What's your diagnosis?

[keeping-it-real]

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40 y/o male construction worker presents with complaints of back pain, left knee pain, and left ankle pain. His back pain has been "present since birth" and he was diagnosed "at some point as having something wrong with his vertebrae" but notes that "they told me that it shouldn't cause me any pain." He has noticed pain in the past when lifting extremely heavy objects but no one has ever been able to diagnose or treat his pain effectively. He has had numerous MRIs that have all been read as normal per the patient with his last MRI being a year and half ago. The pain is random in occurence and used to occur about 2 weeks/6 weeks up until he was in a car accident 6 months ago from which time he says that the pain has increased in frequency to 4/6 weeks but that the actual severity of pain is relatively unchanged. After this car accident he was taken to the ED but didn't know what was done but admits that he may have had a CT scan; he was released the same day as visit to the ED, though, and nothing further has been done. He is currently on Flexeril for his pain but notes that it provides no relief. He denies that he needs specific pain meds but just wants "anything that will stop the pain."

Regarding his knee pain, he states that 8 years ago he fell off of his bike and had to undergo a surgery to remove part of his meniscus. He states that post operatively he was never informed to keep weight off the leg and as such "was active on it for 6 months because the surgeon never told me i shouldn't be using it."

Regarding his ankle pain, he states that 2 years ago he suffered a "severe" sprain and since then has had intermittent pain. He notes that he has seen other people about this problem and they have felt crepitance on exam but said that it shouldn't be causing him pain. He also notes that he's sprained his ankle in the past but "not as severely" and insists that a sprain would not account for his current ankle pain because that pain should not last this long.

On physical exam, the lower lumbar back, midline has point tendereness to palpation. The lateral spinal musculature has minimal tenderness. His left knee has moderate pain to palpation on the medial joint aspect. Valgus and varus forces were unable to elicit pain. No crepitance was noted at the knee joint and full range of motion was appreciated. The patients left ankle had mild crepitance and pain with inversion but was otherwise unremarkable.

Past medical history is unremarkable except for undiagnosed "asthma" that the patient has never seen a physician for and for some stomach aches.

Family history is remarkable for fibromyalgia which the patient is concerned he may now have.

So... with this all said, what would your next step be and what's your current differential in order of likelihood? I'm curious to see what you guys think, thanks for participating.

 

[deleted87716]

Why did he come to the ED? Is something different after all these years?

It sounds like he needs a good primary care physician.

Edit: OK, you wanted diagnoses. Best guesses (horses, not zebras) include mechanical back pain (the guy's a construction worker...it practically comes with the job), degenerating medial meniscus, poorly-rehabilitated ankle sprain with ligamentous laxity. Problems #1 and #3 should improve with physical therapy, problem #2 may need imaging (MRI) +/- ortho referral, depending on what the scan shows (you probably aren't going to order that in the ED). Drug of choice for all three (esp. in the ED) is an NSAID, assuming no contraindications. Consider underlying depression (the guy's been in pain for years and is asking about fibromyalgia), which could intensify his perception of pain and also explain his "stomach aches." Ask about suicidality (his "anything that will stop the pain" comment smacks of desperation).

 

[keeping-it-real]

Why did he come to the ED? Is something different after all these years?

It sounds like he needs a good primary care physician.

Edit: OK, you wanted diagnoses. Best guesses (horses, not zebras) include mechanical back pain (the guy's a construction worker...it practically comes with the job), degenerating medial meniscus, poorly-rehabilitated ankle sprain with ligamentous laxity. Problems #1 and #3 should improve with physical therapy, problem #2 may need imaging (MRI) +/- ortho referral, depending on what the scan shows (you probably aren't going to order that in the ED). Drug of choice for all three (esp. in the ED) is an NSAID, assuming no contraindications. Consider underlying depression (the guy's been in pain for years and is asking about fibromyalgia), which could intensify his perception of pain and also explain his "stomach aches." Ask about suicidality (his "anything that will stop the pain" comment smacks of desperation).

I should have specified that it was community clinic and not an ED. The patient doesn't make a lot of money and hence why he was in at the free clinic.

Also, he said he was on some very strong NSAIDs when he was in the army in his early 20's and at that time there was not much relief.

How worried would you be about lupus, rheumatoid arthritis, or similar problems?

Thanks for your help.

