Moderator ventana Posted January 28, 2011 Moderator Share Posted January 28, 2011 To be completely honest, I didn't ask about chiropractic manipulation... but, I will definitely do so in the future! I would assume that he hasn't though. No history of chronic neck/back pain. don't worry that was a 'joke' with another thread.... but still an okay question Link to comment Share on other sites More sharing options...
eze8923 Posted January 28, 2011 Author Share Posted January 28, 2011 Fever and tachycardia. Can't fake or lie about those. Epidural abscess? How about a CT or MRI of Cervical and thoracic spine. sorry guys, i've been meaning to post more info for you all. so yeah, i guess the big take away from this case ended up being... respect the vitals. if he hadn't been running a temp and tachy, we might have very well sent him home in a hurry with the usual without much more of a w/u. nonetheless, here are some of the labs requested... --- CBC --- WBC 20.5 K/cmm (H) RBC 4.95 M/cmm Hgb 14.3 g/dL Hct 42.5% MCV 85.8 fL MCH 28.8 uug MCHC 33.6 gm/dL RDW 13.1% PLT 255 K/cmm ESR 24 mm/hr NEUT % 86.4% (H) LYMPH % 6.3% (L) MONO % 7.1% EOS % 0.1% BASO % 0.1% NEUT # 19.5 K/cmm (H) LYMPH # 1.43 K/cmm MONO # 1.60 K/cmm (H) EOS # 0.03 K/cmm BASO # 0.01 K/cmm --- CHEM PROFILE --- Glucose 117 mg/dL (H) Na 141 mmol/L K 4.2 mmol/L Cl 103 mmol/L CO2 28 mmol/L BUN 12 mg/dL Creatinine 1.16 mg/dL Ca 9.8 mg/dL Alk phos 110 IU/L T. Bilirubin 1.4 mg/dL (H) D. Bilirubin 0.1 mg/dL AST 28 IU/L ALT 46 IU/L Albumin 3.4 g/dL (L) Protein 6.6 g/dL TSH - pending (actually, don't think we ordered this, but it would be pending anyway) Cardiac enzymes - don't think we initially ordered these, and i don't remember the result if we did. nonetheless, not indicated for diagnosis this time. Amylase/lipase - not initially ordered either, and don't remember if so. PA/lateral CXR: no acute infiltrate. elevation of left hemidiaphram. Pain meds on board - we ended giving IV ketorolac 15 mg x1, IV lorazepam 1 mg x1, followed by morphine later down the road. Tox screen - negative EKG - sinus tachycardia without any acute ischemia/infarction. i'll throw in a couple more too: Lactic acid 1.0 mmol/L Rapid HIV - non-reactive i'll hold off on more imaging at this point, but curious what everyone's thoughts were at this point... thanks for the discussion so far! Link to comment Share on other sites More sharing options...
bradtPA Posted January 29, 2011 Share Posted January 29, 2011 Abnormal CXR with elevation of the left hemidiaphram, and very high white count with a left shift. Looks like his belly is infected somewhere with referred pain to the neck. Posssibly a bowel perforation, a CT of the abdomen and pelvis would help.... Link to comment Share on other sites More sharing options...
VictoriaO Posted January 29, 2011 Share Posted January 29, 2011 Ok, I'm a big ID buff so I'm gonna throw some out here onto the differential: Infectious: TB lymphadenitis (scrofula) usually unilateral and cervical, most common site is SCM muscle. Wouldn't quite present so acutely though. Localized bartonella from cat-scratch actinomycosis (would have likely noticed symptoms beforehand) Lemierre's syndrome (septic thrombophlebitis of a vein) Erythema nodosum Diaphramatic abcess Any surgical hx on this guy (his belly ever been sliced)? Link to comment Share on other sites More sharing options...
eze8923 Posted January 29, 2011 Author Share Posted January 29, 2011 Any surgical hx on this guy (his belly ever been sliced)? no abdominal or any surgical history. Link to comment Share on other sites More sharing options...
