naima-lbp
DESCRIPTION
Clinical presentation on low back painTRANSCRIPT
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Welcome
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A 41 year old man with low back pain, fever and cough
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Presented byPresented by
Dr. Naima Akhter Dina Dr. Naima Akhter Dina HMOHMO
Department of Physical Medicine &Department of Physical Medicine &
RehabilitationRehabilitation
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Particulars of the patient:Particulars of the patient:Name : Name : Md. Ishaq Ali
Age Age : 41 years
SexSex : : Male
Religion : Religion : Islam
Marital statusMarital status : : Married
Occupation Occupation : : Farmhouse worker
Address : Address : Vill: Mohela, P.S: Kalihati
District : Tangail
Date of Admission Date of Admission : : 16.09.13
Date of Examination : 16.09.13 Date of Examination : 16.09.13
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Chief Complaints:Chief Complaints:
1. Low back pain for 2 months
2. Fever for 5 months
3. Cough for 5 months
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History of Present illness:History of Present illness: According to the statement of
the patient he developed low back pain for 2 months which was sudden onset, dull aching in nature, moderate to severe in intensity, localized to low back region, persistent, relieved by walking, associated with morning stiffness (>1 hr) .He gives no H/O joint pain and swelling, headache, redness of eye, bowel/ bladder disturbances.
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Present illness (cont…)Present illness (cont…) He also complained of fever and cough
for 5 months. Initially for 1 month the fever was low grade, occurred at night, subsided by antipyretic. Then after a afebrile period of 15 days, he again developed fever which was recurrent episodic, high grade, intermittent ( 2 times rise/ day, last for 3 hrs), came with chills and rigor, subsided by profuse sweating.
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Present illness (cont…)Present illness (cont…)
The highest recorded temp was 104˚F. The duration of febrile and afebrile period was about 15 days which came alternatively. Fever was associated with anorexia, nausea, vomiting, malaise and fatigue.
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Present illness (cont…)Present illness (cont…)
He also complained of dry cough for the same duration which was persistent, more at night causing sleep disturbance. He gives no H/O blood with cough, chest pain, breathlessness or significant weight loss.
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Present illness (cont…)Present illness (cont…)
He is normotensive, non diabetic & non asthmatic.
For these above complaints he was seen by Doctor in KSA and treated accordingly on 8.09.13 and now he was admitted in this hospital for better management.
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History of Past illness:History of Past illness:
He had history of jaundice 8 years back and brucellosis 1 year back which was diagnosed in KSA and he was treated with Cap. Doxycycline (100mg) twice daily and inj. Streptomycin I/M once daily for 21 days. He had no H/O TB, IHD or any surgical interventions.
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Drug History:Drug History:
Patient was taking Cap. Doxycycline 100mg twice daily, Cap. Rifampicine 150mg once daily, antipyretic and analgesic for his illness.
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Family History:Family History:
He has 2 brothers and he lives with his wife and 2 sons. None of his family members have same type of illness.
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Socio-Economic HistorySocio-Economic History:
He is the only earning member of his family, lived in KSA for last 9 years where he worked as a farmhouse worker ( goat-sheep farm) and earned 25 thousands Tk/ month. In KSA, he lived in a tin-shed house, drank mineral water and did not use sanitary latrine.
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Personal History:Personal History:
He is non-smoker, non-alcoholic & does not take betel nut. He is habituated to normal Bangladeshi and Arabian diet. He had no history of sexual exposure and no history of contact with TB patient.
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Immunization History :Immunization History :
He is not immunized as per EPI schedule.
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General Examination:General Examination:Appearance : anxious
Body build : average
Co-operation : co-operative
Decubitus : on choice
Nutritional status : average
Height : 5 ft
Weight : 55 kg
BMI : 24.44 kg/m2
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General Examination ( cont…)General Examination ( cont…)
Anaemia : mild
Jaundice : absent
Cyanosis : absent
Oedema : absent
Dehydration : absent
Clubbing : absent
Koilonychia : absent
Leuconychia : absent
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General Examination ( cont…) General Examination ( cont…)
Thyroid gland : not enlarged
Neck vein : not engorged
Skin condition : normal
Hair distribution : normal
Bony tenderness : absent
Lymph nodes : not palpable
BCG mark : present
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General Examination ( cont…) General Examination ( cont…)
Pulse : 72 / min.
Blood Pressure : 110 / 70 mm of Hg
Temperature : 980 F
Resp. rate : 18 / min.
