AIM Module 2

Low back pain: “serious” causes

spinal cord/cauda equina compression
metastatic cancer (breast/prostate/lung/thyroid/kidney)
spinal epidural abscess
vertebral osteomyelitis

Low back pain: “less serious” causes (common)

vertebral compression fracture
radiculopathy
spinal stenosis
muscle spasm

Low back pain: “other” causes

axial spondyloarthritis (eg ankylosing spondylitis)
osteoarthritis
scoliosis
psychological distress/somatization
non-spinal etiologies (pancreatitis, AAA, herpes zoster)

Low back pain + urinary retention/saddle anesthesia/leg weakness

spinal cord or cauda equina compression

Low back pain + fever + IVDU/immunocompromised

spinal epidural abscess

Low back pain + fever + focal vertebral tenderness (± bacteremia)

vertebral osteomyelitis

when to suspect vertebral compression fracture

older age/osteoporosis (pain can be severe; trauma not required)

What is radiculopathy?

nerve root irritation/compression → radiating pain (most “sciatica” = radiculopathy)

What is spinal stenosis

narrowing of spinal canal/foramina → neurogenic leg symptoms + back pain

Muscle spasm: typical pattern

acute low back pain after strain/overuse; localized pain, tightness

inflammatory back pain (often young; stiffness > pain; improves with activity)

Axial spondyloarthritis

degenerative/mechanical pain (worse with use, better with rest)

Osteoarthritis

Non-spinal etiologies that can present as back pain

pancreatitis, abdominal aortic aneurysm, herpes zoster

Older patient + sudden severe back pain after minimal strain

Vertebral compression fracture

Low back pain + fever + focal spine tenderness

vertebral osteomyelitis

severe back pain + fever + early neurologic deficits

spinal epidural abscess

Dyspnea can’t-miss diagnoses

Heart failure
ACS / CAD
Arrhythmia
Pulmonary embolism

Dyspnea + orthopnea + edema

Heart failure

Dyspnea + chest pain/diaphoresis

ACS / CAD

Dyspnea + hypotension + JVD

Cardiac tamponade

Acute dyspnea + tachycardia + pleuritic chest pain

Pulmonary embolism

Dyspnea + crackles + hypoxia

Alveolar filling process (edema, pneumonia, hemorrhage)

Lumbar disk herniation epidemiology

May occur spontaneously or after exertion

Lumbar disk herniation clinical features

Acute severe unrelenting LBP
Radiation to buttocks/leg below the knee
Pain ↑ with straight leg raise

Straight leg raise: what does it indicate?

Disk herniation / radiculopathy

Lumbar disk herniation treatment based on severity

If pain alone → symptomatic (NSAIDs/analgesics ± steroids)
If clear/progressive neuro impairment (esp progressive) → consider surgical decompression
Also consider surgery in non-resolving pain

High-risk patient features for SEA/osteomyelitis

Spinal surgery
Overlying infection
Diabetes

Malignancy back pain epidemiology

Older patient (age >50 ↑ likelihood)
Often established malignancy (breast, prostate, lymphoma)

Malignancy back pain clinical features

Progressive back pain, worse with movement, often present lying still
Weight loss
Known malignancy

Epidemiology of vertebral compression fracture

Older patients
Women > men
Osteoporosis or related conditions (chronic steroids, hyperthyroidism, hypogonadism)

Labs in vertebral compression fracture

Normal (except osteoporosis-related labs, e.g. vitamin D deficiency)

Imaging findings in vertebral compression fracture

Plain X-ray: anterior vertebral wedging, end-plate irregularities, vertebral collapse
MRI: clearly shows fracture but usually not required

Pathophysiology of vertebral compression fracture

Osteoporosis → bone fragility → vertebral collapse (thoracic/lumbar)

Treatment of vertebral compression fracture

Symptomatic / expectant management
Calcitonin may help acute pain
Vertebroplasty/kyphoplasty benefit unclear

Epidemiology of ankylosing spondylitis

Young adults (2nd–3rd decade)
Associated with seronegative spondyloarthropathies
Associated with IBD, psoriasis, reactive arthritis

• Chronic low back pain

• Improves with exercise

• Does NOT improve with rest

• Worse at night

ankylosing spondylitis

Associated symptoms of ankylosing spondylitis

– Uveitis
– Inflammatory bowel disease
– Peripheral arthritis

Exam findings in ankylosing spondylitis

Decreased lumbar spine excursion (↓ Schober test)
SI joint tenderness

Labs in ankylosing spondylitis

↑ CRP / ESR (nonspecific)
HLA-B27 positive in ~95% (but low PPV)

Imaging findings in ankylosing spondylitis

Early: SI joint erosions/sclerosis (may be normal initially)
Late: ligament calcification → bamboo spine

