Identifying Data :

Full Name: Mr. TD

Address: Manhassat, NY

Date of Birth: 12/1/52

Age: 69 yo

Date & Time: September 15, 2022 12:30 pm

Location: Northshore University Hospital, New York, NY

Religion: None

Source of Information: Self

Reliability: Good

Source of Referral: Orthopedics

Chief Complaint : “Worsening low back pain,” x 3 weeks. 

History of Present Illness

69 yo male patient with a PMHx of hypertension and  hyperlipidemia and  presents to the ED by orthopedic referral for worsening low back pain x3 weeks. Patient states he had been experiencing low back pain rated a 2/10 for about a year that was alleviated with rest. However, the pain significantly exacerbated in the last 3 weeks that prompted him to see an orthopedic. He describes the pain as dull, rated a 7/10, and constant. Patient reports that the orthopedic for a left iliac bone lesion and compression deformity of T12. He explains his orthopedic highly recommended that he present to the ED for metastatic workup. He was also prescribed 5mg oxycodone with no relief of symptoms. Patient endorses smoking cigarettes for 40 years.  Denies trauma to the area, unintentional weight loss, fever, night sweats, changes in vision, headache, body aches, or numbness and weakness in the lower extremities.

Past Medical History

• Hypertension
• Hyperlipidemia

Past Surgical History

• N/A

Medications

• Atorvastatin (Lipitor) PO 10 mg 
• Metoprolol (Lopressor) PO 50 mg

Allergies

• No Known Allergies

Family History

• Son – age 40, alive, hypertension, asthma
• Daughter – age 37, alive
• Sister – age 73, alive, hypertension
• Endorses family history of hypertension. Denies family medical history of cancer or respiratory complications. 

Social History

Patient is a married 69 year old male who currently resides in a home with his wife in Manhasset, NY. Patient is retired and lives a moderately active lifestyle by doing yard work and going for walks.

Habits : Endorses smoking cigarettes for 40 years. Denies drinking, use of drugs, or use of parijuana marijuana.

Travel : Denies recent travel. 

Diet : Patient eats a balanced diet of carbs, protein, and vegetables.

Exercise : Patient maintains a moderately active lifestyle.

Sexual History : Heterosexual, married, and not sexually active in the last year. Denies history of sexually transmitted diseases.

Review of Systems

General – Male patient appears alert, good pallor, and in mild distress with movement. Denies recent changes to appetite, fever, constipation, and diarrhea.

Skin, hair, nails – Denies erythema, edema, dryness, pruritus, sweating, scars, lacerations, lesions, or moles.

Head – Denies headaches, dizziness, head trauma, coma, or fractures. 

Eyes – Uses reading glasses. Denies visual disturbances, lacrimation, photophobia, or pruritus. Last eye exam – 2 – 3 years ago.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids. 

Nose/sinuses – Denies discharge, obstruction, or epistaxis. 

Mouth/throat – Denies use of dentures. Denies difficulty swallowing, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – 1 year ago. 

Neck – Denies stiffness, pain, swelling, and limited range of motion.

Breast – Denies lumps, pain, or discharge.

Pulmonary System – Denies dyspnea, dry cough, wheezing, hemoptysis, cyanosis, or paroxysmal nocturnal dyspnea (PND). 

Cardiovascular System – History of hypertension. Denies chest pain, palpitations, syncope, and edema.

Gastrointestinal System – Denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, pyrosis, hemorrhoids, constipation, rectal bleeding.  

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain. 

Nervous System– Denies seizures, headache, or loss of consciousness.

Musculoskeletal System – Endorses full range of motion with discomfort of the lower back. Denies numbness or tingling. Denies ecchymosis, atrophy, or deformities in bilateral upper and lower extremities.  

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – Denies ecchymosis, lymph node enlargement, history of anemia, history of DVT/PE. 

Endocrine System – Denies polyuria, polydipsia, polyphagia, history of hyperthyroidism, history of hypothyroidism, goiter, heat or cold intolerance, or excessive sweating.

Psychiatric – Denies history of depression or anxiety. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam

General: Male patient appears alert, good pallor, and in mild distress with movement. Appears well-developed, well-nourished, and hydrated. Appears stated age.

Skin: Warm, good turgor, and poor pallor. Non-icteric, no scars, lesions, masses, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is full, average texture, and average luster.

Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus. 

Visual Acuity : Corrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU. 

Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with a good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. 

Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures. 

Mucosa: Pink, dry. No mass or lesions noted. No leukoplakia. No thrush.

