Chief complaint: Back Pain
Pertinent positives/negatives:
_
—————————-
Complaint specific findings on exam:
Neuro: after adequate analgesia:
Motor 5/5 for corresponding lumbar and sacral regions
Specifically able to squeeze buttock with normal strength
Ambulatory
Specifically, no focal motor neurological deficits.
—————————–
ED COURSE:
no hx of trauma
no hx of spine surgeries
no IVDU.
no inability to urinate/bowel incontinence
no hx of cancer
no pain on urination
no hx of kidney stones
no abd pain
MDM:
_upreg
_UA (evaluation for UTI/pyelo)
_ PVC
Results: PVC < 50cc (which has negative predictive value for making cauda equina less likely)
(PVC calculated by PVC machine by RN)
(PVC calculated by clinician US = ht x w x l x 0.5)
Therapeutically:
analgesics
Pt advised to take ibuprofen around clock for 7 days for anti-inflammatory purposes, advised to continue to ambulate, try yoga/mild exercises.
Working diagnosis:
_ Suspect musculo-skeletal lower back pain
_ Concern for cauda equina
_ emergent neurosurgery consult
_ initiated request for emergent MRI
_ considering CT myleogram given unable to obtain MRI emergently
_ dexamethasome 16mg IV contingent upon neurosurgery’s recommendations
DDx (I considered that there is a small but finite risk for the following processes. The patient’s presentation does NOT meet our criteria for being reasonable for additional pursuit of these entities at this time (i.e. reasonable level of consistency with characteristic findings as detailed parenthetically below):
-Cauda equina syndrome given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e.given no neurological deficits, no saddle paresthesia, good buttock squeeze, no inability to urinate, no bowel incontinence, PVR not c/w cauda equina
-AAA given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e.given no palpable pulsitile mass on abd exam, no abd pain, no hx of AAA nor sufficicent number of risk factors for AAA.
-renal colic given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e.given no CVA tenderness, pain not colicly, UA no rbc’s, no hx of stones.
-Metastatic lesion to vertebral bodies given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e.given no wt loss, no hx of malignancy, not worse in morning.
-Epidural abscess given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e.given no hx of IVDU, no fevers/chills.
-motor cord compression from fracture, retrolisthesis, spondylolisthesis, nerve impingement given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e. no hx of past spine surgery, no recent hx of trauma, no radicular motor symptoms
Disposition:
-home given patient re-examined prior to being discharged – no new medical complaints, clinically improve, ambulatory, neuro exam intact. Patient advised for prompt f/u with PMD for outpatient eval, possible non-emergent MRI, and implored return precautions upon patient including new neuro symptoms, worsening pain, urinary/bowel issues, development of any new symptoms, or inability to arrange prompt follow up.
-Given that the patient was discharged with a prescription for a sedating medication, I counseled the patient of the risks associated with taking the medication. Specifically, I implored the importance of not driving, drinking, operating heavy machinery, and of the fall risk associated with these medications. The patient expressed an understanding and agreed to avoid those situations while on this medication.
*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).