Clinical Pathology

Conference
22 RHF with back pain
Tufts Neurology
October 6, 2009

SR is a 22 year old right handed Hispanic woman who

presents with back pain. She was in her usual state of health
until seven months ago when she developed gradual onset of
lower back pain. Since then she has never been pain free and
in fact it has intensified over time. She rates her pain intensity
15/10 and finds it unbearable. Exacerbating factors include
sitting and moving. Lying flat diminishes the intensity of the
pain. She denies associated urinary or fecal incontinence,
parasthesias, focal motor weakness, or local trauma. The
pain impairs her ability to ambulate.
She was recently hospitalized at Union Hospital in Lynn for
deconditioning. With progression of her back pain she
presented to Lemuel Shattuck Hospital and after initial
diagnostic testing was transferred to Tufts Medical Center for
further care.

Other than back pain her past medical history includes

admissions for failure to thrive, and a cesarean delivery of a
healthy baby boy.
Born in Mexico, she immigrated to the United States at the age of
17. She originally settled in Florida before moving to
Massachusetts. Previously she held a job at a plant nursery. Her
partner died in 2006 of a systemic illness. At present she lives
with her fianc in Lynn. She does not offer any information when
questioned about alcohol, tobacco, or drug use. She has not had
any formal education.
She is unaware of any family history of disease as she no longer
maintains contact with her family in Mexico.
She does not have any allergies. Her medications include
amitriptyline, calcium, vitamin D, celebrex, lovenox, pepcid,
fentanyl patch, lactulose, mirtazapine, multivitamin, zofran,
oxycodone, senna, and colace.

On physical examination her temperature is 101.3 F, heart rate 125

bpm, blood pressure 99/58, respirations 18, oxygen saturation 98% on
room air. She appears cachectic and in moderate pain. Her heart is
without murmur and lungs are clear. Her abdomen is diffusely tender
to deep palpation without rebounding or guarding. Her skin shows
scattered macules with a hyperpigmented circumference and
hypopigmented center over her limbs and trunk.
On neurological examination she is alert and fully oriented. She
speaks Spanish exclusively. She can follow three step commands.
She is unable to read or write, which is her baseline. Her naming is
intact. Cranial nerve testing is normal. Motor testing was limited by
pain but found only 4+/5 weakness in hip extension bilaterally.
Reflexes were absent at the knees, 2+ at the Achilles, and 1+
elsewhere with down going toes. Sensory testing did not reveal any
loss in pin, temperature, proprioception, vibration, or light touch.
Coordination testing was normal. She refused gait examination
secondary to pain.
A diagnostic procedure was performed.

Na 134
BUN 6

K 3.7
Cr 0.51

Cl 103

AP 227
0.1
Alb 2.6

ALT 15

Tbili 0.3

Ca 8.8

Mg 1.4

WBC 6.9
Plt 603

Hg 10.9

CO2 22
Dbili
Ph 4.6
Hct 32.2

MCV 78
PT 13.5

INR 1.1

PTT 26.6

CRP 39.44
Anaerobic, fungal, aerobic blood cultures negative.