Palate: Pink, dry. No lesions, masses, scars.  

Teeth: White and no cavities. 

Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge.

Tongue: Pink, well papillated. No masses, lesions, or deviation.

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0.  Uvula pink, no edema.

Neck – Full range of motion and non-tender to palpation. Trachea midline. No masses, lesions, scars, pulsations noted.  No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – No goiter or lumps. Non-tender to palpation. 

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds.

Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdominal: Abdomen flat and symmetric with no scars, striae  or pulsations noted.  Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits.  Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated

Genitalia:  Unable to obtain without chaperone. 

Rectal:   Unable to obtain without chaperone. 

Neurologic: 

Mental Status: Patient is alert, oriented, and attentive. Speech is clear and fluent. 

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract. 

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.

CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact. 

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in the anterior 2/3 of the tongue. 

CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

CN IX, X: Palate elevates symmetrically. Phonation is normal.

CN XI: Head turning and shoulder shrug are intact.

CN XII: Tongue is midline with normal movements and no atrophy.

Motor/Cerebellar :

Full range of motion, not accompanied with spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Coordination by rapid alternating movement and point to point intact bilaterally. No asterixis.

Sensory :

Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

R L R L

Brachioradialis 2+ 2+ Patellar 0 0

Triceps 2+ 2+ Achilles 0 0

Biceps 2+ 2+ Babinski neg neg

Abdominal 2+/2+ 2+/2+ Clonus negative

Meningeal Signs :

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.

Musculoskeletal : 

Full active range of motion of spine and extremities with discomfort. No soft tissue swelling, erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. No crepitus in all upper and lower extremities bilaterally. 

Vitals

Blood Pressure – 137/82, Temp – 97.8 °F, SpO2 – 99%, Respiratory Rate – 18, Heart Rate – 70, Height – 5’ 10”, Weight – 190 lbs, BMI – 27.3

Assessment & Plan

69 yo male patient with a PMHx of hypertension and  hyperlipidemia and  presents to the ED by orthopedic referral for worsening low back pain x3 weeks. Exam is positive for a full range of motion with discomfort. Patient experiences no relief of pain with outpatient prescription of 5mg oxycodone. Outpatient MRI showed a “4.4cm bone lesion on the left iliac” and “moderate compression deformity of T12 with narrow edema.” Patient may have a compression fracture but is also at risk of multiple myeloma and requires metastatic workup. 

Problem List :

• Low Back Pain 
• Hypertension
• Hyperlipidemia

D/Dx : 

1. Vertebral Compression Fracture – Patient presents with low back pain that has been present for the past year that was confirmed with outpatient MRI bony changes. In the best case scenario, the patient presents with a vertebral compression fracture due to older age, osteoporosis, or lifting of heavy objects rather than a metastatic cause. 

2. Multiple Myeloma – Patient presents with a vertebral compression fracture and bony lesion at the hip. A cancerous cause cannot be ruled out and must be thoroughly assessed. 

3. Lumbosacral Strain – Lumbosacral strain should be included as old muscle injuries can resurface with older age. However, the MRI changes, full range of motion, and presentation of pain suggests a different etiology of back pain. Lumbosacral strain should be considered but not prioritized as the main source of low back pain.

4. Spinal Osteoarthritis – Spinal arthritis causes low back pain due to deterioration of the cartilage in the joints of the spine. These changes were not observed on MRI but should still be considered when assessing an older patient for low back pain. This diagnosis also remains lower on the list as spinal osteoarthritis also presents with symptoms such as stiffness and radiating pain that is absent in this patient. 

5. Spinal Stenosis – Spinal stenosis is a significant contributor to low back pain. However, it also usually presents with muscle weakness, numbness, and tingling in the legs due to nerve compression. No signs of spinal stenosis were noted on the MRI either. For this reason, spinal stenosis should be considered but remains low on the list of differentials. 

Plan : 

Admit patient for metastatic workup. Obtain necessary imaging and lab studies. Consult hematology for bone biopsy and further workup. 

1. Admission
   1. Admit for metastatic workup. 

2. Blood Labs
   1. CBC – assess for leukocytosis, hemodynamic stability
   2. CMP – asses for calcium excretion, kidney function

3. MRI
   1. Obtain outpatient MRI’s for assessment of bony changes

4. Medications 
   1. Continue hypertension and hyperlipidemia medications
      1. Atorvastatin (Lipitor) 10 mg
      2. Metoprolol (Lopressor) 50 mg

5. Hematology Consult
   1. Consult need for bone biopsy and further metastatic workup