Monday, 5 October 2009

A Case for October 2009

Dear Bloggers

A 65 year old retired lady school teacher was admitted to a hospital with a one-week history history of fever and back pain.

The back pain had started gradually over a few days and was worse on movement. Initial pain scale was 3/10 but over several days it worsened. The pain was described as sharp and there was no radiation to the lower extremities.

The fever was continuous and she had episodes when she felt very hot. She did not have a thermometer so she could not provide any home readings. However, she did admit to night sweats and shivering during the fevers.

The patient went to see her local physician who thought this was a 'common cold' with myalgia. The doctor had not formally examined the patient. Some simple anti-pyretic medication was prescribed.

Over several more days the back pain became increasingly worse reaching 10/10 and the patient found it difficult walking up stairs and standing from a crouching position. She also found it difficult to pass urine. When she was admitted to the hospital but was unable to walk, thereby requiring a wheel chair.

She denied thigh pain and joint pains. She denied frequency, dysuria, nocturia and haematuria.
There was no history of upper respiratory symptoms. She denied headache, photophobia, neck stiffness or rash. There were no other abdominal symptoms.

She had a previous medical history of poorly controlled diabetes mellitus and bilateral renal calculi diagnosed several years, the latter which were under observation. She also had a history of a urinary tract infection 8 years ago.

Medications included metformin 1 gram twice daily, aspirin 75mg daily and recent use of acetaminophen when required.

She had no relevant family or social history.

She was post-menopausal from fifteen years before. She had an otherwise previous normal menstrual history without problems. She denied any post-menopausal bleeding or abnormal discharge or pus. She was not sexually active.

There was no history of foreign travel, interaction with sick contacts or recent dental work. She had no pets and did not have any unusual hobbies. She was a non-smoker and non-drinker.

On Examination

She appeared ill. GCS 15/15. Alert.

No J A C C O L. Temp 38.4 deg C

CVS: pulse 120 min regular, BP 100/50mmHg, JVP not elevated, no heaves or thrills, normal heart sounds I + II, no 3rd/4th heart sounds. No extremity edema.

RESP: RR = 18/min, SpO2 - 98% breathing ambient room air, trachea central and no tug, expansion within normal limits, and percussion note resonant. Auscultation revealed no crackles or wheeze.

ABDO: Soft and non-0bese abdomen. Suprapubic area revealed a globular distension, tender to palpation, percussion note was dull and there were no bowel sounds in this area. No rebound or guarding. No hernial orifices were identified. No hepatosplenomegaly. Otherwise, normal bowel sounds. Rectal examination- hard stool ++, no FOB. Patient was unable to grip the examiners finger with her anus.

CNS: No focal abnormality. No neck stiffness or jolt accentuation. Kernig's sign could not be performed because of back pain. Brudziki sign was negative.


  • Tone normal upper limbs but decreased in the lower limbs.
  • Power - normal upper limbs 5/5. Proximal lower limbs muscles 3/5 especially in hip flexion and extension. Distal lower limbs were mildly weak with power 4+/5 bilaterally.
  • Reflexes - normal in the upper limbs. Knee jerks were absent and mildly present in the ankles. Babinski were bilaterally absent (no reaction).
  • Coordination - upper limbs were normal. Difficult to elicit in the lower limbs because of weakness.
  • Sensation - light touch, nociception, vibration and joint position sense were within normal limits.

Musculoskeletal exam - tender spine and muscles from L1-L5 region. Extension of the proximal limbs induced severe pain. Other muscles were non-tender.

Lab Data - revealed a leukocytosis but otherwise, liver and renal blood tests were normal. No urine analysis was available.

Blood cultures revealed E. coli and Klebsiella pneumoniae in two sets of bottles.

Radiology - An abdominal CT scan was performed which apart from other abnormalities reported of seeing gas in the soft tissue.

Question 1: From the history, physical exam, limited laboratory and radiology data, what is your differential diagnosis?

Question 2: What emergency radiology test will you do next?

Question 3: Where is the potential origin of this problem?

Question 4: What emergency treatment(s) will you consider in this patient?

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