Back Pain ER Admission Evaluation and Treatment Sample #1
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who presents with a somewhat long history of low back pain. She states that she has a chronic type of nagging pain in her back. She is a restaurant server. She just came off 2 double shifts and states that this seems to have worsened her back pain. She does stand for most of her shift. She tells me that she does not wear comfortable shoes. She has no symptoms down either leg. She has no bowel or bladder symptoms. She denies numbness or tingling.
PAST MEDICAL HISTORY:
1. Cholecystectomy.
2. Back pain, as mentioned.
SOCIAL HISTORY: She denies alcohol, tobacco, illicit drug use.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: None.
ALLERGIES: None.
REVIEW OF SYSTEMS: As mentioned. Otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 116/76, pulse 80, respirations 20, temperature 98.6.
GENERAL: She is awake, alert, and oriented. No acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy. No carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales, or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft. Nontender. Nondistended. Good bowel sounds with no organomegaly.
MUSCULOSKELETAL: She does have some tenderness to palpation in the paraspinous musculature of her lumbar spine. She has negative straight leg raise. She has no midline tenderness. Sensation is grossly intact distally. She has good reflexes and good peripheral pulses bilaterally.
EMERGENCY DEPARTMENT COURSE: This patient was seen and evaluated for exacerbation of low back pain. This seems to be a subacute issue with frequent exacerbations due to her work. There is no need to x-ray at this time as there are no neurological symptoms. No tenderness to palpation midline. She does need to follow up with a primary care doctor. She states that she does not have one she sees routinely. We did give her a clinic list and advised her to follow up as she may require physical therapy, MRI, etc. She voiced understanding, is acceptable, and is agreeable of this.
DISCHARGE DIAGNOSIS: Acute back pain on chronic back pain.
PLAN:
1. We will treat her with Naprosyn 500 mg twice daily.
2. Flexeril 10 mg 3 times daily, to take for the back pain.
3. Advised moist heat.
4. Rest.
5. No heavy lifting greater than 10 pounds.
6. She should follow up, as mentioned, with primary care doctor.
DISPOSITION: She is discharged to home.
CONDITION: Stable.
Back Pain ER Admission Evaluation and Treatment Sample #2
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old female with a history of epilepsy who presents to the ER after having 2 grand mal seizures yesterday, which were witnessed by both her husband and her daughter. She states she ran out of her Tegretol, which she usually takes and believes this is why she had her seizures overnight.
She states she had increasing back pain, which she rates as a 9/10 starting in her lower back in the middle of spine moving up her back, has a cramping sensation, and it is sharp in nature. Better with sitting still, worse with moving, again, starting in her lower spine up into the middle of her spine and otherwise is nonradiating. No associated shortness of breath or chest pain, no abdominal pain, no nausea, vomiting, diarrhea. No associated bowel or bladder incontinence.
It does not radiate into her buttocks or legs. She has no difficulty with walking. No weakness, numbness, tingling in her extremities. She denies any trauma. She was sitting on the couch at the time of her seizure. She did not fall to the floor. She did not sustain any trauma to her spine, but per her husband, who did witness the seizure, she was writhing back and forth on the couch during them.
PAST MEDICAL HISTORY:
1. Asthma.
2. Seizures.
MEDICATIONS:
1. Depakote.
2. Tegretol.
3. Topamax.
ALLERGIES: Sulfa, Motrin, tetracycline.
PRIMARY CARE PHYSICIAN: Dr. John Doe.
NEUROLOGIST: She has a primary neurologist who she sees, who already refilled her Tegretol for her, which she was previously out of and she started taking this again yesterday.
SOCIAL HISTORY: She is menopausal. Denies tobacco, alcohol or drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As in HPI, all other systems reviewed and otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 138/74, pulse of 82, respirations 18, temperature 96.8.
GENERAL: This is a pleasant, middle-aged female who appears in no acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, reactive to light and accommodation. Extraocular movements are intact.
NECK: Supple.
LUNGS: Clear.
