Decreased to 5/10 after giving IV morphine. She has a history of chronic back pain with L2-L3, L3-L4 partial discectomy and laminectomy in 2009. She denies recent injury, incontinence or urinary retention. She took her Vicodin at home for the 3 days, with the pain gradually increasing.
PMH: HTN, DM, neuropathy, hyperlipidemia, cholecystectomy and back surgery as mentioned above.
• Vital Signs: 142/76, 72, 14, 97.9 and 99% on room air
• General: Slight distress secondary to pain
• Skin: warm, dry and intact
• Chest: lungs CTA
• Cardiac: RRR, no murmurs
• Abdomen: soft, nontender with active bowel sounds
• Extremities: 4/5 strength of the left lower extremity and 5/5 strength of the right lower extremity, sensation intact
• Back: paraspinal point tenderness with muscle spasms and an old healed lumbar scar, no costovertebral angle tenderness
Laboratory studies: WBC count 4.9, H/H 13.4/33, sodium 138, potassium 4.0, BUN 14, creatinine 0.8, glucose 199 and the urinalysis was negative
Lumbar spine x-ray: chronic surgical changes without evidence of an acute fracture or subluxation
Impression: chronic back pain
The plan of care: IV fluid 125 mL/hr, CT scan of the lumbar spine, IV morphine 2 mg PRN and pending orders following CT scan results.
1.1. What is the significant clinical information in the above scenario that would help you make a decision for Inpatient or Observation services for this patient? Please include objective/subjective clinical information. Why?
2.2. Do you have all the information you need? If not, please list what additional information you would like provided to make your decision.