. Emergent MRI
    3. D. Staph Aureus
    Treat with Vanco 30mg/kg IV divided into 2 doses
    Metronidazole 500mg IV q8h and a 3rd generation cephalosporin (Cefotaxime2g IV q6h, or Ceftriaxone 2g IV q12 or Ceftazidime 2g IV q8h)
    Neurosurgical consult

  10. 1-d
    2-b
    3-d

  11. 1. d

    2. b

    3. d

  12. d
    d
    d

  13. 1 d.
    2 c.
    3 d.

  14. spinal epidural abscess, mri, staph a

  15. 1. D
    2. B
    3. D

  16. 1) Epidural Abscess
    2) MRI
    3) Staph aureus

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