ABDOMEN: Soft, nontender, nondistended, no CVA tenderness.
BACK: She does have midline thoracic spine tenderness from T8-T12 and also L4-L5. There is evidence of paraspinal muscle spasm as well.
EXTREMITIES: There is no cyanosis, clubbing or edema.
NEUROLOGIC: Alert and oriented x4. Cranial nerves II through XII grossly intact. Strength is 5/5 throughout. She has equal plantar dorsiflexion bilaterally with no weakness, numbness, tingling in her distal extremities. She has equal bilateral grip strength. No evidence of ataxia. She has a negative leg raise bilaterally.
X-RAY: T spine and L spine x-rays were obtained and were read as negative by the resident radiologist for any evidence of acute fracture, malalignment.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. History and physical was obtained. She was given 2 Percocets here for her pain as she is allergic to Motrin. This did help improve her pain considerably. X-rays were obtained, which were negative. She had normal neurologic exam. We did feel like her pain was likely due to deep musculoskeletal pain due to her twisting and writhing motions during her grand mal seizures.
She has, again, no neurologic deficits here. We feel this would be best treated as an outpatient with Vicodin as needed for pain as well as Flexeril for spasms. She already has refilled her Tegretol with her primary neurologist and is taking this again; therefore, we feel this will likely alleviate the initial cause of her seizures, which was a decreased Tegretol dose due to the medication running out.
She has no bowel or bladder problems, no saddle anesthesia, nothing to suggest central cord syndrome. She is otherwise afebrile, and we think this is just an abscess or an infection. We believe this is mechanical in nature secondary to seizures, and she will be discharged home safely in the company of her daughter.
DIAGNOSES:
1. Musculoskeletal back pain.
2. Seizures.
DISPOSITION: Home in good condition.
PLAN:
1. Vicodin as needed for pain, #15.
2. Flexeril 3 times daily as needed for spasms, #15.
3. Follow up with primary neurologist.
4. Follow up with primary care physician.
5. She is advised to return to light activity but not to lift anything greater than 10 pounds for at least 1 week.
6. Return for worsening symptoms.
Back Pain ER Admission Evaluation and Treatment Sample #3
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: This is (XX)-year-old female with right flank/back pain. It has been going on for about 2 weeks, getting progressively worse and associated with a little bit of nausea and 1 episode of vomiting. She has no abdominal pain. It does not radiate. It is a severity of about 5/10, relieved with Toradol in the ER. Nothing seems to make it worse. She has had some intermittent fevers as well; she is not sure how high. The patient thinks that she has got pyelonephritis. She has been having symptoms of urgency, no burning. She has no other lower abdominal symptoms.
PAST MEDICAL HISTORY:
1. Questionable history of lupus, being worked up.
2. History of kidney infections before, in the past.
3. Scoliosis.
ALLERGIES: Dilaudid.
MEDICATIONS: None currently.
SOCIAL HISTORY: A remote history of IV drug abuse 12 years ago. No alcohol or other problems.
REVIEW OF SYSTEMS: CARDIOVASCULAR: No chest pain. PULMONARY: No shortness of breath. GI: Positive for CVA pain. NEUROLOGIC: No headaches. MUSCULOSKELETAL: No aches or pains. CONSTITUTIONAL: Positive for fevers. SKIN: No rashes. PSYCHIATRIC: No suicidal or homicidal ideation. All other review of systems per HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: See nurse’s note.
GENERAL: The patient appeared well and in no distress.
HEENT: Head: No signs of trauma. Eyes: Pupils are 4-2. Ears, nose throat: TMs clear. Oropharynx clear.
NECK: Nontender to palpation.
PULMONARY: Lungs are clear to auscultation bilaterally.
CARDIOVASCULAR: S1, S2, regular rate and rhythm.
ABDOMEN: Soft, nontender, positive bowel sounds.
NEUROLOGIC: Cranial nerves intact. Motor is intact. Gait was normal.
SKIN No lesions.
GU: The patient had right CVA tenderness.
