Visited ER at 03:21
A 66 Year-Old Man with abdominal pain
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主述:右腳截肢疼痛,腹痛
Triage III
TPR 35.3/89/18 BP 106/54 SpO2 100%
E4V5M6
Ying-Lin,Tan, R1
Emergency Department, SKH
2013/01/09 Morning Meeting.
Consultant:Vs Yang yu- Jeng
Present illness
Chief complaints
• Abdominal pain for 2 days
• Abdominal pain for 2 days
Below umbilicus,back pain(+).
大小便解不出來
Past History
• Past History
~Poor controlled DM
~Right DM foot s/p BK amputation
• No known drug allergy
PE
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Conscious clear
Pale conjunctiva
BS clear
Soft. Tender over lower abdominen.
No knocking pain over CVangle.
• Right BK. Wound:clean.no erytheryma
• Anal tone:intact.
Impression & Management
• DDx
• Management
1. Abdominal pain,cause? • 03:35
– CBC.DC.PLT
2. R/o Anemia
– F/S(121)
3. Right leg pain,r/o – BUN/Cre/AST/NA/K
wound pain.
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Imaging
PT/APTT
IV N/S 60cc/hr
Morphine 4mg IV st
KUB,L‐spine
Stool OB
DRE(Yellow)
Management
• 04:14
Bedside echo:
No GB stone. No AAA. No hydronephrosis. No ascites. Distended bladder.
On Foley. U/A,U/C.
04:30 Initial Lab Report
危險值
• K=2.1
Blood
• WBC:10.6K,Seg:83.5%,Band:
4.5%
• Hb=6.7 gm/dl ( 11/30 9.4)
• Ht=19.9%
• RDW:17.3%
• PLt:100K
BUN:60
Cre:1.94.1
Na:135
• Stool OB: (‐)
Lab Urine analysis
• RBC:>100
• WBC:>100
• Epithelial cell:0‐1
• Bacteria +++
Management
1.Anemia:備輸pRBC 2U
2.Infection,UTI:
B/C X II ,Cefmetazole 1g iv st
VBG(G3),CRP
3.Acute renal failure
4.Hypokalemia:
• KCL 20meq in N/S 100cc IVD run >30 mins
• KCL 20meq po st
• KCL 20meq in N/S 500cc in run 60cc/hr
• Urine Cre,K,Na,osmolarity
• On monitor
• 排Nephro 住院,待轉EC.
5.Back pain,cause unknown
Data
• VBG G3:
PH:7.439 PCO2:35.9 HCO3:24.3 S02:98%
So?
• Lower abdominal pain to back pain:?
L2 compression fracture可以解釋嗎?
CRP:15
EC management. 09:14
Lower back pain
• 你想到甚麼DDx?
26~3 PS admission:Pneumonia,Wound infection,E/coli bacteremia
病人訴:3回家後背痛加劇,無法起來
如何DD with Lower back pain?
Abdominal CT
• T12 prevertebral abscess
• L2 oeteomyelitis
• Left psoas,illopsoas muscle abscess
• Pelvic dirty ascites.
Bone fracture?
Leukocytosis,CRPinfection
Spinal stenosis
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Further management
• Consult Infection,GU,NS
13:42 NS Dr: Supportive therapy and Abx.
Monitor lower limb muscle power
16:30 Uro Dr:Suggest medical therapy at first.
20:00 GU note
1.Antibiotic treatment first and medical treament first.
2.Surgical drainage may be arranged after antibiotic therapy
3.Correct ARF status
00:08 NS note
• Muscle Power:
Upper limb:Lt/Rt:4/4
Lower limb:Lt/Rt:2/3
‐>NS:Decreased muscl epowersuggest to arrange emergent L‐spine MRI if no contraindication. 09:49 Infection
Clinical Course
• May keep Oxacillin 2g iv Q6H and Ceftriaxone 2g iv Q12H
• Correct anemia,hypokalemia
• May discuss with NS Doctor again due to decreased muscle power.
• May discuss with Uro doctor for abscess drainage
23~25 ER EC‐>25 GU28 Seizure+desaturation‐
>DNR ‐>1/2 Expired
Lower back pain
Discussion
1.Approach to lower back pain
2.Psoas muscle abscess.
Uptodate:Approach to acute back pain in adult
TIntinallis:Chapeter:neck and back pain
Neurologic emergency
• Acute:<6weeks
• Emergent:
Abdominal aortic aneurysm,
Epidural compression syndrome
Lower back pain
1. Age:
18y/o:tumor,infection
50y/o:AAA,fracture,spinal stenosis,tumor
2. Pain Location and Radiation
To buttock& thigh:Sciatica ‐>disc herniation
3. Trauma
Minor trauma+Risk factor of osteoporosis
‐>fracture
Lower back pain
4. Systemic Complaints
•Fever, chills, night sweats, malaise, undesired weight loss •Risk factors: recent bacterial infection, urinary tract infection, or pneumonia; recent GU/ GI procedure; immunocompromised status; injection drug use; alcoholism, renal failure, diabetes.
Risk factors for osteoporosis :old aged female sex, steroid use, alcoholism.
Lower back pain
5. Pain Features
•Benign:improves with rest ,lying
•Red flag:night pain,BW loss,unrelenting pain
•Worsening by:Valsalva maneuver, sitting ‐>disk herniation.
•Neurologic claudication ‐> Spinal stenosis •Neurologic DeficitsBowel or bladder incontinence (overflow incontinence)
Back to our case
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Age>50 y/o, DM,back pain:
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Trauma history(‐),X‐ray:osteolytic change in L spine,elevation CRP(ESR?),DM infection(osteomyelitis)
Back pain+UTI+poor response ti TxPsoas muscle abscess
Osteomyelitisextension to psoas,illopsoas m.Spinal cord involvement(?)
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Psoas muscle abscess
• Primary VS Secondary.
Primary abscess
Secondary psoas abscess
• Hematogenous or lymphatic seeding • Risk factors :diabetes, intravenous drug use, human immunodeficiency virus (HIV) infection, renal failure, and other forms of immunosuppression. Trauma,hematoma formation
• Most prevalent in older patients.
• In Taiwan, 2 retrospective reviews were carried out, and 20 % were classified as having primary abscesses.
• Direct spread of infection to the psoas muscle from an adjacent structure. • Risk factors :trauma ,instrumentation in the inguinal region, lumbar spine, or hip region.
Microbiology
• Primary :Staphylococcus aureus.
• Secondary:monomicrobial or polymicrobialenteric organisms ,Anaerobes
• Klebsiella pneumoniae is an important cause of psoas abscess in Taiwan, especially in patients with diabetes.
Thank You for your Attention!!!