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Musculoskeletal Musculoskeletal System System examination:examination: Gait : Gait : normal
Arms : Arms : normal
Legs :Legs : normal
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Spines:
look look - no spinal deformity- no spinal deformity
- no swelling- no swelling
- no muscle wasting- no muscle wasting
feel - tenderness over L5-S1
region and over left
sacroiliac
joint present ( grade II )
-step sign : negative
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move -flexion : restricted
-extension : restricted
-lateral flexion : restricted
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Special tests :
Modified Schober’s test : positive(4 cm)
Finger -Floor distance : positive(20 cm)
Wall -Occiput distance : 0 cm
FABER test : negative
Gaenslen’s test : negative
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Special tests :
Pelvic compression test : negative
Pelvic distraction test : negative
Straight leg raising test : 70 degree
(both sides)
Total chest expansion : restricted
(2.5 cm)
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Respiratory system examination:Respiratory system examination:
Inspection:
Chest shape : normal
Chest movement : bilaterally
symmetrical
Visible pulsation : absent
Suprasternal, intercostal
or subcostal indrawing : absent
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Palpation
Position of trachea : central
Position of apex beat : left 5th ICS, just
medial
to mid clavicular line
Chest expansion : symmetrical
Total chest expansion : restricted (2.5cm)
Vocal fremitus : normal
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Percussion:
Percussion note : resonant
Auscultation:
Breath sound : vesicular with
no added sound
Vocal resonance : normal
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Alimentary system examination:Alimentary system examination:
Oral cavity Lips, tongue, palate, gum & vestibule
are normal.
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Abdomen proper
Inspection:
Shape of the abdomen : normal
Flanks : not full
Umbilicus : centrally placed,
inverted
Skin condition : normal
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Superficial palpation
Temperature : normal
Tenderness : absent
Muscle guard : absent
Muscle rigidity : absent
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Deep palpation:
Liver : not palpable
Spleen : not palpable
Kidney : not ballotable
Urinary bladder : not palpable
Fluid thrill : absent
External genitalia : normal
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Percussion:
Percussion note : tympanitic
Auscultation:
Bowel sound : present
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Nervous system examination:Nervous system examination:
Higher psychic function : normal
Cranial nerves : intact
Motor system : normal
Sensory system : normal
Sign of menengial irritation : absent
Cerebeller sign : absent
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Cardiovascular system Cardiovascular system examination:examination:
Inspection:
Chest shape : normal
Apical impulse : absent
Scar mark : absent
Palpation:
Position of apex beat : left 5th ICS, just medial to mid clavicular line
Thrill : absent
Left parasternal heave: absent
Palpable P2 : absent
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Percussion:
Area of cardiac dullness : normal
Auscultation:
1st and 2nd Heart sound : present
Added sound : absent
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Salient featuresSalient features
Md. Ishaq Ali, 41 years, male, muslim, married, non-smoker, normotensive, non- diabetic, non asthmatic, farmhouse worker in KSA for last 9 years, hailing from Tangail, admitted into this hospital through OPD on 16/09/13 with the complaints of low back pain for 2 months, fever and cough for 5 months.
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Salient features ( cont …)Salient features ( cont …)
The patient developed low back pain for 2 months which was sudden onset, dull aching in nature, moderate to severe in intensity, localized to low back region, persistent, relieved by walking, associated with morning stiffness (>1 hr).
He gives no H/O joint pain and swelling, headache, redness of eye, bowel/ bladder disturbances.
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Salient features ( cont…)Salient features ( cont…)
He also complained of fever and cough for 5 months. Initially for 1 month the fever was low grade, occurred at night, subsided by antipyretic. Then after a afebrile period of 15 days, he again developed fever which was recurrent episodic, high grade, intermittent ( 2 times rise/ day, last for 3 hrs), came with chills and rigor, subsided by profuse sweating.
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Salient features ( cont…)Salient features ( cont…)
The highest recorded temp was 104˚F. The duration of febrile and afebrile period was about 15 days which came alternatively. Fever was associated with anorexia, nausea, vomiting, malaise and fatigue.
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Salient features ( cont…)Salient features ( cont…)
He also complained of dry cough for the same duration which was persistent, more at night causing sleep disturbance. He gives no H/O haemoptysis, chest pain, breathlessness or significant weight loss.
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Salient features ( cont…)Salient features ( cont…)
For these above complaints he was treated with Cap. Doxycycline 100mg twice daily and Cap. Rifampicine 150mg once daily in KSA.
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Salient features ( cont…)Salient features ( cont…)
He had history of jaundice 8 years back and brucellosis 1 year back which was diagnosed in KSA and he was treated with Cap. Doxycycline (100mg) twice daily and inj. Streptomycin I/M once daily for 21 days. He had no H/O TB or contact with TB patient.
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Salient features ( cont…)Salient features ( cont…)
On examination, patient is anxious, mildly anaemic, lymph nodes are not palpable, his pulse- 72 / min, blood pressure- 110 / 70 mm of Hg, temperature- 980F, no deformity of spine, grade II tenderness present over L5-S1 region and left sacroiliac joint, all movements of spine restricted, Modified Schober’s test: positive (4 cm), total chest expansion:
restricted (2.5 cm), no organomegaly.
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Provisional diagnosisProvisional diagnosis
?
