Triage: c/o low back pain– seen for same yesterday- worse today – denies dysuria

History of Present Illness: Patient is a female in her late 50’s with coronary artery disease, stents and HTN here for reevaluation of right upper back pain. Contrary to triage note, patient has no lower back pain. Was evaluated yesterday and the day before for the same symptoms. Atraumatic right upper back pain, worsening with movement. Possible pleuritic component as well. Denies fever/chills, headache, chest pain, shortness of breath, nausea/vomiting, abdominal pain, dysuria, diarrhea. No numbness/tingling/weakness of the extremities. Her symptoms initially improved after pain control in the ED yesterday but worsened overnight.

Vital Signs: T: 37.0 °C,  HR: 103,  RR: 35,   BP: 153/104,   SpO2: 99%

Physical Exam:

Resident exam: MSK: R trapezius and upper chest TTP.

Testing:

  • CBC: WBC 16 with 84% PMN, CRP 19, PCT normal
  • MRI: no root compression or SEA
  • CT C-spine: no acute osseous abnormalities. However, it did note left-sided opacities that may represent infection
  • CXR: possible small effusion but no visible infiltrate

Resident MDM: On evaluation, patient is nontoxic-appearing. Exam notable for right trapezius and upper chest tenderness. No shoulder tenderness. Ranging the shoulder fully but her pain is exacerbated with resisted movement of the shoulder. Lungs clear to auscultation bilaterally. Vitals within normal limits. Afebrile. Labs today shows a developing leukocytosis 16.3 from 15.7 yesterday. No anemia. No AKI or significant electrolyte/LFT abnormalities. Her CRP is elevated at 19.8. Patient had a complete cardiac workup done last night that was reassuring. Unlikely that her symptoms are caused by a cardiac process. Considered traumatic/infectious etiologies of her symptoms. X-ray right shoulder overall reassuring. CT C-spine showed no acute osseous abnormalities. However, it did note left-sided opacities that may represent infection. To evaluate for spinous infection, patient had an MRI spine survey with and without contrast which did not show any osseous abnormalities or signs of infection/abscess. Given findings on her CT, chest x-ray reordered. Independent read with possible right lower opacities. Given constellation of symptoms, leukocytosis, elevated inflammatory markers, and concern for pneumonia on imaging, treatment for community-acquired pneumonia started.

Attending MDM: Patient states pain is more triggered by using right arm then pleuritic but seems to be both. CT scan of the neck done for radiculopathy shows evidence of apical pneumonia but mostly on the left side, which is confusing. Chest x-ray shows questionable bilateral pleural effusions with possibly a infiltrate on the right. Will treat patient for pneumonia. Patient did get emergent workup for spinal epidural abscess due to symptoms concerning for radiculopathy with elevated inflammatory markers. Case discussed with hospitalist plan is for admission. Lead on the differential diagnosis at this time is pneumonia but entire clinical picture not entirely clear.

What additional testing is indicated?

  • A) None
  • B) Drug screen
  • C) CT brain
  • D) Lumbar puncture

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What additional testing is indicated?

 

 

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CASE CONCLUSION: CT chest showed septic emboli.  Blood culture grew gram-positive cocci in clusters, 4 out of 4 bottles. Patient on IV ceftriaxone and azithromycin for CAP so vancomycin added.  echocardiogram to evaluate for endocarditis.

CASE LESSONS: