There is accommodation throughout this section to reflect on your own assessment and treatment plan for this patient. Take Time out to have a think!
Case study :
A 49 yr old man attended A&E complaining of lower back pain
PMH: alcohol excess, nil else
Drug History- Nil
Social history: Manager in the retail industry, married with 2 children. Car driver. Non smoker
Allergies: Nil
Description of pain. – Isolated to lumbar spine, exaggerated on hip flexion.
Duration: had been present of 2 days.
Had tried simple analgesia but with little effect. All vital signs were within normal parameters
Diagnosis: Sciatic type pain +/- possible prolapsed intravertebral disc (PID)
Plan: discharge from A&E with Tramadol, NSAID and low dose diazepam.
Time out:-- Do you agree with this?. What would you do differently?
3 days later attended a different DGH within the same locality. Pain now much worse and extending into left side, left arm and left leg. Additionally had developed haematuria and started to vomit. No fever, vital signs remained unremarkable. Chest was clear. Bowel sounds were present, abdomen was soft, but was tender at left iliac fossa.
2nd diagnosis: Urethral colic +/- UTI
Differential diagnosis: possible hepatitis secondary to alcohol misuse.
Plan:
• IV fluids
• Check all routine bloods
• Urinalysis showed blood +++, protein +++ nitrate negative
• AXR- NAD
• Admitted to urology with orthopaedic opinion requested.
Blood results:
Hb 12.2
WCC 14.0
Platelets 130
Na+ 133
K+ 3.9
Cl 93
Hco3 30
U 9.6
Cr 103
AST 114
ALT 112
A.Phos 228
GGT 423
Bilirubin 66
Total Prot 63
Time Out: Do you agree with the diagnosis now? Is there anything you would add?
Hospital at Night (H@N) review
Asked to see patient as a result of pyrexia: temp. 39.9oC
MEWS 3
A—patent, could complete sentences. A/E good to all area, no additional sounds or rubs. Trachea central. No productive cough.
B—R/R 18 Sats 99% on room air
C—H/R 102 BP 130/85, CRT normal – H/S 1+2+0 – no heave or thrills present,
JVP ó
D- Temp 39.9, Avpu, passing urine spontaneously, BM 4.7mml
E- Abdo—
• inspection unremarkable
• Auscultation, - bowel sounds present, no bruit heard over renal, aortic or femoral distribution.
• Palpation- tender over left iliac fossa, extending from left mid intercostals to medial aspect left thigh.
• Percussion- unremarkable- no shifting dullness or other signs of ascities
• Unable to fully extend arms or legs, worse on left side.
• Hands showed some evidence of palmer erythaema
• No splinter haemorrhage
• Full neurological assessment difficult
• Planters down going—no sign of clonis
• Spine: midline – non tender-
• No pain in C. spine
• Poor range of movement
• Unable to weight bear.
Differential Dx.
1:- Possible sepsis- consider biliary pathology
Plan: continue current care, plus check amylase & arrange Liver & abdo U/S
2:- Possible atypical neurology
Plan: Arrange head C/T
3:- alcohol related
Plan: add Pabrinex, PPI cover and CIWA
Time Out: From what you know now what is your diagnosis?
Scan Results:
Head C/T- NAD
• Abdo /pelvis: Marked enlargement of the left iliopsoas muscle with inflammation spreading around the adjacent common & external iliac vessels.
• Multiple peripheral wedge shaped infiltrates in spleen indicative of infarcts
• Other organs normal
Definitaive Dx.
• Primary source of infection of the iliac psoas muscle
• Splenic changes infracts from septic emboli
Treatment Plan amendments:
Abx. Gentamicin, Flagyl, Amoxicillan, Flocloxacillan
Cardiac ECHO- showed no evidence of SBE
MRI- spine & pelvis- showed no infiltrates.
Following this considerably more extensive plan of investigation and treatment the patient did well and made a full recovery. He additionally accepted help to overcome his alcohol problem.
His presentation for this condition was unusual. His diagnosis ranged from sciatic type back pain – to alcohol related condition. However the correct diagnosis was uncovered and the correct treatment put in place.
Written by: Elaine Headley. 12/12/10