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Provisional diagnosisProvisional diagnosis
Brucellar Spondylitis
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Differential diagnosisDifferential diagnosis• Recurrent flue like illness with
spondyloarthopathy
• Tuberculosis of spine
• Undifferentiated Spondyloarthopathy
• Non specific low back pain with recurrent flue like illness
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CBC
1st hospital day16.09.13
8th hospital day23.09.13
13th hospital day28.09.13
Hb%(gm/dl) 10.3 12.8 13.9
ESR (mm in 1st hr) 140 65 70
WBC(/cmm) 5000 2800 3000
Neutrophil % 65 24 18
Lymphocyte% 30 70 68
Eosinophil % 03 04 02
Monocyte % 02 10
Myelocyte% 02
Platelet count(/cmm)
170000 150000
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Investigations (cont…)Investigations (cont…)
• PBF(23.09.13):
RBCs - mild rouleaux formation with anisochromia and anisocytosis
WBCs - are mature with above count and distribution
Platelets - are normal
Comment- Leucopenia with high ESR
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Investigations (cont…)Investigations (cont…)
• PBF(28.09.13):
RBCs - mild rouleaux formation with anisochromia and anisocytosis
WBCs - are mature with above count and distribution
Platelets - are normal
Comment- Leucopenia with high ESR
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Investigations (cont…)Investigations (cont…)
• Urine R/M/E : normal study
• S. creatinine : 0.7 mg/dl
• FBS : 76 mg/dl
• 2 hrs ABF : 105 mg/dl
• S. billirubin : 0.4 mg/dl
• SGPT : 36 U/L
• HBsAg : non-reactive
• Anti-HCV : non-reactive
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Investigations (cont…)Investigations (cont…)
• MT test : negative
• Sputum for AFB : negative
• Sputum for Gram stain : both extracellular
and intracellular
Gram negative
diplo cocci is
present
• Sputum for C/S : no growth
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Investigations (cont…)Investigations (cont…)
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Investigations (cont…)Investigations (cont…)
• USG of whole abdomen : Normal study
• ECG : Normal study
• Echocardiography : Normal study
• Chest X-ray ( P/A view) : normal study
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Chest X-ray ( P/A view)
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Investigations (cont…)Investigations (cont…)
• X-ray Lumbo-sacral spine
(A/P & lateral view) : grade I
spondylolisthesis
of L5 over S1 with
lumbar spondylosis
• X-ray both SI joints
(Oblique view) : normal study
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X-ray Lumbo-sacral spine
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X-ray both SI joints (Oblique view)
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• MRI of D/L spine & both SI joints:
-degenerative disc & spine disease
- L4-L5: disc bulging with corresponding thecal sac indentation
- L5-S1: central & both para central disc protrusion with corresponding thecal sac indentation & bilateral foraminal narrowing.
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MRI of D/L spine
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MRI of D/L spine
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• Bone marrow study:
- Average cellular marrow with normal M:E ratio
- Erythropoiesis is active and normoblatic
- Granulopoiesis is also active and maturing
into segmented forms
- Megakaryocytes are normal
- Lymphocytes and plasma cells are increased
- No sign of hemophagocytosis, no granuloma,
ectopic cell or parasite is seen
Comment: Features suggestive of secondary reactive marrow
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Confirm diagnosisConfirm diagnosis
Brucellar spondylitis
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Management:Management:
A. General Management:
a. Rest
b. Assurance
c. Patient education
- about disease
- about management
- about outcome
- about prevention
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Management(Cont … )Management(Cont … ) B. Specific management:
(Acc. to WHO) management of brucellar
spondylitis :
Cap. Doxycycline 100 mg twice daily for 6 weeks
Cap. Rifampicin 900 mg/day for 6 weeks and
Inj. Streptomycin 1 g/day IM for 3 weeks.
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Management(Cont … )Management(Cont … )
-Others:
Cap. Indomethacine
Cap. Omeprazole
Tab. Tolperisone
Tab. Levosulbutamol
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Management(Cont … )Management(Cont … )
ADL advices:
-avoid heavy lifting
-use firm mattress and single pillow
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Present condition of the patient:Present condition of the patient:
• Symptoms:
Fever - subsided
Cough - improved
Low back pain - improved
• On examination:
All movements of spine - restored
Expansibility of chest - restored
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• CBC (05.10.13):
Hb% - 11.0 gm/dl
ESR - 43 mm in 1st hr.
WBC - 4260/cmm
Neutrophil - 30.5%
Lymphocyte - 56.8%
Monocyte - 6.6%
Eosinophil - 5.9%
Basophil - 0.2%
Platelet count - 216000/ cmm
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• PBF (05.10.13):
RBCs - normochromic and normocytic
WBCs - are mature, total and differential
counts are within normal limit
Platelets - are normal
No MP is seen
Comment: Non - specific morphology
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Follow-up:Follow-up:
• essential for ensuring that the patient complies with the full 6-week antibiotic regimen
• continued until the infection is cured and laboratory findings return to reference ranges.
• to monitor the course of low back pain
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Prevention:Prevention:• Avoid potential sources of infection
-avoiding infected animals
-using precautions(eg, gloves and mask)when
dealing with a potentially infected animal
-avoiding potentially contaminated foods
• For farmers, immunization of cattle against the disease
• For laboratory workers, maintenance of the appropriate level of containment
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Thank You