A Divorced Man With Back Pain After Trip With New Girlfriend

Ankit Raiyani, MBBS, MD, DNB (Hematology); Vikramjit Kanwar, MBBS, MBA, MRCP(UK)


May 09, 2022

Physical Examination and Workup

Upon examination, the patient is alert and oriented but appears tired. He is afebrile, with normal vital signs, including a heart rate of 84 beats/min, respiratory rate of 16 breaths/min, and blood pressure of 128/78 mm Hg. His oxygen saturation is 98% on room air via pulse oximetry.

Mild conjunctival pallor is noted, but he has no icterus, lymphadenopathy, cyanosis, or clubbing. Minimal pedal edema is observed, but skin examination findings are otherwise unremarkable. His chest is clear to auscultation, and his abdomen is soft, nontender, and nondistended, with no hepatosplenomegaly. Neurologic examination findings are normal and reveal no focal deficits. He is able to extend and flex his back. No deformity is visible. No warmth, swelling, or tenderness is noted over his lower back. His joints are otherwise mobile, and a musculoskeletal exam reveals normal bulk, tone, and power.

Initial blood tests include a complete blood cell count, which shows a hemoglobin level of 9.5 g/dL (reference range, 14-18 g/dL), with normal total white blood cell, differential, and platelet counts. Peripheral blood smear confirms normocytic normochromic anemia; clumping of red blood cells is noted, but no blasts or other abnormal cells are observed. His erythrocyte sedimentation rate (ESR) is elevated at 104 mm/hr. Blood chemistries on a routine panel are significant for an elevated serum creatinine level of 2.1 mg/dL, elevated serum calcium level of 11.1 mg/dL, and decreased serum albumin of 3.2 g/dL. His additional serum electrolyte levels and liver enzyme levels are within the reference range.

HIV screen test results are negative. Urine examination reveals mild proteinuria but no leukocytes, red blood cells, or casts. Findings on chest radiography and radiography of the thoracolumbar spine are both normal. An MRI of the spine has been scheduled.


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