CHIEF COMPLAINT: Back spasms.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old, otherwise healthy, Hispanic gentleman who presents to the emergency department with the above complaint. The patient states on Friday he twisted the wrong way and has had pain in his low back. The patient does state the pain has gradually gotten better until today. He noticed some significant spasms in his back. The patient describes it as a spasm, achy sensation, rating it a 4/10. The patient has taken ibuprofen at approximately 7 p.m., which was of very little relief. The patient denies any direct injury or trauma to his back; however, he does state he has a history of disk herniation. The patient does state he has on several occasions had muscle spasms in the back. The patient denies any numbness or tingling to his extremities. The patient also denies any bowel or bladder incontinence, abdominal pain, chest pain or shortness of breath. The patient states he has had an MRI in the past; however, this was several years ago.
PAST MEDICAL HISTORY: Herniated disk.
CURRENT MEDICATIONS: Ibuprofen as needed.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies use of tobacco, alcohol, illicit or IV drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As stated above; otherwise, negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 130/80, pulse 72, respirations 18, temperature 98.4, and O2 saturation is 99% on room air.
GENERAL: This is a well-developed, well-nourished (XX)-year-old male who is alert and oriented x3 and appears to be in no acute distress. The patient is cooperative, communicates well, was ambulatory without difficulty in the emergency department.
HEENT: Normocephalic and atraumatic. Eyes: Equal, round, and reactive to light and accommodation. Extraocular movements are intact bilaterally. Conjunctivae are pink without discharge. Sclerae are anicteric. TMs appear clear. Buccal mucosa is pink and moist. Pharynx is without erythema or exudate.
NECK: Supple without lymphadenopathy. Trachea is midline.
LUNGS: Clear to auscultation bilaterally. No wheezing, rales, or rhonchi noted.
HEART: Regular rate and rhythm. No murmurs, rubs, or gallops noted.
BACK: The patient denies tenderness with palpation over the midline cervical, thoracic, and lumbar spine. The patient does have some reproducible tenderness in the upper lumbar paravertebral musculature. There is no erythema, edema or ecchymosis. The patient has full range of motion of his back; however, he has pain with both flexion and extension.
ABDOMEN: Soft, nondistended, and nontender to palpation in all four quadrants. There is no rebound or guarding noted. There are no masses noted. Bowel sounds are present in all four quadrants.
EXTREMITIES: Distal pulses 2+ bilaterally. The patient has full range of motion of all extremities. Sensation is intact to light touch.
NEUROLOGIC: Cranial nerves II-XII are intact. DTRs are 2+ bilaterally in both upper and lower extremities. Muscle strength is 5/5 of all extremities. No focal deficits noted.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: The patient was examined. At that time, the patient was given 60 mg of Toradol IM for his pain, which he tolerated well.
IMPRESSION: This is a (XX)-year-old gentleman who presents to the emergency department with a musculoskeletal strain in the upper lumbar region. Upon examination, the patient had some reproducible muscle spasms noted with pain in the paravertebral musculature. The patient has no midline tenderness nor any history of direct injury or trauma; therefore, we did not feel he needed x-ray of his spine. We did discuss with the patient that an MRI would be the next step for possible disk herniation, and the patient will call Dr. John Doe first thing in the morning. The patient will be discharged with a muscle relaxer as well as few Vicodin for pain, and we did warn him that these cause drowsiness and no driving or drinking alcohol while taking.
DIAGNOSIS: Musculoskeletal strain.
PLAN:
1. Vicodin 5/500, #12, as needed for pain not relieved by ibuprofen.
2. Flexeril 10 mg, #15.
3. Rest, ice areas for 20 minutes every 2-3 hours, alternate with moist heat.
4. Follow up with PCP.
5. Return for any worsening symptoms such as numbness, tingling in extremities, bowel or bladder incontinence, abdominal pain or other concerns.
DISPOSITION: The patient was discharged to home in stable condition.
