2. Morning Report 7/7/1999 Victor Ghobrial, MD William Fink, MD

3. HPI 91 F presented to the hospital with 2 days Hx of cough, scanty yellowish sputum production and elevated temp. Also C/O low back pain which has been going on for the past three years but has been worse lately. She denied CP, N/V or other symptoms.

4. PMH HTN DJD No DM, CAD or cancer

5. H&P NKDA Tylenol daily SH: No smoking or alcohol abuse Family Hx: non- contributory

6. Physical Exam Elderly female in no distress T 102 BP 160/80 P 94 RR 24 Pox 97% RA HEENT : PERRBL, No ear or nose D/C Neck : Supple without JVD Ht : RRR S1 S2 audible without murmurs Lungs : Bibasilar crackles no wheezes or rhonchi

7. H&P Abdomen : Soft not tender with positive BS and without organomegally Ex : No E, C, C. +1 PP Neuro : Disoriented to time. No focal deficits or CN palsies

8. Labs Na K Co2 Cl BUN Cr 142 3.2 22 100 9 0.6 Glucose 120 CXR

9. Hospital Course Pt was admitted for 3 days, treated with Abx for community acquired pneumonia Back pain continued and spinal films revealed compression fx of lumbar vertebrae with Rt scoliosis Pt was prescribed vit D with Ca and percocet PRN

10. Structure of the back : vertebrae and discs are supported by ligaments and paravertebral ms, discs consist of gelatinous nucleus pulposus and surrounding annulus fibrosus Sinovertebral n. arises from corresponding spinal n. and carries sensation

11. Trauma : bone, joints or ligaments Mechanical : pregnancy, obesity or scoliosis Degenerative : osteoarthritis Infections : osteomyelitis, TB, meningitis Metabolic : osteoporosis, osteomalicia

12. Neoplastic : myeloma, Hodgkin’s, pancreatic Ca, breast mets, prostate, lung GI : ulcers, pancreatitis, cholelithiasis, IBD Renal : hydronephrosis, calculus, neoplasm, renal infarcts, pyelo-nephritis Hematological : sickle cell crisis, hemolysis

13. Vascular : leaking aortic anurysm, subarachnoid or spinal he Gynecologic : tumors of uterus, ovary, dysmenorrhea, uterine prolapse Inflammatory : ankylosing spondylitis, arthritis, Reiter’s syndrome, strain Psycogenic : malinger, anxiety, hysteria

14. Differentiate between two main types: Mechanical xxx Medical Most of the time it is self-limited; about 50% will improve in 1st week, 51-86% in 1st month and 92% in 2 months Identify pts with Cancer, Infection, Neuro deficits, Inflammatory dis & Leaking AAA

15. Standing Position 1- Kyphosis, lordosis and scoliosis 2- Localize tenderness 3- Schober test: 10cm line at LSJ & above should extend > 15cm Sitting & Supine 1- Reflexes: Knee(L4) Ankle(S1) 2- SLR: + if elevated 60*or less, spes 40%, sens 95%. 3- Crossed Straight Leg 90&25%

16. CBC & ESR :Inflammatory&Neoplastic Ca & Alka phos : Diffuse bone disease Serum & Urine Electrophoresis : MM Acid phos & PSA : Prostate Ca UA : Renal disease Occult Stool : GI diseases

17. Not necessary for initial work up unless hx of trauma, infection, malignancy or inflamm By age 50, 67% of normal population have evidence of disc disease and 2/3 of pts who have evidence of lumbar disc degeneration are asymptomatic Should be reserved for persistant pain, tenderness, elderly and if Rx fails

18. Highly diagnostic Reserved for pts in whom information will change Rx Needed urgently if suspecting Cauda equina or Epidural mass Not needed in disc herniation

19. CT if used instead of MRI must be with intrathecal contrast to yield high resolution Radionuclide Bone Scanning has limited utility, useful in osteomyelitis or mets. It is normal in MM (lytic lesion)

20. 1st line NSAIDs for analgesia if failed narcotics usually not longer than 2 weeks Muscle relaxants of no proven value but if needed should be used for no longer than 2 weeks Corticosteroid injection of unknown value

21. Once thought as cornerstone of therapy, now are ineffective for acute pain 2 days of bed rest gives better results than 7 days The value of traction and corsets is doubtful Early mobilization is the current trend

22. Needed urgently if evidence of evolving neurologic deficits, consistent pain syndrome that failed conservative Rx for 4:6 weeks Percutaneous lumbar discectomy is safe and effective (75%) alternative to laminectomy