Need help with direction for dx

[JackieHouse, LPN, EMT-B]

I have searched for years to try and help, but it is getting so bad now I have nowhere else to turn. I hope someone can push me in the right direction. This involves my spouse and I do have his permission to post.

Case follows: 41y/o male presenting with moderate back pain, c/o additional nodules on rib cage (photos enclosed) stating they are sore to the touch, also states suffering from muscle spasms in his back. States pain feels like hot acid and spreads from thoracic/lumbar area around chest to abdomen. States he has postprandial pain/spasms. Also states at times he has widespread pain that makes arms and leg muscles sensitive to the touch. States he had severe pain in his knuckle of big toe several days ago, no hx of gout noted. VS stable and WNL. ROM is limited in upper right extremity to about shoulder level, limited in flexion and extension of the spine. Twisting spine to right is at about 50% remaining ROM.

Hx of twisting spinal injury in 1999 while closing a lift gate on a utility trailer, hx of abdominal surgery x2 for appendectomy (removal, then reentry for debriedment/infection, thanks USAF!) with deep scarring on RLQ. Pt is unable to 'pop' his spine on his own, has to have assistance via downward bilateral pressure to 'pop' and relieve muscle tension. Muscles around thoracic spinal region are stiff to the touch, present with knots at times in tight areas. Previous MRI/CTs in 2010 show DDD, disc space narrowing from L4 to S1, L4/L5 bulging disc, osteophyte formation along posterior-left lateral aspect of L4/L5, mild stable S curvature of thoracic spine, levocurvature at cervicothoracic junction with cervical spine straightening, mild disc space narrowing at C6-7 and C7-T1, C6-7 show facet degeneration and disc bulge/osteophyte complex with narrowing of the spinal canal. Current MRI shows significantly more degeneration in these areas. Nerve conduction tests show no significant findings x2. Pt has been tested for RA, findings were negative x2.

Previous txs include Darvocet, Percocet, cyclobenzaprine, methocarbamol, tizanidine, orphenadrine, baclofen, lorazepam, routine naproxen and acetaminophen regimen, ibuprofen regimen, Voltaren gel, TENS unit, trigger point injections x15+, radiofrequency ablasion x2, epidural x3, massage thx x4yrs+ @ qWeek, prolotherapy x3, kratom capsules, compression bracing, and stretches.

Current txs include metaxalone 800mg TID, Norco 10/325 TID/PRN, duragesic 50mcg patch q72hr, gabapentin 300mg TID, clonazepam 0.5mg qAM, nortriptyline 50mg qHS, Centrum Mens MV qDay, magnesium oxide 800mg qDay, ES Tylenol 1gm/PRN up to 3x day, nightly massage with Gold Cup/Tiger Balm PRN. Daily stretches PRN. 6% CBD oil 5gtts SL BID/PRN.

Pt is looking to get away from opioid use d/t stigma and it's inability to help with pain after 10 years on the same dose, has future appointment to discuss other alternatives, including medicinal cannabis.

Current blood levels show (04/12/2019)

BUN: 18 (7-25)

Creatinine: 0.94 (0.60-1.35)

eGFR: 100 (> or =60)

Protein: 7.4 (6.1-8.1)

Albumin: 4.8 (3.6-5.1)

Globulin: 2.6 (1.9-3.7)

Bilirubin: 0.3 (0.2-1.2)

Alkaline Phos: 64 (40-115)

AST: 26 (10-40)

ALT: 21 (9-46)

\*\*Creatine Kinase: 465 (44-196)\*\* Previous CK: 68 on 01/20/2015

TSH: 2.12 (0.40-4.50)

Zinc 68 (60-130)

hla-B27: Negative

\*\*Testosterone: 19.7 (46.0-224.0)\*\*

TSI: <89 (<140)

ESR: 9 (< or =15)

Aldolase: 4.6 (< or =8.1)

CBC w/ auto diff all WNL

Iron, ferritin, B12, Rheumatoid factor, C-reactive protein, CCP are all WNL.

Sjogren Panel: Negative

Antinuclear Antibodies: Negative

Lyme Screen: Negative/Normal

Celiac Disease Panel: Negative

Hep Panel (A, B, C): Non-reactive, normal

Myositis Panel: <11 (<11)

No significant muscular injury noted prior to bloodwork besides continuing/worsening chronic pain, nodules on ribs appeared about 12mos+/- ago. Pt is a social drinker, 3-4 beers per week. No kidney issues noted. Pt has elevated cholesterol (229), and very high triglycerides (433), states family hx on paternal side.

Pt has seen multiple doctors and specialists over the last 20 years attempting to get answers, from allergist and rheumatologists, to PCPs, sports medicine/orthopedists, and pain management. Pt has been to Shands @ Gainesville to see the orthopedic physician, MRI revealed 'nothing they could do except surgery' and was told that the surgery relief would only last a few years at best. Pt believes this may be a muscular problem rather than nerves or bones, and wonders if anyone has seen this or something similar before and may be able to point him to a dx, certain type of specialist, or test that may help figure out what exactly is going on.

Any help or advice, direction, or maybe something you have seen in your experience is greatly appreciated.

[HomeBound]

We are not permitted to assist in diagnosing patients. Diagnosing is not in our scope of practice.

This is your husband and that is even more inappropriate. He needs to see and speak to his physicians and if you want a second opinion you need to seek one from a qualified medical practitioner.

Sorry to be so blunt but even if we had an opinion, it is out of our scope of practice to offer advice.

[JackieHouse, LPN, EMT-B]

I am not specifically looking for a dx, I realize I can’t go online and get that, I’m looking for anything, anything at all to help with finding some sliver of anything we haven’t tried or looked at or didn’t see. A hint of who to see next. What haven’t we looked at. We have seen a string of doctors here and they either say they don’t know or won’t even try anything because he’s on opioids. In desperation and exasperation I came to somewhere I felt would have qualified people who may have an inkling of a clue to help me in the right direction. I am shamelessly asking for help in direction on behalf of my spouse’s chronic pain, apologies if it was worded poorly.

[MunoRN, RN]

The only medical advice we can give is to see a doctor for medical advice.

From a nursing perspective, I would point out that when medical tx isn't working to a patient's satisfaction, more and more medical tx isn't necessarily the answer, sometimes you can overdo it and then who knows if the problems are due to excessive medical tx or the lack thereof. Once someone has added Kratom to their medical tx regimen, a dangerous drug with only recreational uses, maybe they've overshot that balance.

That MRI actually sounds better than mine, I take nothing for my back, I see a physical therapist for exacerbations and do the maintenance exercises in between. It hurts, sometimes excruciatingly so, but that's what one should expect from the normal aging process combined with probably more than average wear-and-tear on the back. I rely on that feedback (pain) to know when I'm at risk of damaging it more and to take steps to avoid further damage, dulling those feedback signals are almost guaranteed to just cause more damage.

[traumaRUs, MSN, APRN]

Please see a provider in person.