The Case of the Miniature Muscleman.

[RustedFox]

The Case:

HPI: 45 year old African-American male comes to the ED with a CC of back pain. He states that the back pain happened after picking up a load that he says "was too heavy for him". He works in a local pub, as one of the line cooks. States that the pain localizes to the "middle of his back", and pats the area in the mid-thoracic region with the back of his hand. States that the pain is best described as a dull, throbbing, ache and it is without any area of radiation. He states that the pain began immediately after he attempted moving a large drum of fryer grease by himself; a job that he admits "usually takes two guys to do, but I've managed a couple of times". He states that he took 2 tylenol prior to arrival, which did not alleviate his pain.

ROS: Otherwise negative.

PMHX: HTN.

SurgHx: Denies all.

Rx: Lisinopril

SocHx: Does not smoke. Drinks beer only when he watches his football team. States that his dad had a drinking problem, and knows the dangers of alcohol. Denies any illegal drugs.

NKDA

PE: Vitals: BP: 154/76. HR: 88 and regular. RR: 18 and nonlabored. SaO2: 99% RA. Temp: Afebrile

General exam/impression: Well-muscled for a short guy. 5'7'', 180 lbs. Built like a house. Guy is in obvious pain. Asks politely for you to help him out with this pain.

HEENT: NC/AT. EOMI. PERRL. No LAD/JVD. Trachea midline.
CHEST: S1/S2+. RRR. No murmurs/gallops/rubs. CTA B/L. No wheezes/rales/ronchi.
ABD: Soft, NT/ND. +BSx4. No marks, masses, organomegaly. No pulsations felt.
EXTR: Distal pulses +x4. No clubbing, cyanosis, edema.
NEURO: CN 2-12 intact. No FND. No cerebellar signs/ataxia. Pain to back with ambulation.
SKIN: Clean,dry,intact. No rashes/marks.



Now, there's a thousand directions to take this. I'm just going to play it by ear. Have at it. As an aside: the HPI is written in the style of how I actually write my charts (medicolegal reasons). Note the voice: Patient states x. Patient states y. Patient denies z. I didn't say or do or interpret anything. Its a simple retelling of what HE said, not what I heard.

---

Members don't see this ad.

 

[It'sElectric]

Sounds like a nice guy...he's screwed.

 

[RustedFox]

Guy was real polite.

 

[WilcoWorld]

I might've missed his MI if I wasn't hearing about it in this context. Unless that BP was done on the left arm and you're going to tell me that the right arm had a systolic pressure of 200.

 

[It'sElectric]

I might've missed his MI if I wasn't hearing about it in this context. Unless that BP was done on the left arm and you're going to tell me that the right arm had a systolic pressure of 200.

Yeah, Aortic pathology definitely high on the differential given the context.

 

[Rendar5]

Sorry but with that presentation, I'd miss everything =p

I'd want to know if the pain was pleuritic and I'd want to know what the back exam was like.

 

[gro2001]

Strength and sensation? Rectal tone/saddle anesthesia? Midline tenderness?

 

[RustedFox]

Pain not pleuritic.

Normal neurologic exam in all regards. Normal saddle. No bowel/bladder symptoms.

Initially, I gave the guy Toradol 60 IM while planning my imaging. No help. Then, 1 of Dilaudid with minimal relief. Another milligram, and he said it was tolerable, 2-3/10.

Anyone want to image him ?

 

[Rendar5]

If there were midline ttp, I'd image him.

 

[migm]

Back exam would be good (erythema, step offs, swelling, ROM, straight leg, cross-leg, point tenderness).. I would not image him unless there was something making me worried about serious pathology (ie not acute musculoskeltal)

 

[WilcoWorld]

I'm going to press him on Aortic/neuro/cardiac/PE related ROS questions. If there are no red flags (or spidey sense), the most imaging I'm doing is a CXR (since it's thoracic).

 

[migm]

Oh it's thoracic.. that's a little weird

FHX of connective tissue dz?

 

[WilcoWorld]

Oh it's thoracic.. that's a little weird

FHX of connective tissue dz?

Yep - and while it's still back pain, thoracic makes it "chest pain".

