Bouncebacks The Case of a 71-Year-Old Man with Back Pain Bouncebacks appears semi-monthly in JUCM. Case presentations on each patient, along with case-by-case risk management commentary by Gregory L. Henry, past president of The American College of Emergency Physicians, and discussions by other nationally recognized experts are detailed in the book Bouncebacks! Emergency Department Cases: ED Returns (2006, Anadem Publishing, www.anadem.com; also available at amazon.com and www.acep.org). Michael B. Weinstock, MD and Ryan Longstreth, MD, FACEP T hough it is easy to predict the usual eti- ology of common complaints, we need to be able to exclude life-threat- ening causes of symptoms. In law, we are innocent until proven guilty. In medicine, we are required to prove certain diseases are not occurring; we are, in a sense, guilty until proven innocent: A 50- m year-old man with chest pain and .co es ag I / m diaphoresis has an MI until proven ler tab otherwise. A 22-year-old woman with nS t ar o B lower abdominal pain has an ectopic © pregnancy until proven otherwise. Our case this month involves a pa- tient with back pain. He could walk into— and out of—any urgent care practice in the coun- try unless the provider has an index of suspicion for potential life-threatening causes of his symptoms. An easy way to put this principle into practice is to com- plete the history and physical, then to revisit the symp- toms with a “back door” approach by specifically evalu- ating for the life-threatening causes of the symptoms. For example, if a patient has a headache, subarach- noid hemorrhage and meningitis need to be consid- ered. After the provider has obtained information on the character of the pain, onset, duration, and exac- erbating factors, specific questions can be asked to ex- clude these important diagnoses. w w w. j u c m . c o m A 71-Year-Old Man with Back Pain Initial Visit (Note: The following is the actual docu- mentation of the providers, including punctuation and spelling errors.) CHIEF COMPLAINT (at 20:36): Back pain Time 20:48 00:11 Temp (F) 97.1 Pulse 72 71 Resp 20 16 Syst 140 113 Diast 80 67 POS L S O2 sat 98 O2% RA Pain scale 6 2 HISTORY OF PRESENT ILLNESS (at 21:09): 71yo WM with h/o HTN reports was watching the game and it had just started overtime when felt a spasm and pain in left lower back. Denies any twisting/turning/lifting/ trauma to the back. Reports lay down on the hard floor to help the pain, took 2 advil from his wife and placed a cool cloth on the back. Still with spasm and unable to get up off the floor, so called 911 for assistance to ED. Denies any known recent back injury. No prior illness. No cough/rhinorrhea/chest pain/ear ache/sore throat/dysuria/ JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | M a y 2 0 0 8 23