The Verdict Is In

Vague presentations with multiple complaints can sometimes have complex outcomes.

A 44-year-old presented to the urgent care with a CC of back and right arm pain. He mentioned to the physician assistant he was trying to get clean from heroin and needed something for withdrawal symptoms. The patient was an unreliable historian mentioning last heroin use was 3 days ago and at other times last use was yesterday. States last meth was 10 years ago. He says there is pain in the neck and it shoots into the right scapula and arm. Gradual onset, 3 days ago, constant, denies trauma. Rates pain 9/10

ROS: "really unobtainable as pt is not answering questions and varying off on tangents".
PMH: unknown
Meds: soma, oxycodone, another unknown medication
Social: hx of substance abuse. + smoker

Exam

VS: T 36.9. BP 139/92. P 109. R 18. O2 sat 96% on RA
Constitutional: disheveled, thin but not cachectic. Unable to sit still. Myoclonic activity in the thorax, upper extremities and head
HEENT: NCAT. PERL. Dentition is poor w caries. Numerous extractions, missing teeth
Neck: supple. Trachea midline
CV: RRR
Lungs: Clear to auscultate bilaterally w normal respiratory effort
Neuro: alert and oriented to person, place, time. Speech for the most part clear but occasionally difficult to understand. Some myoclonic activity with gait but otherwise normal. Good strength and tone.
Psych: Thought process is tangential. Able to follow directions. Cooperative
Skin: lesion on R middle forearm, radial aspect. Lesion is crusted over and appears to have been draining recently. There is no redness, warmth or swelling around it

MDM: High risk for cellulitis given hx of IVDA and draining abscess. Will tx with Bactrim and Keflex. In regard to withdrawal symptoms it is unclear when he last used. He is exhibiting quite a bit of myoclonic activity suggestive of recent meth use. Nonetheless I am going to give him an rx of Ativan and Zofran to help his withdrawal. In regard to his pain, he is not exhibiting any tenderness to palpation and appears to be having pain in the R paraspinal musculature medial to the scapula. I gave Toradol and advised him to take Ibuprofen tid prn. Written dc instructions given for back and neck pain.

Impressions: Substance abuse. Back Pain. Possible Withdrawal

There was a 5-day delay between this visit and subsequent presentation at an outside hospital. Symptoms were now drastically different, including loss of movement in lower extremities and weakness in upper extremities.

Allegations: Failure to diagnose and treat a cervical spine epidural abscess resulting in quadriplegia in a 44-year-old. Adverse jury potential due to life care plan was potentially >9 million. Case settled.

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Survey Questions

1. Why were experts critical of the physician assistant's care?:

  1. Patient had a vague dx, had myoclonic activity (which could indicate evolving spinal lesion), and had abnormal vs. The case was not presented to a supervising physician
  2. There is no indication that spinal epidural abscess was in the differential despite evidence of active infection. If it was, there was not adequate work-up to r/o the dx
  3. Documented musculoskeletal/back exams were substandard (for a cc and dx of back pain)
  4. All the above
  5. None of the above

2. It is not reasonable (nor are we suggesting) to order and MRI on every spine case. In this case, it may have been indicated. We do recommend:

  1. A high index of suspicion
  2. Know the red flags of back and neck pain (i.e.: bilateral radiation of symptoms, objective neuro findings, fever, CA, etc.)
  3. Performing and documenting very thorough histories and exams
  4. Addressing abnormal vitals
  5. When MRI indicated, imaging as much of the spine as possible
  6. All the above

3. True or False? The classic triad of fever, back pain, and neurologic deficits is present in most patients with SEA

  1. True
  2. False