Lumbago Chronic diastolic heart failure Hyposmolality and/or hyponatremia Atrioventricular block complete Other symptoms referable to back Spinal stenosis lumbar region without neurogenic claudication Congestive heart failure unspecified Long-term (current) use of anticoagulants Cardiac pacemaker in situ Abnormal coagulation profile Anticoagulants causing adverse effects in therapeutic use Personal history of other malignant neoplasm of skin Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Monoclonal paraproteinemia
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Penicillins / Spironolactone
 
Attending: ___.
 
Chief Complaint:
- low back pain
 
Major Surgical or Invasive Procedure:
- none
 
History of Present Illness:
On admission:
___ y/o M with history of diastolic CHF, heart block s/p 
pacemaker, atrial fibrillation (on Coumadin) who presented with 
worsening low back pain x 3 days. Pain does not radiate and is 
worse with movement. Has had episodes of back pain in the past, 
but not this severe, managed with pain control and physical 
therapy in the past. Most recent episode was probably ___ yrs ago. 
Pain is different from sciatic back pain. He denies CP/worsening 
of his SOB, F/C/N/V, dysuria. 
.
In the ED, vitals were WNL and imaging (CT abd/CT 
chest/CXR/L-spine X-ray) was negative for an acute process. He 
received Tylenol 1g po x 1 for pain, with no relief.
.
This morning, minimal pain at rest but has "spasms" with 
movement that are not relieved with morphine and Percocet. CT 
showed moderate to severe spinal stenosis worst at L4-L5. He 
denies any incontinence, weakness/numbness, other neurologic 
deficits.

 
Past Medical History:
- arthritis
- chronic diastolic dysfunction
- atrial fibrillation
- h/o complete heart block s/p pacemaker
- BPH
- monoclonal gamopathy
- basal cell and squamous cell carcinoma
- sciatica
- hypercholesteremia
- hyponatremia
 
Social History:
___
Family History:
- positive for heart problems in parents and siblings
 
Physical Exam:
On admission:
Vitals:  T:96.6 BP:128/62 HR:60 RR:20 O2sat:97%RA
Gen: comfortable at rest, some wincing with movement
HEENT: oropharynx clear, MMM
NECK: supple, no appreciable JVD
CV: RRR, ___ systolic murmur
LUNGS: CTAB
ABD: soft, no TTP
EXT: +TTP lower back, b/l, no TTP over spine, neg. straight leg 
raise, pulses 2+ b/l, no calf TTP 
NEURO: alert and oriented, responsive, sensation to light touch 
intact throughout, strength ___ lower extremities, DTR's 2+ b/l
 
Pertinent Results:
___ WBC-10.0 Hgb-12.6 Hct-35.5 Plt ___
___ WBC-8.0 Hgb-12.3 Hct-34.7 Plt ___
___ WBC-6.7 Hgb-11.5 Hct-33.9 Plt ___
.
___ ___ PTT-48.9 ___
___ ___ PTT-49.8 ___
___ ___ PTT-58.3 ___
___ ___ PTT-66.0 ___
___ ___ PTT-66.2 ___
.
___ Glucose-128 UreaN-26 Creat-1.1 Na-129 K-4.4 Cl-97 
HCO3-25
___ Glucose-104 UreaN-19 Creat-1.0 Na-130 K-4.3 Cl-97 
HCO3-27 
___ Glucose-90 UreaN-34 Creat-1.3 Na-130 K-4.7 Cl-95 
HCO3-27 
___ Glucose-119 UreaN-31 Creat-1.2 Na-129 K-4.6 Cl-93 
HCO3-28 
.
Urinalysis: unremarkable   
.
SINGLE PA VIEW OF THE CHEST: 
IMPRESSION: 
1. Cardiomegaly without evidence of overt pulmonary edema. 
2. Bibasilar opacities likely reflect atelectasis. 
.
AP VIEW OF THE PELVIS, AND TWO VIEWS OF THE LUMBAR SPINE:  
IMPRESSION: 
1. No fracture or subluxation within the lumbar spine. 
2. Severe lumbar spondylosis. 
3. No fracture or dislocation within the pelvis. 
.
CT CHEST/ABD/PELVIS: IMPRESSION: 
1. No pulmonary embolism. 
2. Multilevel degenerative changes within the lumbar spine 
result in 
moderate to severe spinal stenosis. MRI can be obtained for 
further 
evaluation. 
3. 1-cm right thyroid nodule. Ultrasound could be obtained for 
further 
evaluation if clinically indicated. 
4. Small pericardial effusion is slightly larger since ___, 
without 
evidence of tamponade. 
5. Hepatic hypodensities likely represent cysts although are not 
fully 
characterized. 

