a pain in the back copyright © 2013, all rights reserved from the publishers of
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A Pain in the Back
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Dear Consult Guys;
I need your advice in my care of a
patient with back pain.
I saw Mr. G earlier today for back
pain. I last saw him 3 weeks ago for
treatment of a “boil” located on his
back. He had a low grade fever but
otherwise seemed well.
I advised him to do warm soaks and
according to him the boil resolved….
Dear Consult Guys;
I need your advice in my care of a
patient with back pain.
I saw Mr. G earlier today for back
pain. I last saw him 3 weeks ago for
treatment of a “boil” located on his
back. He had a low grade fever but
otherwise seemed well.
I advised him to do warm soaks and
according to him the boil resolved….
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He returned today with 3 days of
back pain. He’s had no incontinence
or lower extremity weakness. There
was mild tenderness to palpation but
his exam otherwise normal. He is a
diabetic and his diabetes is well
controlled.
I’ve tried to be selective in ordering
imaging tests so in this case rather
than ordering an imaging test I
initiated anti-inflammatory medical
therapy and suggested that he see
me in follow-up in 4 weeks.
In thinking more about the case I am
just not sure that not ordering an
imaging study was correct . What
would you guys have done?
He returned today with 3 days of
back pain. He’s had no incontinence
or lower extremity weakness. There
was mild tenderness to palpation but
his exam otherwise normal. He is a
diabetic and his diabetes is well
controlled.
I’ve tried to be selective in ordering
imaging tests so in this case rather
than ordering an imaging test I
initiated anti-inflammatory medical
therapy and suggested that he see
me in follow-up in 4 weeks.
In thinking more about the case I am
just not sure that not ordering an
imaging study was correct . What
would you guys have done?
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ACP Guideline Published in 2011
http://annals.org/article.aspx?articleid=746774
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Back pain is very commonA selective approach to back pain
imaging is recommended
Key Points
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Indications for immediate imaging
Major risk factors for cancer as a
cause
Risk factors for spinal infection
Evidence of cauda equina syndrome
Urinary retention
Fecal incontinence
Saddle anesthesia
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Mr. G
Diabetic
Boil 3 weeks ago
Malaise
Tenderness L3-L4
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Epidural abscess
Identifiable portal of entry in 2/3 Spinal surgery Epidural catheter Skin – soft tissue infection Hematogenous (iv drug use)
Classic: fever + spine tenderness + neurologic Most not classic
MRI
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Consult Guys Replies
Mr. G’s presentation suggests epidural abscess
An MRI should be done
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