MUSCULOSKELETAL: No CT or L-spine tenderness.
PSYCHIATRIC: Normal mood and affect.
LABORATORY DATA: Significant for a CBC with positive nitrites, 50-100 white blood cells. CBC that showed a white count of 5.0.
EMERGENCY DEPARTMENT COURSE: The patient was treated with 1 liter of normal saline for dehydration, Phenergan for nausea, Toradol for pain and Cipro antibiotic for pyelo.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old female here with a history and physical exam consistent with pyelonephritis. She appears nontoxic and is tolerating p.o. in the ER. As such, we do not think that she has a perinephric gastric abscess that is going to require IV antibiotics as an inpatient. The patient appears, after a liter of fluid, to be hydrated and tolerating p.o. She will be sent home with ibuprofen for pain, Phenergan for nausea and Cipro antibiotic. We do not think there is any sort of intra-abdominal infection or other process such as right lower lobe pneumonia. We think her history and physical exam is clear for pyelonephritis.
CLINICAL IMPRESSION: Pyelonephritis.
PLAN:
1. Take Cipro.
2. Follow up with primary care doctor.
3. Return if symptoms worsen.
Back Pain ER Admission Evaluation and Treatment Sample #4
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who is otherwise healthy, who is presenting to the ER with complaints of low back pain that started 1 hour prior to arrival while she was walking. She denies any trauma or recent straining. She complains of a constant aching pain, which is occasionally sharp, worsened when she ambulates and when she bends over. She denies any bowel or bladder incontinence, urine retention or constipation. She denies UTI symptoms. She currently is rating her pain as a 9/10 in severity. It does not radiate. She denies paresthesias, numbness, coldness, loss of range of motion or weakness in the extremities. She has not taken any medicine prior to arrival to relieve her pain. She otherwise has no complaints.
PAST MEDICAL HISTORY: MVA in February of (XXXX) after which she had back pain, followed by a chiropractor for approximately 2 months.
MEDICATIONS: None.
ALLERGIES: Amoxicillin.
FAMILY HISTORY: Not elicited.
SOCIAL HISTORY: She works in (XX).
REVIEW OF SYSTEMS: As stated above in the HPI, significant for low back pain associated with positioning. She has otherwise been well without fevers, chills, nausea, vomiting, abdominal pain, changes in urinary or bowel habits, polyuria, polydipsia, heat or cold intolerance, fatigue, recent weight changes, rashes or lesions. Further review is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/80, pulse 100, respirations 18, temperature 97.8, pulse ox on room air is 97%.
GENERAL: This is a well-developed, well-nourished female in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist.
NECK: Supple without lymphadenopathy.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Soft, nondistended, nontender.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: Warm, dry and intact.
MUSCULOSKELETAL: The patient has minimal tenderness with palpation to the paralumbar musculature, right greater than left, without palpable spasm. She has full range of motion of the back with increased pain on extreme flexion. She ambulates without difficulty. She has good movement in all 4 extremities.
NEUROLOGIC: Patellar and Achilles tendon reflexes are symmetric bilaterally. She has full 5/5 strength with resisted movement in all muscle groups of the lower extremities bilaterally. Sensation is intact throughout to light touch. There is no saddle anesthesia as reported by the patient. She has a negative straight leg raise. There are no focal neurologic deficits.
EMERGENCY DEPARTMENT COURSE: The patient was given ibuprofen here in the department for her pain. Dr. John Doe saw the patient and agrees with the assessment and plan.
DIAGNOSIS: Lumbar strain.
PLAN:
1. She is given prescriptions for Naprosyn and Flexeril to take as directed for pain.
2. She is to follow up with local clinic of choice if there is no improvement in the next 4 to 5 days.
3. Apply ice as needed for pain or heat for stiffness.
4. Return to the ER for any worsening symptoms.
5. She is to avoid bending at the waist or lifting anything greater than 20 pounds for the next week.
DISPOSITION: She is discharged home in good condition and ambulated out of the department without difficulty.
