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Patient Profile
23 year old AA male presented to outpatient clinic with
• Back pain• Fatigue X 3months
History of Present Illness
• Lower back pain– 5/10 intensity– No radiation– No lower extremity weakness– No bowel/bladder incontinence
• Non productive cough with intermittent fever• Decreased appetite
• Denies – trauma– loss of weight– diarrhea– hemoptysis– rashes– lymph node enlargement– cold intolerance
Past medical and surgical history
• Negative HIV 2 years ago• PPD positive 3 years ago- not followed up
• Father with diabetes and hypertension• Uncle who died of tuberculosis when patient
was a child
Family Medical history
Personal and Social history
• 1-2 beers on weekends• 1 cigar/day x quit 5 months ago• No illicit drug use• Multiple sexual partners in past 1 year
• Spent past 2 years in a homeless shelter in New Orleans
• Unemployed
Physical Examination
• Vitals – 100.4ᴼF– Pulse 88/’– BP 119/80– SpO2 98% in room air
• No pallor, icterus• 2x2 cm Rt. supraclavicular node• Tenderness over L2 vertebra• No kypho-scoliosis
• Chest– Bilateral lower rib tenderness– Clear on auscultation
• Abdomen– No hepatosplenomegaly
• Neurological– Straight leg raising test negative– Power 5/5 in all limbs ; Reflexes normal– No sensory loss
Investigations
• CBC, U/A, BMP, LFT, S.Creat: Normal• Serum electrophoresis: negative• Chest X-ray: Negative• Awaiting PPD, blood culture
• CT showed multiple lytic osseous lesions in ribs and L2 spine with invasion into posterior soft tissues
• MRI- Rt. Paravertebral mass at L2 destroying pedicles and transverse process. Reactive inflammatory changes in psoas muscle
Assessment and plans1. HIV, RPR2. Bone scan3. FNAC supraclavicular lymph node, CT biopsy
lumbar mass4. Fentanyl IV 50µg bolus every 3 hrs5. Empiric treatment with • INH (5mg/kg)• Rifampin (10mg/kg) • Pyrazinamide (15-30mg/kg) • Ethambutol (15-25mg/kg)
Summary• 23 year old AAM• lower back pain and fatigue x 3months• history of non productive cough, fever and loss of
appetite for 3 months• Chronic smoker quit 6 months back• Unemployed and lives in homeless shelter• R. supraclavicular lymph node, bilateral lower rib
tenderness and tenderness over L2. • Paravertebral mass at L2 with inflammatory
changes in psoas muscle in MRI