[##]-year-old [male/female] with back pain with history and exam
consistent with likely musculoskeletal back pain.
Initial consideration in this patient included herniated intervertebral
disc, acute ligamentous injury, acute muscle strain, spondylolisthesis and
other musculoskeletal etiologies, cauda equina, spinal fracture, spinal
stenosis, epidural abscess and hematoma, cancer metastases, and kidney stone
among others.
Patient presented with lower back pain, and was noted to have [no/one of
the] red flag signs or symptoms on presentation [describe]. Patient [reported/denied] preceding
trauma. Patient noted to have a normal
neurologic examination in the ED to include deep tendon reflexes in the lower
extremities. Patient felt to have [no
indication for imaging at this time/indication for imaging with plain films/MRI
of the spine obtained in the ED, and noted to be unremarkable /notable for
injury]. Doubt cauda equina or central
herniation at this time based on [history and exam/imaging]. No history of recent surgery or injections in
the back, fever, or other findings to suggest risk for epidural hematoma or
abscess. Doubt kidney stone or urinary
tract infection given absence of urinary symptoms, significant costovertebral
angle (CVA) tenderness, [abnormal findings on urinalysis,] or other suggestive
findings. Patient [reported/denied]
history of similar episodes [with prior treatments]. Patient reported significant improvement in
pain with [treatment] in the ED prior to discharge.
Prior to discharge, we discussed modified activity with emphasis on
avoiding prolonged bedrest. We discussed
return precautions, specifically for worsening pain or focal neurologic
deficits, treatment with [NSAIDs/muscle relaxants/etc.], and follow up with
primary care doctor within one week for further evaluation, and the patient
demonstrated understanding and agreement with this plan. We specifically discussed follow up with
primary care doctor for referral to physical therapy and consideration of
outpatient imaging.
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