MDM //

Patient presents with several days_ of lower back pain, atraumatic, afebrile. Given history and exam, suspect likely musculoskeletal etiology_. Nontoxic appearing and no overt risk factors for epidural hematoma or abscess. No overt e/o cauda equina or acute critical cord compression with nonfocal neuro exam. Neurovascularly intact distally. No e/o prostatitis or Fournier's. No peritoneal signs or abdominal pain on exam with low suspicion for AAA. Patient presents with acute lower back pain likely musculoskeletal related. Possibly muscle strain vs herniated disc vs radiulopathy. No red flags of incontinence or saddle anesthesia or weakness to suggest caudal equina syndrome or epidural abscess. No signs of diskitis. Not ivdu. No fevers. Not septic. No pulsating abdominal mass to suggest AAA. Ambulating well. No urinary symptoms to suggest pyelonephritis or renal colic/stones. No direct spinal tenderness on percussion and no stepoffs, not fracture or dislocation. Treatment is conservative therapy, pain control, anti-inflammatory medications, rest, back exercises and proper lifting techniques. Patient has been advised to follow up with their primary care doctor in 1-2 weeks if they have no improvement.



[Back to Main Menu]