Posters
Presentation Type
Poster
Discipline Track
Patient Care
Abstract Type
Case Report
Abstract
Background: This case is a great example of remembering the basics. We teach our medical students, residents and fellows the importance of getting a thorough history and exam. However, this case is a reminder to apply those lessons in the real world.
Case Presentation: 15 yo Female came in complaining of sacral pain. 2 years prior she had a fall causing a coccyx fracture which resolved with conservative treatment. She didn’t have any issues since then until 3 weeks prior to today when she began to have pain in the same area. She denied any new inciting events such as trauma or falls. She saw pediatrician for annual wellness exam 2 weeks prior who ordered imaging showing mildly displaced fracture of the anterior distal coccyx and normal soft tissue appearance and was given ortho referral. Mom says ortho didn’t say much with no follow up plans. The pain increased over the next week almost causing her to go to ER. She then saw a Chiropractor who recommend against manipulation given the x-ray findings. Reported to have normal pain free bowel movements. Pain is aggravated with sitting. She denied any radiation of pain, numbness, tingling, urinary changes, fevers, chills or night sweats. Last menstrual period was 3 weeks prior and normal.
Differential Diagnosis:
- Coccyx Fracture
- Disc herniation
- Spondylolysis
Physical Examination:
T: 98.3F
BP: 129/74
Pain: 8/10
Pulse: 109bpm
General: Moderate distress
Respiratory: No respiratory distress
Musculoskeletal:
Back -
ROM: Full forward flexion, side bends, twisting, extension.
Special Maneuvers: Negative slump test bilaterally. Straight leg raise deferred due to pain.
Bilateral Lower Extremities-
Strength: Hip flexion, knee flexion, knee extension, ankle dorsiflexion, ankle plantar flexion all 5/5.
DTR intact knee and ankle 2+
Inspection: T-spine/L-spine no gross abnormalities, erythema, rashes, bruising or lacerations.
Sacrum noted large erythematous cyst/abscess at the superior intergluteal natal cleft with no visible openings or superficial sinus or drainage noted.
Palpation: T-spine/L-spine non-tender. Superior intergluteal natal cleft with roughly 3cm area of fluctuance tenderness to palpation.
Treatment: In office incision and drainage performed at intergluteal natal cleft abscess using local anesthesia. Moderate amount of foul-smelling purulence was drained and washed out.
- Oral antibiotics prescribed
- CT scan ordered
- General surgery referral provided
Test Results: Wound culture – Negative
CT pelvis w/wo contrast – abscess measuring 2.8 x 1.8 x 3.6cm, some moderate proliferative enhancement.
Final Diagnosis: Pilonidal Abscess
Outcomes: Excellent learning case highlighting the extreme importance of a thorough physical exam. Mom mentioned nobody had previously looked at the area of complaint meaning that the patient was seen by 3 providers who failed to perform a basic exam. Patient had to unnecessarily endure over 3 weeks of pain. Left untreated, this could have progressed to sepsis and hospitalization. Patient later saw general surgery but decided against further intervention due to financial reasons. However, she did well overall.
Academic/Professional Position
Faculty
Mentor/PI Department
Family Medicine
Recommended Citation
Perez, Evan D., "Sacral Pain "Recurrence" Not Exactly The Teenage Dream" (2024). Research Symposium. 16.
https://scholarworks.utrgv.edu/somrs/2023/posters/16
Included in
Sacral Pain "Recurrence" Not Exactly The Teenage Dream
Background: This case is a great example of remembering the basics. We teach our medical students, residents and fellows the importance of getting a thorough history and exam. However, this case is a reminder to apply those lessons in the real world.
Case Presentation: 15 yo Female came in complaining of sacral pain. 2 years prior she had a fall causing a coccyx fracture which resolved with conservative treatment. She didn’t have any issues since then until 3 weeks prior to today when she began to have pain in the same area. She denied any new inciting events such as trauma or falls. She saw pediatrician for annual wellness exam 2 weeks prior who ordered imaging showing mildly displaced fracture of the anterior distal coccyx and normal soft tissue appearance and was given ortho referral. Mom says ortho didn’t say much with no follow up plans. The pain increased over the next week almost causing her to go to ER. She then saw a Chiropractor who recommend against manipulation given the x-ray findings. Reported to have normal pain free bowel movements. Pain is aggravated with sitting. She denied any radiation of pain, numbness, tingling, urinary changes, fevers, chills or night sweats. Last menstrual period was 3 weeks prior and normal.
Differential Diagnosis:
- Coccyx Fracture
- Disc herniation
- Spondylolysis
Physical Examination:
T: 98.3F
BP: 129/74
Pain: 8/10
Pulse: 109bpm
General: Moderate distress
Respiratory: No respiratory distress
Musculoskeletal:
Back -
ROM: Full forward flexion, side bends, twisting, extension.
Special Maneuvers: Negative slump test bilaterally. Straight leg raise deferred due to pain.
Bilateral Lower Extremities-
Strength: Hip flexion, knee flexion, knee extension, ankle dorsiflexion, ankle plantar flexion all 5/5.
DTR intact knee and ankle 2+
Inspection: T-spine/L-spine no gross abnormalities, erythema, rashes, bruising or lacerations.
Sacrum noted large erythematous cyst/abscess at the superior intergluteal natal cleft with no visible openings or superficial sinus or drainage noted.
Palpation: T-spine/L-spine non-tender. Superior intergluteal natal cleft with roughly 3cm area of fluctuance tenderness to palpation.
Treatment: In office incision and drainage performed at intergluteal natal cleft abscess using local anesthesia. Moderate amount of foul-smelling purulence was drained and washed out.
- Oral antibiotics prescribed
- CT scan ordered
- General surgery referral provided
Test Results: Wound culture – Negative
CT pelvis w/wo contrast – abscess measuring 2.8 x 1.8 x 3.6cm, some moderate proliferative enhancement.
Final Diagnosis: Pilonidal Abscess
Outcomes: Excellent learning case highlighting the extreme importance of a thorough physical exam. Mom mentioned nobody had previously looked at the area of complaint meaning that the patient was seen by 3 providers who failed to perform a basic exam. Patient had to unnecessarily endure over 3 weeks of pain. Left untreated, this could have progressed to sepsis and hospitalization. Patient later saw general surgery but decided against further intervention due to financial reasons. However, she did well overall.