MDM - Shingles

[##]-year-old [male/female] with [rash/burning pain to the location] with history and exam consistent with likely herpes zoster (shingles).

Initial considerations in this patient included varicella zoster virus reactivation (shingles), bullous pemphigoid, primary varicella, contact dermatitis, disseminated gonoccal disease, and other infectious and non-infectious etiologies of rash amongst others.

Patient presents with [maculopapular/vesicular] rash to the [location] in a dermatomal distribution that does not cross the midline suggestive of shingles.  Patient describes [current/antecedent] pruritus, paresthesia, and pain consistent with shingles.  Patient [reports/denies] history of prodromal symptoms [describe headache, malaise/etc.].  [Patient noted to have rash to the face without evidence of eye pain or redness, involvement of the tip of the nose (Hutchinson’s sign), or other findings suggestive of ophthalmic involvement (herpes ophthalmicus).]  [Patient noted to have no evidence of vesicular lesions to the tympanic membrane to suggest otic involvement (Ramsey-Hunt syndrome).]  Patient [noted to be/reports being] up to date on vaccinations including for varicella.  No evidence of disseminated rash, severe disease, or systemic symptoms to suggest immunocompromise in this patient.

Prior to discharge, we discussed analgesia with [NSAIDs/opiodis/Gabapentin] and Diphenhydramine for pruritis.  We discussed starting [Acyclovir/Valacyclovir] antiviral treatment [given presentation les than 72 hours from onset of rash and likely benefit/despite lower likelihood of benefit given presentation over 72 hours from the onset of rash given low risk of harm from this treatment].  Glucocorticoids [were/were not] given at this time after consideration and discussion with the patient of limited evidence of benefit and potential harms of this treatment (such as hyperglycemia and transient immunocompromise). 

We discussed return precautions and recommended follow up with primary care provider within one week, and the patient demonstrated understanding and agreement with this plan.

Discussion - Chronic Pain

Reassessed patient at this time and discussed recurrent [site] pain issues with [him/her].  This is the [###] time the patient has been evaluated in this Emergency Department for [site] pain in the past [time frame].  I emphasized with the patient that my training is primarily in the treatment of acute pain complaints, that [his/her] exam is reassuring at this time, and that definitive care of chronic pain is not the role of the Emergency Department.

[He/She] also was noted to be demonstrating the following behaviors known to be associated with inappropriate use of pain medications and addiction:

    -inability to restrict medications or take them on an agreed upon schedule

    -taking multiple medications together

    -doctor shopping

    -the use of non-prescribed psychoactive medications in addition to prescribed medications

    -noncompliance with recommended non-opioid medications or evaluations

    -a preoccupation with opioid medications

    -insistence on rapid-onset formulations and routes of administrations

    -reports of allergy or no relief whatsoever from non-opioid treatments

I explained to the patient that I felt that providing opioid medications from the Emergency Department was counterproductive in that this may cause or exacerbate tolerance, acute overdose, physiological or psychological dependence, or withdrawal.  We discussed that opioid use in the management of chronic pain is best managed by a single practitioner, such as a primary care provider or pain specialist.  We discussed adjunctive therapies such as heat, ice, and exercise, as well as non-opioid medications such as Acetaminophen, NSAIDs, antidepressants, lidocaine patches, Gabapentin, and Pregabalin.  We discussed that additional medications for pain management should be discussed with a primary care provider, as some require close monitoring.

I reiterated to [Patient’s Name] that the most effective management of [his/her] chronic pain is a multimodal approach coordinated by [his/her] primary care provider, that may include physical therapy, cognitive behavioral therapy, and referrals to specialists in pain management.

https://www.acep.org/patient-care/smart-phrases/why-narcoticopioid-medications-were-not-prescribed/
https://www.acep.org/patient-care/smart-phrases/emergency-naloxone-programs---information-for-providers/
https://www.acep.org/patient-care/smart-phrases/emergency-naloxone-programs---patient-information/

MDM - Musculoskeletal Back Pain

[##]-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.

https://www.acep.org/patient-care/smart-phrases/mri-for-low-back-pain/

https://orthoinfo.aaos.org/en/about-orthoinfo/OrthoInfo-Basics/basics-handouts/

https://orthoinfo.aaos.org/globalassets/pdfs/low-back-pain.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/about-your-back.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/herniated-disk.pdf

https://orthoinfo.org/globalassets/pdfs/2017-rehab_spine.pdf