 

[loveoforganic2]

How unlikely is thoracic disc herniation? I know everyone's jumping to aneurysm, but he seems pretty low risk to me other than being AA and hypertensive

FHX of connective tissue dz?

ah, good q, along with assessing joint mobility & check sclera. would fit for ehler's

 

[Hypomanics]

When did this pain start / lifting of the drum take place? Earlier in the same day?
Has it been constant?
Worsening, or pretty much the same since initial insult?

 

[RustedFox]

Pain has been constant since trying to pick up the big drum full of grease. Occurred a few hours prior to arrival; a dull, throbbing ache in the center of the back. Midline not tender. Focused back exam is negative for all those things: step-offs, rash, etc. The paraspinal areas are tender, nothing weird there.

ROS was otherwise unremarkable. No pleuritic pain, no palpitations, no dizziness/lightheadedness/syncope/numbness/tingling/paresis/paresthesias. Nothing.

I did CXR, T-and-L spine films. I read them as "normal". Radiology read them as "normal". Guy's pain is "better" after the second dilaudid. He still moves about a little bit stiffly. Other tests/dispo?

(We'll get to the end here soon, guys. - I wanna allow time and space for thoughts/differential/objections.)

 

[Rendar5]

Pain has been constant since trying to pick up the big drum full of grease. Occurred a few hours prior to arrival; a dull, throbbing ache in the center of the back. Midline not tender. Focused back exam is negative for all those things: step-offs, rash, etc. The paraspinal areas are tender, nothing weird there.

ROS was otherwise unremarkable. No pleuritic pain, no palpitations, no dizziness/lightheadedness/syncope/numbness/tingling/paresis/paresthesias. Nothing.

I did CXR, T-and-L spine films. I read them as "normal". Radiology read them as "normal". Guy's pain is "better" after the second dilaudid. He still moves about a little bit stiffly. Other tests/dispo?

(We'll get to the end here soon, guys. - I wanna allow time and space for thoughts/differential/objections.)

Dispo home with pain meds, follow-up, and clear instructions to call 911 if neurologic deficit, any new symptoms, or spread of pain to include any other area. It's really hard to suggest anything else on the guy, even an EKG. The only reason I would ever do more on this guy is if I had a bad clinical gestalt. And that's not something you can put down on paper. I'd have to physically see the guy myself.

 

[migm]

Dispo home with pain meds, follow-up, and clear instructions to call 911 if neurologic deficit, any new symptoms, or spread of pain to include any other area. It's really hard to suggest anything else on the guy, even an EKG. The only reason I would ever do more on this guy is if I had a bad clinical gestalt. And that's not something you can put down on paper. I'd have to physically see the guy myself.

+1 and add some flexeril

 

[bad virus]

Med student here and I know it is unlikely, especially with the constant dull back pain, but I would still hook him up to an ecg just for funsies. The problem is lets say we find something . . . further into the rabbit hole.

If I wasn't being a pesky med student, I would send him home on Cyclobenzaprine and return papers if things change.

 

[name?]

Did you get an EKG? Regardless, I'm pretty sure I'm with these guys. The fact you're putting it up here makes it a zebra in all likelihood; but, common things being common, the guys has a back boo-boo and needs some symptomatic care unless things progress. Home/NSAIDs/Short course vicodin. Strict return precautions.

 

[ER PA]

dont see (read) anything that would trigger further suspicion.... i would ask if he ever has abdominal pain (but u did mention negative ROS) , listen for abdominal bruits. theres nothing (that i have read) to steer me towards aortic pathology. with him not having any loss of B/B function or neuro sx this looks like benign MS pain other than it being thoracic instead of typical lumbago... but sounds MS with him having tenderness to palpation and worse with movement.... honestly not sure i would have even imaged him with him not having midline tenderness and no direct trauma.... would have d/c him on vicodin, NSAID and flexeril with out-pt f/u for further eval (MRI) if sx not improving, return for acute worsening/new sx.

i'm ready for the kicker

 

[woeiru]

Given how well-built this guy is, it seems likely that he works out a decent amount and should know how to lift properly. The location of the pain doesn't really correlate with someone who was using good technique. I might probe a little more into the story and make sure there isn't anything I'm missing.

