(P43) The Percocet I Was Prescribed Are No Longer Working

Chief Complaint : I Have been having back pain for weeks now.

History of Present Illness : The patient is a 59-year-old male with a past medical history of hypertension, and nephrolithiasis resulting in urosepsis, who presented to the emergency department for evaluation of upper back pain. He notes a history of back pain usually controlled by over-the-counter medications; however, over the last two to three weeks, he has found the pain difficult to control. He was discharged recently from the ICU after treatment for urosepsis. He denies fever, chills, shortness of breath, chest pain, abdominal pain, syncope, headache, and vomiting.

Pertinent Physical Exam: physical exam revealed patient is in significant distress, and unable to find a comfortable position. Vital signs were remarkable for BP of 143/101mmHg, and an HR of 123bpm, the rest of the patient’s vital signs were remarkable Including, a RR of 20 breaths per minute, oxygen saturation of 95% on RA, and a temperature of 98.4. A cholecystostomy tube was present in the right upper quadrant. Diminished strength and reflexes in both lower extremities but preserved strength in the upper extremity and sensation in all four extremities, including pinpoint sensation. He also has a loss of rectal and bladder tone.

Pertinent Laboratory Data: Laboratory findings on the CBC, inflammatory markers, and urinalysis were noted as a WBC of 13200 per microliter (4800 – 10800 per microliter), a neutrophile count of 87% (36 -66%), additionally ESR and CRP were 48 millimeters per hour (0 – 20 millimeter per hour); 98 milligrams per liter (0 – 3 milligrams per liter) respectively. Alkaline phosphatase at 194 Units per liter (24 – 117 Units per liter). Urinalysis was remarkable for a WBC of 101 – 200/HPF and an RBC of 21 – 50/HPF. It also contained trace bacteria and a large amount of leukoesterase.

Case Discussion: The patient presented for concerns with continued back pain, progressive lower extremity weakness, and a fever with a Tmax of 101.3. He denied any history of spinal trauma or procedures, intravenous drug use, or diabetes mellitus. However, He admitted to a renal dysfunction history stemming from nephrolithiasis that needed nephrotomy tube placement approximately five weeks prior. He added a history of mild back pain which he noted was responsive to over-the-counter medication. On review of medical records, it was noted that he presented to the ED on three prior occasions with a back pain complaint testing and imaging were unremarkable. He was discharged home with opioid medication and a follow-up for pain management. He noted that the opioids did not control the pain. Due to the history obtained from the patient, physical exam, and laboratory findings, we had a high suspicion of a spinal epidural abscess and knew he need MRI imaging but due to pain wouldn’t tolerate the exam, so he was intubated for airway protection before obtaining the MRI as not to risk aspiration while being imagined. MRI confirmed the diagnosis of a posterior spinal epidural abscess at T5 through T8, with associated discitis and osteomyelitis at T6 and T7. The patient was transferred to a neurosurgical facility for definitive surgery.

References and Acknowledgements (Optional): N/A