Assessment Note

The patient is a 47-year-old incarcerated male with a history of neurogenic bladder, left shoulder and right hand neuropathy, and recent upper back pain that has progressed to weakness, numbness, and inability to walk. He has a history of IV drug abuse and recent surgical procedures.

Differential Diagnosis

• Single Most Likely Diagnosis
  • Spinal Epidural Abscess (SEA): Given the patient's recent history of spinal surgery, IV drug abuse, and progressive neurological symptoms (weakness, numbness, and loss of bowel sensation), SEA is a highly likely diagnosis. The patient's upper back pain, worsened by movement, and recent history of fever, chills, and weight loss also support this diagnosis.
• Other Likely Diagnoses
  • Spinal Cord Compression: The patient's progressive neurological symptoms and upper back pain could be due to spinal cord compression, which may be caused by a variety of factors, including tumor, infection, or disc herniation.
  • Osteomyelitis or Discitis: The patient's recent surgical history and IV drug abuse increase his risk for osteomyelitis or discitis, which could cause his upper back pain and neurological symptoms.
  • Sepsis: The patient's history of fever, chills, and weight loss, combined with his recent surgical history and IV drug abuse, raises the possibility of sepsis.
• Do Not Miss Diagnoses
  • Cauda Equina Syndrome: Although the patient has a history of neurogenic bladder, his recent progression of neurological symptoms, including loss of bowel sensation, warrants consideration of cauda equina syndrome, which is a medical emergency.
  • Spinal Hematoma: The patient's recent surgical history and anticoagulation (if any) increase his risk for spinal hematoma, which could cause his neurological symptoms.
  • Meningitis: The patient's history of fever, chills, and recent surgical history raises the possibility of meningitis, which is a medical emergency.
• Rare Diagnoses
  • Spinal Cord Infarction: Although rare, spinal cord infarction could cause the patient's neurological symptoms, particularly if he has a history of atherosclerosis or other vascular disease.
  • Multiple Myeloma: The patient's recent weight loss and upper back pain, combined with his history of IV drug abuse, raises the possibility of multiple myeloma, although this is a less likely diagnosis.