VictoriaO Posted January 29, 2011 Share Posted January 29, 2011 no abdominal or any surgical history. Whoops, missed that. Sorry. Link to comment Share on other sites More sharing options...
eze8923 Posted January 29, 2011 Author Share Posted January 29, 2011 Abnormal CXR with elevation of the left hemidiaphram, and very high white count with a left shift. Looks like his belly is infected somewhere with referred pain to the neck. Posssibly a bowel perforation, a CT of the abdomen and pelvis would help.... wouldn't necessarily consider a perforation or an isolated primary abdominal process given a completely benign abdominal exam though, no? we did end up eventually lighting the abdomen and pelvis up, but for other reasons. Link to comment Share on other sites More sharing options...
eze8923 Posted January 29, 2011 Author Share Posted January 29, 2011 Lemierre's syndrome (septic thrombophlebitis of a vein) oh no worries! thanks for adding to the discussion... you guys are getting warmer. confirmatory study of the diagnosis has already been indirectly mentioned, and so i'll post the results shortly. lemierre's syndrome! not for this one, but have come across this one as well. interesting thought! a didactic student might very well know this one... any anatomy buffs? Link to comment Share on other sites More sharing options...
discogenic Posted January 29, 2011 Share Posted January 29, 2011 Splenic abscess? CT would confirm it. Link to comment Share on other sites More sharing options...
bradtPA Posted January 29, 2011 Share Posted January 29, 2011 wouldn't necessarily consider a perforation or an isolated primary abdominal process given a completely benign abdominal exam though, no? we did end up eventually lighting the abdomen and pelvis up, but for other reasons. It just seemed a likely source for that abscess lifting up the diaphragm:), and I have seen my share of crazy things to not completely rule it out. I had a 77 y/o patient six months ago with nausea as the c/c with pain the day before but none now show a sealed perforation from a ruptured small bowel diverticulitis... Link to comment Share on other sites More sharing options...
eze8923 Posted January 29, 2011 Author Share Posted January 29, 2011 It just seemed a likely source for that abscess lifting up the diaphragm:), and I have seen my share of crazy things to not completely rule it out. I had a 77 y/o patient six months ago with nausea as the c/c with pain the day before but none now show a sealed perforation from a ruptured small bowel diverticulitis... fair enough... i had a feeling there was a story behind your suspicion. :) Link to comment Share on other sites More sharing options...
VictoriaO Posted January 29, 2011 Share Posted January 29, 2011 Splenic abcesses are also common in IVDU, though our guy supposedly hasn't been using for a long time. (That's what "seeded" the diaphramatic abcess in my ID differential) ;) Link to comment Share on other sites More sharing options...
jmj11 Posted January 29, 2011 Share Posted January 29, 2011 Interesting case. I would say, pain in left C 2-3 location including left phrenic nerve involvement + fever + leukocytosis - clear belly on exam = epidural abscess at the left C2-4 area. Probably from recent IV drug use. Thanks for posting this. Mike Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 29, 2011 Moderator Share Posted January 29, 2011 Agree with mike- epidural abscess at the top of my differential as well...mri is the modality of choice... Link to comment Share on other sites More sharing options...
eze8923 Posted January 29, 2011 Author Share Posted January 29, 2011 Fever and tachycardia. Can't fake or lie about those. Epidural abscess? How about a CT or MRI of Cervical and thoracic spine. so we're pretty much to the end of this... no MRI capabilities immediately accessible, but went with the neck CT, which reported the following... Neck CT: The retropharyngeal space shows a questionable early retropharyngeal abscess versus phlegmonous collection measuring 6 mm in thickness. This extends from the level of the C2 vertebral body down to the level of C5. followed it up with CT of the head, chest, abdominal, pelvis... Head CT: Normal brain. No acute intracerebral abnormality. Chest/abdomen/pelvis CT: Multiple pulmonary nodules in the lungs. There is an infiltrate in the left lung base. Primary consideration is infectious etiology. Consider septic emboli versus fungal or mycobacterium etiology. appropriately followed these findings by starting ceftriaxone and vancomycin after blood cultures x3, which ended up growing MRSA. dilaudid added on top of everything so far for pain. ENT consult and sent upstairs from the ED. was ultimately determined to be non-surgical and was eventually d/c'ed to SNF for IV abx. that's the last i heard of this case... ED Diagnoses: [478.24] Retropharyngeal abscess [995.90] Systemic inflammatory response syndrome, unspecified [723.5] Torticollis, unspecified [401.9] Essential hypertension, unspecified in retrospect, i think the acute onset of pain was a big factor that initially threw us a curve, in addition to the lack of oropharyngeal findings. nonetheless, in presenting this case to the attending, the "distant" IVDU and fever that apparently was repeatedly confirmed the hunch. sorry if i didn't do a perfect job at it, but this guy was more on the "sick" end of the spectrum that was in obvious discomfort... even though his complaints seemed relatively benign. i just remember initially grabbing the chart thinking... oh wonderful, this should be a quick MSK-type case given the complaints that perhaps resembled cervical radiculopathy. but just couldn't get around those vital signs... on a separate note, the pulmonary findings were an interesting addition as well. i'm sure everyone has had their share, but another important point to remember is that a CXR doesn't catch a whole bunch of pathology and/or radiology report shouldn't replace clinical judgment and findings. (e.g. just because the report suggests pneumonia in a 40 pack year hx smoker, doesn't mean that a f/u chest CT is then read as malignancy :)) hope this was a worthwhile case to share. Link to comment Share on other sites More sharing options...