 

[highdesert]

Ankylosing spondylitis and other sero-negative arthropothies should be entertained also...

 

[deleted87716]

How worried would you be about lupus, rheumatoid arthritis, or similar problems?

Not very, given his history of trauma in each case. It would be an odd distribution for a rheum disorder, esp. RA, which is usually symmetrical, and almost always affects the small joints of the hands or feet. You could essentially r/o SLE with an ANA and anti-SSA Ab. If the joints are warm and erythematous, you could consider gout or pseudogout...synovial fluid analysis could be useful there. Lots of less-common things come to mind, too...such as Reiter's, GC, Lyme, TB, AVN...but these aren't very likely.

 

[keeping-it-real]

Ankylosing spondylitis and other sero-negative arthropothies should be entertained also...

any reason for suspecting this?

 

[keeping-it-real]

Not very, given his history of trauma in each case. It would be an odd distribution for a rheum disorder, esp. RA, which is usually symmetrical, and almost always affects the small joints of the hands or feet. You could essentially r/o SLE with an ANA and anti-SSA Ab. If the joints are warm and erythematous, you could consider gout or pseudogout...synovial fluid analysis could be useful there. Lots of less-common things come to mind, too...such as Reiter's, GC, Lyme, TB, AVN...but these aren't very likely.

That's what i thought. I didn't really think lupus or RA was likely because there was an explanation for both the ankle and knee pain and the back pain had been since he was a kid. All of his previous MRIs had also been read as normal. As well, the rest of the physical exam was unremarkable. No warm joints and no joint deformities in the hands or feet or any other joint for that matter.

The attending physician was somewhat concerned about lupus or RA so that's why i wanted to see what others thought. I felt like i was missing something or didn't fully appreciate his history and exam. I brought up the fact that trauma explained both the knee and ankle but the attending said that because someone had looked at his ankle previously and told him that it shouldn't cause pain, he thought that something like lupus or RA might be likely. I guess to me, these didn't really seem like a constellation of symptoms so much as 3 different problems with 3 different etiologies.

 

[deleted87716]

I brought up the fact that trauma explained both the knee and ankle but the attending said that because someone had looked at his ankle previously and told him that it shouldn't cause pain, he thought that something like lupus or RA might be likely. I guess to me, these didn't really seem like a constellation of symptoms so much as 3 different problems with 3 different etiologies.

To be fair, you'll never find something if you don't look for it...but I think it's a long shot. 😉

 

[Apollyon]

To be fair, you'll never find something if you don't look for it...but I think it's a long shot. 😉

I wouldn't say "never" - one of the tenets of EMD (Emergency Medical Dispatch) is that "things not looked for are rarely found". Even a broken clock is right twice a day, so, you're mostly right - but, sometimes, you find things you're not specifically looking for.

 

[deleted87716]

I wouldn't say "never" - one of the tenets of EMD (Emergency Medical Dispatch) is that "things not looked for are rarely found". Even a broken clock is right twice a day, so, you're mostly right - but, sometimes, you find things you're not specifically looking for.

Even a blind squirrel finds a nut occasionally...not that anyone should aspire to that. 😉

You're correct, however, that "never" and "always" are usually wrong.

 

[krabmas]

to the OP - did you watch the guy walk?

did he have an antalgic gait or any other abnormalities in gait?

If there is trauma to explain all of the pain and the back was previously diagnosed as abnormal why does everyone think this guy might have an arthrity besides OA/DJD/traumatic arthritis?

and if crepitous was felt on the ankle and he has a history of sprains the talus could have an osteochondral defect, which can be repaired with a scope and debridement and or transplant of cartilage back into the talar dome.

 

[keeping-it-real]

to the OP - did you watch the guy walk?

did he have an antalgic gait or any other abnormalities in gait?

If there is trauma to explain all of the pain and the back was previously diagnosed as abnormal why does everyone think this guy might have an arthrity besides OA/DJD/traumatic arthritis?

and if crepitous was felt on the ankle and he has a history of sprains the talus could have an osteochondral defect, which can be repaired with a scope and debridement and or transplant of cartilage back into the talar dome.

the patient had a normal gait. his entire presentation was on the whole unremarkable; unless he told you of his chronic pain problems, you would not know anything was wrong with him.

and i would've liked to know what the previous back abnormality was. per the patient it was an inappropriate fusion which the doctors said shouldn't cause any symptoms. i asked about spina bifida occulta but he said it didn't ring any bells.

