mobey Posted April 14, 2013 Share Posted April 14, 2013 Since our "Dyspnea" patient is long dead, I thought I'd start a new scenario. The old dawgs here have seen this before (Ya Dwayne... that includes you), so I trust you won't spoil it for the rest. A 27y/o obeise (230lb) male presents to the ER with runny nose, malaise, and fever. He is having 10/10 pain in his lower back. He is walking semi-hunched over with little steps. He is given 10mg Morphine, Naproxen, and gravol and scheduled for a CT the next day. Bloodwork is normal overall with slightly elevated WBC. Vitals are normal X-Ray of lumbar is normal..... as interpreted by the smalltown family medicine doc. The next morning the patient awakens with pain shooting down his right leg and numbness to the bottom of his right foot. 2 Link to comment Share on other sites More sharing options...
MariB Posted April 14, 2013 Share Posted April 14, 2013 (edited) MRI? I know when my Discs in neck acting up my fingers buzz and go numb. Sciatic Nerve? Edited April 14, 2013 by MariB Link to comment Share on other sites More sharing options...
medicgirl05 Posted April 14, 2013 Share Posted April 14, 2013 Significant trauma? Which came first, the back pain or the fever? A herniated disc causing pressure on the sciatic nerve could cause the foot problem, but I'm thinking the fever and elevated white blood count are significant... Infection causing pressure on the sciatic nerve? What does the CT show? Link to comment Share on other sites More sharing options...
mobey Posted April 14, 2013 Author Share Posted April 14, 2013 The CT is cancelled, he is being transferred to a big city centre to be assessed by neuro and expedited CT. 2 Years ago he did hurt his lower back lifting concrete. Fever/sniffles came on 2 days prior to backpain. Link to comment Share on other sites More sharing options...
RSI Posted April 14, 2013 Share Posted April 14, 2013 (edited) ASSESSMENT Pre-existing medical history: Aside from the spinal injury, does this patient have diabetes or anything significant? Has this ever happened before (the pain/numbness)? Current medications? Lower back pain relieved by meds? How much exercise does the patient get? PHYSICAL EXAM What does the skin on his affected leg look like? Intact pulses on his right foot? Palpation of his lower spine? Does right leg pain increase on movement or constant? DDX DVT or Claudication secondary to - Peripheral Artery Disease or Lumbar Spinal Stenosis? I believe his WBCs will be elevated due to his sickness and the inflammatory response may or may not be the cause of his symptoms (not good enough at pathophysiology to guess). I believe the signs/symptoms of his leg pain/history, associated back pain, and medical history may tell a lot before he gets the new CT scan. Thanks for doing this, mobey! Edited April 14, 2013 by RSI Link to comment Share on other sites More sharing options...
ERDoc Posted April 14, 2013 Share Posted April 14, 2013 Fever, back pain and neuro deficits. Uh oh, this is bad. Any hx of drug use? Link to comment Share on other sites More sharing options...
DartmouthDave Posted April 14, 2013 Share Posted April 14, 2013 Hello, With a history of malaise (fever, runny nose, fever) he could have GBS. Back pain, neurovascular compromise of his right leg could be an AAA. What is his BP like? Cheers Link to comment Share on other sites More sharing options...
HellsBells Posted April 15, 2013 Share Posted April 15, 2013 he could have GBS. Gastric Bypass Surgery? Gay Bowel Syndrome? Link to comment Share on other sites More sharing options...
scubanurse Posted April 15, 2013 Share Posted April 15, 2013 Guillain Barre Syndrome (GBS) Link to comment Share on other sites More sharing options...
mobey Posted April 16, 2013 Author Share Posted April 16, 2013 (edited) ASSESSMENT Pre-existing medical history: Aside from the spinal injury, does this patient have diabetes or anything significant? Has this ever happened before (the pain/numbness)? No, No, No Current medications? Tylenol/Advil PRN for intermittent back pain since hurting it originally Lower back pain relieved by meds? Somewhat tollerable...... not really. 20MG Morphine IV made it a 3/10 How much exercise does the patient get? Average amount for a laborer PHYSICAL EXAM What does the skin on his affected leg look like? Human, and unremarkable Intact pulses on his right foot? Yes Palpation of his lower spine? will not let you near it out of fear it will hurt Does right leg pain increase on movement or constant? Constant DDX DVT or Claudication secondary to - Peripheral Artery Disease or Lumbar Spinal Stenosis? I believe his WBCs will be elevated due to his sickness and the inflammatory response may or may not be the cause of his symptoms (not good enough at pathophysiology to guess). I believe the signs/symptoms of his leg pain/history, associated back pain, and medical history may tell a lot before he gets the new CT scan. I believe you may be on the right track Thanks for doing this, mobey! ER Doc: No drug use. Dave: Finally I am starting to think slightly more like you! GBS was also my 1st thought. His BP is equal bilat. The patient states the pain is like a electric shock going from his right buttox down to his ankle, then no feeling at all on the bottom of his foot. Ankle reflex is absent. Now that some pain is decreased you ask him to stand, which he does and can do so unassisted. He is not willing to try walk for fear of falling, and he is unable to bend his knee while standing stating "It feels like my foot is too heavy to get off the floor" Edited April 16, 2013 by mobey Link to comment Share on other sites More sharing options...
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