08-13-2008, 05:05 PM
An 81-year-old Chinese-American woman is brought to the emergency department by her husband because of back pain. She says, "My back hurts and the pain is getting worse." The patient tells you that 2 days ago, an epidural block was done by a staff anesthesiologist because of a chronic, painful left L5 radiculopathy. She obtained temporary relief immediately after the procedure, but about 24 hours ago she began having midline low back pain without radiation that has increased in severity. She was unsuccessful today in contacting the orthopedist who arranged the procedure. Vital signs now are: temperature 38.5°C (101.3°F), pulse 101/min and blood pressure 140/85 mm Hg. On physical examination there is tenderness over the L3-5 area in the midline, which is slightly swollen. Straight leg-raising test is negative bilaterally. Anal sphincter tone is normal. There is decreased sensation over the left lateral calf, an absent left ankle reflex and moderate weakness of left great toe extension. The remainder of the neurologic examination of the leg is normal.
Item 1 of 2
35. Which of the following is the most accurate statement?
A
) An epidural abscess has developed
B
) The epidural block has worn off
C
) The original injection was subdural
D
) A radiculopathy has developed at a different level
E
) She is having a reaction to the anesthetic
Item 2 of 2
36. Which of the following is the most appropriate next step?
A
) Administer an analgesic and diphenhydramine
B
) Administer an analgesic, intravenously, and arrange myelography
C
) Contact the anesthesiologist about repeating the epidural block
D
) Reassure the patient and have her make an appointment with the orthopedist for tomorrow
E
) Request an emergency MRI of the spine
Item 1 of 2
35. Which of the following is the most accurate statement?
A
) An epidural abscess has developed
B
) The epidural block has worn off
C
) The original injection was subdural
D
) A radiculopathy has developed at a different level
E
) She is having a reaction to the anesthetic
Item 2 of 2
36. Which of the following is the most appropriate next step?
A
) Administer an analgesic and diphenhydramine
B
) Administer an analgesic, intravenously, and arrange myelography
C
) Contact the anesthesiologist about repeating the epidural block
D
) Reassure the patient and have her make an appointment with the orthopedist for tomorrow
E
) Request an emergency MRI of the spine