Treatment of ankylosing spondylitis

NSAIDs + exercise / physical therapy
Anti-TNF agents in selected patients

Typical course of ankylosing spondylitis

Slowly progressive
May cause severe skeletal deformity
↑ Long-term risk of spinal fractures

Anterior wedging of vertebra on X-ray

Vertebral compression fracture

“Bamboo spine” on imaging

Ankylosing spondylitis

Leg edema: first branching questions

1. Unilateral vs bilateral

2. Acute vs chronic

Unilateral leg edema — acute causes

DVT
Cellulitis

Acute unilateral leg edema = concern for

DVT (until proven otherwise)

Unilateral leg edema — chronic causes

Venous insufficiency
Lymphedema (radiation, surgery)
Malignancy (abdominal/pelvic)
CRPS

Bilateral leg edema — acute causes

Medications
Bilateral DVT

Bilateral leg edema — chronic causes

Systemic disease
– cardiac
– renal
– hepatic
– pulmonary HTN
Venous insufficiency
OSA
Lymphedema
Lipedema

Acute unilateral leg swelling + pain

DVT

Unilateral leg swelling + erythema + warmth

Cellulitis

Chronic unilateral leg swelling after surgery or radiation

Lymphedema

Chronic unilateral leg swelling + history of pelvic/abdominal cancer

Malignancy causing venous obstruction

Acute unilateral leg edema — first test

Compression venous ultrasound

Suspected cellulitis — key labs

CBC (↑ WBC)
CRP (↑)

Chronic bilateral leg edema — initial labs

BMP
LFTs
Urinalysis (proteinuria)

Suspected cardiac cause of leg edema — tests

BNP
Echocardiogram

Cardiac edema — treatment

Diuretics + treat underlying HF

Renal cause of edema — key test

Urinalysis (protein)
Serum creatinine

Hepatic cause of edema — key labs

AST/ALT
Albumin
INR

Hepatic edema — treatment

Sodium restriction
Diuretics
Treat cirrhosis

PE tests

CTPA, ECG, D-dimer

ACS tests

ECG, troponin

Acute HF tests

TTE, CXR, BNP

Asthma exacerbation tests

Peak flow, PFTs, CXR

Arrhythmia tests

ECG, cardiac monitoring

Common vital sign abnormalities in heart failure

Tachycardia
Tachypnea
Hypoxemia

Left-sided heart failure — lung exam findings

Rales
Wheezing

Rales in dyspneic patient suggest

Pulmonary congestion (left-sided HF)

S3 gallop indicates

Systolic dysfunction (dilated, compliant ventricle)

Laterally displaced LV impulse suggests

LV dilation

S4 gallop indicates

Diastolic dysfunction (stiff ventricle)

Right-sided heart failure — key exam findings

Jugular venous distension
Lower extremity pitting edema
Ascites
Pulsatile liver

Positive abdominojugular (hepatojugular) reflux indicates

Right-sided heart failure
Impaired RV accommodation to venous return

Chest pain emergent causes — think

4 + 2 + 2

4 cardiac emergent causes of chest pain

Acute coronary syndrome
Aortic dissection
Cardiac tamponade
Takotsubo cardiomyopathy

2 pulmonary emergent causes of chest pain

Pulmonary embolism
Pneumothorax

2 esophageal emergent causes of chest pain

Esophageal rupture
Esophageal impaction

Chest pain + hypotension + JVD + muffled heart sounds suggests

Cardiac tamponade

Acute chest pain + dyspnea + tachycardia suggests

Pulmonary embolism

Best initial test for pneumothorax

Chest X-ray

Chest pain + fever + cough — diagnostic test

Chest X-ray

Pleuritic chest pain — pleural causes

Pulmonary embolism
Pneumonia
Pleuritis / pleural effusion
Pneumothorax

Pleuritic chest pain + pleural effusion can be caused by

Infection
Malignancy
Autoimmune disease
Drugs

Chest pain reproducible with movement or palpation suggests

Musculoskeletal cause

Mediastinal causes of pleuritic chest pain

Pericarditis
Aortic dissection
Epicardial fat necrosis
Pneumomediastinum

Pleuritis test

CXR

Pericarditis test

EKG

Pneumothorax test

CXR

ST segment that is concave up (“smiley face”) suggests

Pericarditis

ST segment that is straight, concave down, or horizontal suggests

STEMI

PR segment depression (with PR elevation in aVR) suggests

Pericarditis

Reciprocal ST depression in electrically opposite leads suggests

STEMI

Chest pain following viral prodrome suggests

Pericarditis

Acute lower GI bleed + abdominal pain =

Think ischemic colitis or diverticulitis

Acute large-volume painless hematochezia =

Diverticular bleeding or colonic AVMs

Lower GI bleed + systemic illness / hypotension =

Ischemic colitis

Bloody diarrhea + dull abdominal pain in older patient with vascular disease =

Ischemic colitis