discogenic Posted January 29, 2011 Share Posted January 29, 2011 Thanks for your efforts! Interesting case. Link to comment Share on other sites More sharing options...
Moderator ventana Posted January 29, 2011 Moderator Share Posted January 29, 2011 ahh I love thinking! thanks!!!!!!!!!! Link to comment Share on other sites More sharing options...
cobramarty Posted January 29, 2011 Share Posted January 29, 2011 Great case! Most patients are poor historians and lie. They want narcotics, work release note, attention and it is hard to tell the fakes from the real patients. The only truths patients ever seem to tell is smoking history, everything else they leave out or lie. But the basics are the truths. Vital signs. I am more and more relying on them for help. HR is especially important and you better be able to explain any abnormalities. Temp, BP, orthostatic and Pulse ox. Can't fake these. If you try and justify to yourself an abnormal value you better think twice and look into it. This patient if they came in at 2am and I was tired or would have been triaged to fast track, I would have wanted to kick them out with pain meds but I would have wondered/worried about that temp and HR. Good for you to order lab tests on Muscular/Skeletal type sx. Link to comment Share on other sites More sharing options...
VictoriaO Posted January 29, 2011 Share Posted January 29, 2011 Great case! Please bear with me as a student learning the diagnostic w/u ropes, but would anyone else have ordered a sed rate with the initial bloodwork? (Just to point towards pus under pressure somewhere vs. other origins of the pain) Link to comment Share on other sites More sharing options...
Piper Posted February 1, 2011 Share Posted February 1, 2011 Great case! Added more learning points to my arsenal. Thanks. Link to comment Share on other sites More sharing options...
eze8923 Posted February 1, 2011 Author Share Posted February 1, 2011 Great case! Please bear with me as a student learning the diagnostic w/u ropes, but would anyone else have ordered a sed rate with the initial bloodwork? (Just to point towards pus under pressure somewhere vs. other origins of the pain) *putting on my wanna-be clinical preceptor hat* ;) not quite sure what you are trying to getting at, or what more info an ESR would give you to benefit yourself diagnostically in a guy like this... what did you have in mind? Link to comment Share on other sites More sharing options...
cobramarty Posted February 1, 2011 Share Posted February 1, 2011 Maybe fever, tachycardia and slightly elevated sed rate means something is going on, they are all non-specific, vague indicators of something, so don't dismiss them and keep digging and looking. At least be able to explain them. Fever b/c he just drank a cup of coffee, tachycardia b/c he is in pain, ESR b/c it's winter/he had a cold last week/he is coming down with a cold. 3 independent explanations when 1 common explanation will explain all three findings. I'm not a probability expert, but... Link to comment Share on other sites More sharing options...
eze8923 Posted February 2, 2011 Author Share Posted February 2, 2011 some of my preceptors swore by it, but i guess that i'm not a huge fan of ordering an ESR unless i'm looking for findings to support ruling out badness, so to speak. nonetheless, as mentioned, even then it's definitely not an end-all-say-all and more or less is another non-specific inflammatory marker... that in this particular case, i think most would assume is elevated. and, more food for thought... if you end up ordering an ESR on everyone, and it happens to be elevated on someone you don't expect it to be, now what are you gonna do to explain it?! :) Link to comment Share on other sites More sharing options...
bradtPA Posted February 2, 2011 Share Posted February 2, 2011 Also, an ESR is not a STAT lab (takes about an hour to run), so it's usually not performed in the ED. Link to comment Share on other sites More sharing options...
jmj11 Posted February 2, 2011 Share Posted February 2, 2011 Also, an ESR is not a STAT lab (takes about an hour to run), so it's usually not performed in the ED. You can speed it up a bit with a centrifuge:=D: Link to comment Share on other sites More sharing options...
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