 

[mikecwru]

40 y/o male construction worker presents with complaints of back pain, left knee pain, and left ankle pain. His back pain has been "present since birth" and he was diagnosed "at some point as having something wrong with his vertebrae" but notes that "they told me that it shouldn't cause me any pain." He has noticed pain in the past when lifting extremely heavy objects but no one has ever been able to diagnose or treat his pain effectively. He has had numerous MRIs that have all been read as normal per the patient with his last MRI being a year and half ago. The pain is random in occurence and used to occur about 2 weeks/6 weeks up until he was in a car accident 6 months ago from which time he says that the pain has increased in frequency to 4/6 weeks but that the actual severity of pain is relatively unchanged. After this car accident he was taken to the ED but didn't know what was done but admits that he may have had a CT scan; he was released the same day as visit to the ED, though, and nothing further has been done. He is currently on Flexeril for his pain but notes that it provides no relief. He denies that he needs specific pain meds but just wants "anything that will stop the pain."

Regarding his knee pain, he states that 8 years ago he fell off of his bike and had to undergo a surgery to remove part of his meniscus. He states that post operatively he was never informed to keep weight off the leg and as such "was active on it for 6 months because the surgeon never told me i shouldn't be using it."

Regarding his ankle pain, he states that 2 years ago he suffered a "severe" sprain and since then has had intermittent pain. He notes that he has seen other people about this problem and they have felt crepitance on exam but said that it shouldn't be causing him pain. He also notes that he's sprained his ankle in the past but "not as severely" and insists that a sprain would not account for his current ankle pain because that pain should not last this long.

On physical exam, the lower lumbar back, midline has point tendereness to palpation. The lateral spinal musculature has minimal tenderness. His left knee has moderate pain to palpation on the medial joint aspect. Valgus and varus forces were unable to elicit pain. No crepitance was noted at the knee joint and full range of motion was appreciated. The patients left ankle had mild crepitance and pain with inversion but was otherwise unremarkable.

Past medical history is unremarkable except for undiagnosed "asthma" that the patient has never seen a physician for and for some stomach aches.

Family history is remarkable for fibromyalgia which the patient is concerned he may now have.

So... with this all said, what would your next step be and what's your current differential in order of likelihood? I'm curious to see what you guys think, thanks for participating.

Percocetapenia

Deadly disease

 

[kungfufishing]

Percocetapenia

Deadly disease

We must be vigilant about this diagnosis - often patients present with a "normal" percocet home volume (PHV) yet are relatively percocetopenic and still require replacement therapy.

 

[Dimoak]

I'm no expert, but it seems that this pt's financial state may be one of the predominant reasons for his situation. An MRI would probably be able to pinpoint the reasons behind his pain; a 40yo construction worker with traumas, some of which requiring surgery, and insufficient rehabilitation would almost guarantee such problems. The MRI is a pricey test though, and the possibility exists that the pt is just drug-seeking. I assume if lupus was the case, the sores would be evident. You could probably run some clotting antibody tests to rule it out, from what I've read. Perhaps you should just treat the symptoms, test for the attendings' suspicions, and just see if you can get the pt scanned.

 

[Annette]

Go back to the H+P. Does he have the classic tender points of fibro? What about muscle pain? Fibro generally isn't just joint pain. Any joint effusions or limitations in ROM? Any history of STD's or symptoms of one? If you are worried about RA, lupus, or other connective tissue disease, a cheap way is to check a CRP or ESR. If they are positive, then go one to further lab tests.

Can you get any of his reports?

 

[mikecwru]

Go back to the H+P. Does he have the classic tender points of fibro? What about muscle pain? Fibro generally isn't just joint pain. Any joint effusions or limitations in ROM? Any history of STD's or symptoms of one? If you are worried about RA, lupus, or other connective tissue disease, a cheap way is to check a CRP or ESR. If they are positive, then go one to further lab tests.

Can you get any of his reports?

YES! This guy has acute on chronic fibromyalgia with secondary percocetapenia.

