Red flag patients
Mildly tender over lower thoracic/L1 region and right lower rib cage. BM1 21.
- Red flags - Pain in thoracic region
- (Bony tenderness)
- thoracolumbar x-ray.
- FBC, ESR, UE, LFT, PSA, bone profile.
- Vertebral Collapse Fracture (VCF) L1, bones osteopenic on xray, FBC normal except MCV 101 (chronic- normal haematinics), ESR=18, PSA= 2.5, calcium - normal
- Pain diagnosed as related to crush fracture ? from previous fall/ osteoporosis.
bisphosphonate and calcium/vit d started.
Over next 4 months managed with increasing analgesia- codeine phosphate - stopped due to nausea, Buprenorphine patch5- 10mcg - no help at all- stopped. Tramadol 100mg qds- small benefit, limited by elment of confusion.
Physiotherapy (core strengthening, gentle mobilisation of back) and advice to stay active - continued walking dog - but becoming increasingly difficult.
Review - 4 Months
- Increasing pains, not responding to treatment, keeping awake at night, some dyspepsia, reduced appetite and weight loss. Omeprazole added - dyspepsia improved.
- Bloods repeated- ESR = 26, FBC/ bone profile - remain the same. felt to be appropriate for age. cont above management.
Reviewed 1 month later
- Further weight loss, pain worse in right lower rib cage.
- CXR requested - demonstrated lytic lesions in multiple ribs right lower rib cage.
- 2 week referral to haematology- bone marrow aspirate confirms Multiple Myeloma.
- Beware pain that is increasing, esp at rest.
- False reassurance with normal blood results (although normal range for ESR = 1-10, in older patients ESR < age/2 often accepted as normal)
- Acceptance of osteoporotic crush fracture as cause of pain
- Weight loss partially attributed to dyspepsia and assoc. reduced appetite