Also, curious if he's ever had pain like this before.

 

[Hypomanics]

Given how well-built this guy is, it seems likely that he works out a decent amount and should know how to lift properly. The location of the pain doesn't really correlate with someone who was using good technique. I might probe a little more into the story and make sure there isn't anything I'm missing.

Also, curious if he's ever had pain like this before.

Yea, I keep trying to think about how the shortness/muscles may be related... that has to be the clue here.

 

[migm]

Anabolic steroid --> arterial dissection?

 

[loveoforganic2]

Anabolic steroid --> arterial dissection?

http://www.ncbi.nlm.nih.gov/pubmed/2322060

Neat!

 

[Tiger26]

did you examine his back? i'm sure you did, but i didn't see it in your documentation . . .

 

[bad virus]

If this is really like one of them Encyclopedia Brown cases, the answer should be evident from the first post by closing our eyes and asking one good question.

 

[loveoforganic2]

How unlikely is thoracic disc herniation? I know everyone's jumping to aneurysm, but he seems pretty low risk to me other than being AA and hypertensive



ah, good q, along with assessing joint mobility & check sclera. would fit for ehler's

Along w/the other stuff that's come up, I missed this

He works in a local pub, as one of the line cooks.

as an aneurysm risk factor despite his "not smoking"

 

[gutonc]

Along w/the other stuff that's come up, I missed this

as an aneurysm risk factor despite his "not smoking"

Are there still places where you can smoke in bars? Srs question.

 

[RustedFox]

Are there still places where you can smoke in bars? Srs question.

Certain bars in Florida are smoke-friendly. I was terribly disappointed one day, as I walked into a "Golf-themed bar" (which is where I was told the locals who follow the PGA tour go to hang together and debate Tiger vs. Rory), and walked immediately out of it because the whole place reeked of cheap cigarettes.

There is nothing that I find more insulting that cigarette smoking. Its like they're saying - "Yeah, I won't care about my health until I show up in your ED from COPD/PE/CAD/osteoporosis with compression fractures (especially for the older females), and I become YOUR problem, and then I'll look at you like you're a lunatic when you suggest that <gasp> smoking might be what's really behind my terrible, relentless, excruciating (HATE that word) pain."

 

[RustedFox]

Dispo home with pain meds, follow-up, and clear instructions to call 911 if neurologic deficit, any new symptoms, or spread of pain to include any other area. It's really hard to suggest anything else on the guy, even an EKG. The only reason I would ever do more on this guy is if I had a bad clinical gestalt. And that's not something you can put down on paper. I'd have to physically see the guy myself.

I did exactly this. I was a resident. Attending agreed with my management, saw the patient himself. I sat down with him, told him that we found nothing on our x-rays, and very CLEARLY said:

"Hey, bud - I care about you. I really do. If anything changes, or if your pain comes back and just wont go away. Come on back. It means that something may be different."

That was the only thing that saved my as$. Guy came back next day. Worsening back pain. We scanned him for PE. Thoracic aortic dissection with false lumen that had clotted off. We got him to vascular. I found him and said - "Hey, thanks for coming back. You did the right thing; we can't always see the whole picture in just one sitting."

Fella looked back and said - "Well, you told me to come back, Doc. I was just following your instructions."


Moral of the story: You're going to miss stuff. No matter what. A good bedside manner and CLEAR discharge instructions might totally save you one day.

 

[migm]

Cool case, thanks for doing it. Please do more as time allows

 

[loveoforganic2]

Are there still places where you can smoke in bars? Srs question.

At least some places in Louisiana and Alabama (if not the entire states) as far as I'm aware. There's a strong campaign in LA to ban smoking in bars and casinos, but it hasn't happened yet. Just this past year LSUHSC banned on campus smoking.

Have to love the south

Thanks for posting the case!

 

[gutonc]

At least some places in Louisiana and Alabama (if not the entire states) as far as I'm aware. There's a strong campaign in LA to ban smoking in bars and casinos, but it hasn't happened yet. Just this past year LSUHSC banned on campus smoking.

Have to love the south

Thanks for posting the case!

I don't believe in the South.