Why does fibro classically only respond to antidepressants.....hmmmmmm?

mike

 

[keeping-it-real]

I'm no expert, but it seems that this pt's financial state may be one of the predominant reasons for his situation. An MRI would probably be able to pinpoint the reasons behind his pain; a 40yo construction worker with traumas, some of which requiring surgery, and insufficient rehabilitation would almost guarantee such problems. The MRI is a pricey test though, and the possibility exists that the pt is just drug-seeking. I assume if lupus was the case, the sores would be evident. You could probably run some clotting antibody tests to rule it out, from what I've read. Perhaps you should just treat the symptoms, test for the attendings' suspicions, and just see if you can get the pt scanned.

He had his most recent MRI 1.5 years ago and it was read as normal. He did get into his car accident since then (about 6 months ago) but he went to the ED straight away and he said they likely performed a CT but didn't find anything.

The thing about his pain is that he's had this back pain since birth and it only gets worse when he really physically exerts himself. He has hurt himself a number of times, though, by lifting heavy objects and each of these insults have made the chronic pain a little worse. But, in each of these instances he's had MRIs performed (except for his recent car accident 6 mo ago for which he only had CT). There was also no history of knee pain or ankle pain until he tore his meniscus and sprained his ankle, respectively. The rest of physical exam is absolutely normal.

I guess i'm just missing why lupus or RA would be high on the differential list.

 

[keeping-it-real]

Go back to the H+P. Does he have the classic tender points of fibro? What about muscle pain? Fibro generally isn't just joint pain. Any joint effusions or limitations in ROM? Any history of STD's or symptoms of one? If you are worried about RA, lupus, or other connective tissue disease, a cheap way is to check a CRP or ESR. If they are positive, then go one to further lab tests.

Can you get any of his reports?

No tender points of fibro and not a single issue of muscle pain on PE. No effusions or limitations in ROM. I didn't ask about STD's or symptoms (i should've though, good point).

I think CRP or ESR would've been good to get as a primary test. We don't have onsite testing at the clinic, though.

 

[NinerNiner999]

AS would be unlikely given his prior normal studies and his age (top end of age distribution is by age 30). My official ED diagnosis is "not sick" and he should be discharged to follow with his PMD.

 

[Annette]

Why does fibro classically only respond to antidepressants.....hmmmmmm?

mike

Sometimes, fibromyalgia will respond to physical therapy if it is started slowly. In particular, water PT works fairly well.

As to why RA and lupus are high on the diff, I have no idea. Something to think about, but it wouldn't be number 1 on my list. The pain with exertion leads me to believe this is mechanical/fibro. PT might be a very good option (as well as some amytriptyline 🙂 )

 

[spyderdoc]

Funny, I always put "fibromyalgia", "irritable bowel syndrome", and "chronic fatigue syndrome" in quotes on the chart when that is what the pt tells me SHE has. It's amazing how this group of "diseases" tend to occur together (the triad)...
Sorry for my pessimism on this one, but I agree with Mikecrwu on this one...I love that one (percocetopenia), and will definety incorporate that into my medical jargon!

 

[NKMU]

percocetopenia is definitely the new word of the week. is it your own neologism?

 

[TPS report]

see your MD in the AM

 

[stoic]

most likely: ankle/knee = post-traumatic arthritis. lower back pain = probably mechanical and nothing important, especially if he's really had a series of MRI's.

what i'd want to rule out would be chronic reactive arthritis (reiters syndrome), particularly if there is a history of STD's. it tends to effect unilateral lower extremities. it doesn't always present with the classic triad and in like 15% of cases becomes a chronic, flaring disorder. get a sed rate, hla-b27, ana.

of course that's all academic bull****. 99% chance he just wants drugs. he's probably just going from clinic to clinic until he finds someone to give him what he wants... god help whoever does that cause they'll never get rid of him.

 

[mikecwru]

Funny, I always put "fibromyalgia", "irritable bowel syndrome", and "chronic fatigue syndrome" in quotes on the chart when that is what the pt tells me SHE has. It's amazing how this group of "diseases" tend to occur together (the triad)...
Sorry for my pessimism on this one, but I agree with Mikecrwu on this one...I love that one (percocetopenia), and will definety incorporate that into my medical jargon!

There used to be an Adam Corolla skit where he defined medical terms in layman's terms: IBS = "You need to take a crap." CFS = "Lazy."

Yes, I coined the term percocetopenia... at least no one ever taught it fto me. Although, I'm sure some similar jaded prick like myself came up with on their own.

mike