Monday, April 18, 2011

Intern Report Case Presentation 3.8


Case Presentation by Dr. Dan Paling


History and Physical
61-year-old obese male was sent to the local Emergency Department by his primary care physician with a complaint of low back pain. He reported a history of intermittent, worsening low back pain over the past 2 months. The patient experienced pain with movement of his low back.  The pain was characterized as dull, aching, and rated 6-7/10 in intensity located at the level of L3-L5. He patient denied any radiation of the pain down his legs, but admitted that sitting and standing for long periods aggravated his pain. He denied recent or remote falls and/or trauma to this region of his back. The patient denied urinary or fecal incontinence. He stated that he had similar pain about one year ago and was treated for a lumbar muscular strain. The patient felt that he has had fevers intermittently over the past 3 months for which he took acetaminophen. He denied any complaint of chest pain or shortness of breath. He also reported having occasional epigastric abdominal pain with nausea, but no vomiting. He attributed this to a history of heartburn.

Past Medical History:  hypertension and peripheral artery disease.  No surgical history
Medications:  hydrochlorothiazide and metoprolol, but has been noncompliant. 
Social History:  40-pack-year tobacco, currently smoking 4 to 5 cigarettes a day. 

Physical Examination:  BP is 184/112, HR 78, RR 15, Temp 38.2 (oral), O2 Sat 95% on RA. 

General appearance:  mild distress secondary to pain. 
HEENT: AT/NC, PERRL, EOMI
CV: RRR, S1 S2, no m/r/g
Resp: CTAB/L, equal breath sounds, no wheezes or ronchi appreciated
ABD: obese, soft, diffuse tenderness to palpation worse in the umbilical region, no rebound or guarding, no CVA tenderness
Extremities: 2+ distal pulses present in all extremities, no cyanosis, clubbing, or edema
Rectal exam:  guaiac negative, normal tone, no masses
Neuro: strength 5/5 bilaterally in all extremities, no sensory or motor deficits, straight leg test positive bilaterally at 60 degrees of hip flexion, reflexes 2+ b/l 
Musculoskeletal:  point tenderness over spinous processes of L3, L4, and L5, no soft tissue pain

Laboratory Results
WBC 21, Hb 13.6, Platelets 426, Na 134, K 4.5, Cl 102, CO2 content 23, BUN 28, Cr 1.1
ALT 35, AST 38, Alk Phos 98, Lipase 23, Lactate 0.8 

Diagnostic Studies
EKG:   


Acute abdominal Series is unremarkable. No free air. No evidence of obstruction 

MRI Lumbar Spine:  as shown…

Interpretation:  Osteomyelitis of L3 and L4 vertebral bodies. Inflammation extends into adjacent structures including the abdominal aorta. Marked dilation of the abdominal aorta at approximately 4 cm in diameter showing inflammatory changes of the vessel wall.

Questions

1.  Which of the following is a modifiable risk factor for developing an abdominal aortic aneurysm?
    1. alcohol abuse
    2. diabetes mellitus 
    3. stress
    4. insomnia
    5. tobacco smoking


2.  Which of the following cases requires medical management ONLY?
    1. AAA that has enlarged from 3.0 to 3.7cm over the past 6 months 
    2. AAA that has enlarged from 4.7 to 5.0cm in the past 6 months
    3. 55 YOM with newly diagnosed symptomatic 4.5cm infrarenal AAA 
    4. 65 YOM with asymptomatic 5.7cm infrarenal AAA
    5. 71 YOM with ruptured 5.0cm AAA exhibiting good mentation and stable vital signs

3.  Which is the most important predictor of AAA rupture?
    1. advanced age
    2. aneurysm diameter
    3. expanding AAA
    4. family history of AAA rupture
    5. female gender  
Please submit your answers as a comment. 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

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