Obese Woman With Fibromyalgia and Worsening

Back Pain
By Brady Pregerson, MD | August 16, 2013
Dr Pregerson is a staff emergency physician at Cedars-Sinai Medical Center in Los Angeles and Tri-City
Medical Center in Oceanside, Calif. He is the author of the Tarascon Emergency Department Quick
Reference Guide, the A to Z Pocket Pharmacopoeia, and Quick Essentials: Emergency Medicine. He is also
Editor in Chief of EMresource.org, a free online medical education Web site for emergency medicine and
urgent care practitioners.
An obese woman in her thirties with a history of fibromyalgia syndrome (FMS), polycystic ovarian
syndrome, diabetes mellitus (DM) and depression presented to the emergency department with gradually
worsening midline back pain of one week's duration. She initially attributed the pain to her FMS, but because
it did not improve as usual after a few days, she saw a chiropractor. When this did not help, she visited her
physician, who prescribed /acetaminophen and hydrocodone(Drug information on hydrocodone)
, also to no avail. cyclobenzaprine(Drug information on cyclobenzaprine)

For the 24 hours before coming to the emergency department, the patient had been constipated and had
difficulty urinating. Both legs began to feel wobbly and numb. She described the pain as extending from
below her neck down to her waist in the midline, usually worst just above her bra strap.

The patient said that this episode definitely was not like her typical FMS attack. She had no other complaints,
and when asked specifically, she denied fever, abdominal pain, and vomiting.

On physical examination, the patients pulse was 91 beats per minute; blood pressure, 138/76 mm Hg;
respirations, 22 breaths per minute, with a pulse oximeter reading of 99%; and temperature, 37.4C (99.4F)
taken orally.

Findings from inspection of the head and neck were unremarkable, but the astute doctor, suspecting the
worst, checked for meningismus, as indicated by the combination of fever and back pain. Chest examination
findings were completely normal. Her back and flank areas were not particularly tender. Neither was her
abdomen (although she is quite obese).

The neurological examination showed decreased subjective pinprick sensation in both leg, even up to the
lower abdomen. The patient had normal distal leg strength with both plantar flexion and dorsiflexion of the
foot, but during a straight-leg raise test she could only keep her legs up for one or two seconds.
The radiologist refused to call in the techs for an after-hours MRI scan, opting to begin with a CT scan which
he said would anything of consequence in the spine. If results were negative, he said, an MRI could always
be ordered the next day if indicated.
Vol. No. August 16, 2013
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A CT image at the level of greatest pain appearas above. Do you see anything noteworthy? What diagnosis
do you suspect?
Click here to see the . complete case study

Vol. No. August 16, 2013

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