Red flag patients

Patient: 72-year-old.

Examination

Mildly tender over lower thoracic/L1 region and right lower rib cage. BM1 21.

  • Red flags - Pain in thoracic region
    - Age
  • (Bony tenderness)

Investigations

  • thoracolumbar x-ray.
  • FBC, ESR, UE, LFT, PSA, bone profile.

Findings

  • 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.

Learning points

  • 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