As forth case...I didn't weigh in but was thinking dissection from the opening bell. That's primarily because I took care of a dude in the CCU with a nearly identical story except he was a construction worker on a project at the hospital. Lifted something heavy, felt a pop and the back pain, etc.

He didn't make it out of the OR though.

 

[Arcan57]

How unlikely is thoracic disc herniation? I know everyone's jumping to aneurysm, but he seems pretty low risk to me other than being AA and hypertensive



ah, good q, along with assessing joint mobility & check sclera. would fit for ehler's

Mid-thoracic back pain from an MSK source outside of MVC/direct trauma is uncommon. Hearing a pt c/o mid thoracic pain makes the hairs on the back of my neck stand up. It's a completely different entity from low back pain. If you exclude MVCs I've seen severe pathology presenting with mid thoracic pain more often then I have seen benign causes.

 

[beakerdan]

As a medical student interested in Emergency, these case threads are great! It's really good to see the thought processes of the posters here. Thanks to those who have been posting them lately!

 

[loveoforganic2]

Mid-thoracic back pain from an MSK source outside of MVC/direct trauma is uncommon. Hearing a pt c/o mid thoracic pain makes the hairs on the back of my neck stand up. It's a completely different entity from low back pain. If you exclude MVCs I've seen severe pathology presenting with mid thoracic pain more often then I have seen benign causes.

Thanks for the info! Good to know

 

[mmmmd]

Hi, thanks for posting this, it's really awesome. I'm an ignorant pre-med with a question...

Guy came back next day. Worsening back pain. We scanned him for PE.

...was making that decision really that simple?

 

[Rendar5]

Yes, if someone comes back with a concerning story, you perform more of a workup. CT is the logical next step here, as the bad things will be from the lung, heart, and aorta.

 

[Laeno]

Hi, thanks for posting this, it's really awesome. I'm an ignorant pre-med with a question...



...was making that decision really that simple?

MS4 here, so take this with a grain of salt.

Actually yes. They had already gotten plain films (X-ray) based on what I gathered from the rest of this thread. The guy came back with worsening pain, and a CT with contrast is pretty good for showing a lot of the scary pathology in the chest. Since this guy had pain worse enough to return to the ED, better to be safe than sorry. There really aren't any other good routes to take. You could send him home, but then why'd you bother giving him return precautions?

Do we know the rest of the story? Specifically, did he make it longer term?

 

[bad virus]

MS4 here, so take this with a grain of salt.

Actually yes. They had already gotten plain films (X-ray) based on what I gathered from the rest of this thread. The guy came back with worsening pain, and a CT with contrast is pretty good for showing a lot of the scary pathology in the chest. Since this guy had pain worse enough to return to the ED, better to be safe than sorry. There really aren't any other good routes to take. You could send him home, but then why'd you bother giving him return precautions?

Do we know the rest of the story? Specifically, did he make it longer term?

There is one caveat to this whole thing. A CT Chest Angio is best at one thing, PE's. Sure you can see other pathology, but remember, whenever ordering a radiological study, try helping your radiologist out by ordering the study that allows them to see the most. For example, if your looking for a GI bleed, maybe a CT isn't what you need. Or if you are looking for nephroliths, don't order contrast etc . . .

None the less, this was the right study.

 

[gro2001]

There is one caveat to this whole thing. A CT Chest Angio is best at one thing, PE's. Sure you can see other pathology, but remember, whenever ordering a radiological study, try helping your radiologist out by ordering the study that allows them to see the most. For example, if your looking for a GI bleed, maybe a CT isn't what you need. Or if you are looking for nephroliths, don't order contrast etc . . .

None the less, this was the right study.

Just to clear it up for everyone: you can phase the CT angiogram for either the venous or the arterial phase if you want to optimize for a PE study or an aortic dissection one, respectively.

The radiologists at our institution say that the PE optimized study will pick up most dissections, but the converse is not necessarily true.

 

[bad virus]

Just to clear it up for everyone: you can phase the CT angiogram for either the venous or the arterial phase if you want to optimize for a PE study or an aortic dissection one, respectively.

The radiologists at our institution say that the PE optimized study will pick up most dissections, but the converse is not necessarily true.