 
Brief Hospital Course:
*)Back pain: a thorough work-up did not reveal evidence of an 
acute process, although CT and X-ray did show moderate to severe 
spinal stenosis in the lumbar spine, which was likely 
contributory to his symptoms. An element of muscle spasm was 
also thought to be likely, based on his symptoms. He was given 
morphine and Percocet initially for pain control. He was 
transitioned to Percocet only, and low-dose Flexiril was added 
to aid with control of muscle spasm, as well as heat to the 
area. His symptoms continued to be significant and limiting to 
his progress with physical therapy. The Chronic Pain Service was 
consulted, and recommended a new medication regimen. He was 
given Toradol x 2 doses, and started on standing Tylenol, 
gabapentin, and tizanidine as well as oxycodone as needed. The 
following morning his symptoms had improved, and he was able to 
transition more easily in and out of bed. He was transferred to 
a rehabilitation facility for extended physical therapy. 
.  
*)Atrial fibrillation: also with a history of complete heart 
block with a pacemaker, rate-controlled on admission. His INR 
was found to be supra-therapeutic at 4.4, and his Coumadin was 
held for one day. On re-check, his INR continued to increase, so 
his Coumadin was stopped. Metoprolol was continued during his 
hospitalization. His INR will need to be followed, and Coumadin 
re-started once INR is less than 3. 
.
*)Elevated creatinine: his creatinine was at his baseline at 1.1 
on admission, with an increase to 1.3 after he received Toradol. 
This will need to be followed up with repeat labs; he did not 
receive any additional NSAIDs and was not discharged on any. On 
the day of discharge his creatinine had begun to trend back 
down.
.  
*)Hypertension: BP was well-controlled on his home medication 
regimen.  
.  
*)Chronic diastolic heart failure: felt to be at baseline on 
admission. His home medication was continued.  
.  
*)BPH: finasteride and Flomax were continued during his 
hospitalization.
.
*)Hyponatremia: stable at baseline. 
 
Medications on Admission:
- eplerenone 25mg every other day  
- finasteride 5mg daily  
- Lasix 20mg daily  
- Latanoprost 0.0005%  
- meclizine 12.5mg as needed  
- metoprolol 50mg twice daily  
- Flomax 0.4 twice daily  
- Valsartan 320mg daily  
- Coumadin as directed ___  
- aspirin 81mg daily  
- coenzyme Q10  
- vitamin D 400mg daily  
- folic acid  
- glucosamine 750mg daily  
- multivitamin  
- niacin 400mg daily  
- omega 3 fatty acid  

 
Discharge Medications:
1. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO EVERY OTHER 
DAY (Every Other Day).  
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at 
bedtime).  
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID 
(2 times a day).  
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) 
Capsule, Sust. Release 24 hr PO HS (at bedtime).  
7. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 
 
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
9. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
10. Niacin 500 mg Capsule, Sustained Release Sig: One (1) 
Capsule, Sustained Release PO DAILY (Daily).  
11. Omega-3 Fatty Acids     Capsule Sig: One (1) Capsule PO 
DAILY (Daily).  
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 
times a day).  
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H 
(every 6 hours).  
14. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO Q6H (every 6 
hours) as needed.  
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 
(2 times a day).  
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 
times a day) as needed.  
17. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a 
day (at bedtime)).  
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
___ Diagnosis:
- muscle spasm/low back pain
- spinal stenosis
.
- arthritis
- chronic diastolic dysfunction
- atrial fibrillation
- h/o complete heart block s/p pacemaker
- BPH
- monoclonal gamopathy
- basal cell and squamous cell carcinoma
- sciatica
- hypercholesteremia
- hyponatremia

 
Discharge Condition:
- improved/stable

 
Discharge Instructions:
You were admitted to the hospital for an episode of severe back 
pain. Imaging showed some narrowing of your spinal column, and 
no evidence of any other acute process. Your pain was thought to 
be musculoskeletal in origin. You were given medications to 
control your pain and relax your muscles, and were seen by 
Physical Therapy. You are going to a rehabilitation facility for 
additional help with physical therapy. Please follow up with 
your primary care doctor after you leave rehabilitation. 
.
Changes to your medications:
Added: Tylenol, gabapentin, tizanidine.
Stopped: Coumadin (warfarin)
Your Coumadin was stopped because a lab value that we use to 
track the proper dosing was high. This will need to be followed 
up at the rehabilitation facility and with your primary care 
doctor; once the lab value comes down, your Coumadin will need 
to be re-started.
.
Please call your doctor for the following: incontinence of stool 
or urine, weakness/numbness in your legs, inability to walk, 
severe or increasing pain that is not helped by medications, 
nausea/vomiting, fever, any new or concerning symptoms.
 
Followup Instructions:
___

{'low back pain': ['Lumbago', 'Spinal stenosis', 'lumbar region', 'without neurogenic claudication'], 'atrial fibrillation': ['Atrioventricular block', 'complete'], 'chronic diastolic dysfunction': ['Chronic diastolic heart failure'], 'hyponatremia': ['Hyposmolality and/or hyponatremia'], 'muscle spasm': ['Other symptoms referable to back'], 'spinal stenosis': ['Spinal stenosis', 'lumbar region', 'without neurogenic claudication']}