Exactly, thanks for clearing that up. When in doubt, call rads and give em your differntial so you can get the best protocol for your study.

 

[8654Marine]

Rusted Fox, great case.

For those who are still learning, (as I still am after 10 years of practice), I wish to caution folks about these cases.

We should always consider worse case scenarios. But in case presentation, we always seem to see worse case scenarios or zebras or uncommon presentation of common things.

For those of you who would consider CT scanning everyone with back pain, MOST back pain will be non-emergent, non-lethal. Getting an MRI or CT scan for your patient because of this case, will not help.

MOST cases will be solved NOT by scanning, but by good history and physical AND, as this case illustrates, good discharge instructions. I believe that is the teaching point here.

 

[bad virus]

Rusted Fox, great case.

For those who are still learning, (as I still am after 10 years of practice), I wish to caution folks about these cases.

We should always consider worse case scenarios. But in case presentation, we always seem to see worse case scenarios or zebras or uncommon presentation of common things.

For those of you who would consider CT scanning everyone with back pain, MOST back pain will be non-emergent, non-lethal. Getting an MRI or CT scan for your patient because of this case, will not help.

MOST cases will be solved NOT by scanning, but by good history and physical AND, as this case illustrates, good discharge instructions. I believe that is the teaching point here.

Thanks for the teaching.

Who's got the next case. It doesn't have to be a zebra.

 

[RustedFox]

Thanks for the teaching.

Who's got the next case. It doesn't have to be a zebra.

I have some more interesting ones. Not all are zebras. Lemme chew on it.

 

[gro2001]

i have some more interesting ones. Not all are zebras. Lemme chew on it.

moar cases!

 

[jdh71]

And here I was thinking that EVERYONE got a CT chest if they show up at the ED - that and trops . . .

(I keed, I keed)

Good case, though, I think we were all, "Yup this is gunna be a dissection" (or weirder) based on the fact that it was being presented. I know for me the diagnosis that is always high in any "chest" kind of case, but seems to take a relative back seat is PE, which can present in many ways similar to other presentations, so I actually have to make sure I ask myself every single time I see a patient, "could this be PE," it's like some weird hole in my initial and intuitive approach.

Saw a dissection in residency - guy initially came in with chest pain, hx/o CAD, had been doing cocaine at the snoop dogg (now snoop lion) concert, ED sent him up to us as a r/o after giving him a couple of good slugs of dilauded for pain and a benzo to counter the cocaine after initial set of negative trops and an essetniall unchanged EKG outside of some non-specific t-wave stuff out in the lateral leads - I think the dissection was missed initially by the ED and admitting team because 1) the pain got better and 2) he wasn't hypertensive when he came in. Anyway, the pain moved from his chest to his abdomen by AM rounds, subsequent CT showed dissection, still not hypertensive, we got vascular and CT involved since the dissection started in the ascending arch, started usual medical management, went to the unit for obs, but when he desatted, developed a new systolic murmur and flash pulmonary edema, he went to the OR and never made it out.

It's cases like that and the one presented in the OP that leave imprints on your mind for certain diagnoses.

 

[RustedFox]

I know for me the diagnosis that is always high in any "chest" kind of case, but seems to take a relative back seat is PE, which can present in many ways similar to other presentations, so I actually have to make sure I ask myself every single time I see a patient, "could this be PE," it's like some weird hole in my initial and intuitive approach.

THIS.

PE is such a weird thing. Everyone has missed a PE and sent it home, I don't care who you are.

PE is like that episode of family guy where Peter finds the "beyond" section of "Bed Bath and Beyond".... yep. PE is in the "beyond" section.

 

[Apollyon]

PE is such a weird thing. Everyone has missed a PE and sent it home, I don't care who you are.

PE is like that episode of family guy where Peter finds the "beyond" section of "Bed Bath and Beyond".... yep. PE is in the "beyond" section.

PE is like syphilis and an appy - the "Gread Pretender". These are some of the common (or formerly common) things that, actually, are rare in "classic" presentation, but can look a lot like a lot of other things, and be nebulous - so, I guess they are "anti-pathognomonic"!