ABCs

• Check vital signs (especially fever, hypotension)
• Check random blood glucose (exclude diabetic emergencies)
• Assess red flags early to avoid missing serious pathology

Red Flags for Back Pain

• Urinary or fecal incontinence
• Saddle anesthesia
• Bilateral lower limb weakness or numbness
• Progressive neurological deficits
• History of significant trauma
• Fever or systemic signs of infection
• Unexplained weight loss or known malignancy
• Absent peripheral pulses
• Severe or unrelenting pain, especially at rest or at night

HPI & Examination

• Characterize the pain:
• Onset (sudden vs. gradual)
• Location
• Radiation to legs or elsewhere
• Associated symptoms:
• Trauma
• Neurological signs: numbness, weakness, urinary/fecal incontinence
• Constitutional: fever, weight loss
• Rule out referred causes:
• Pancreatitis: epigastric pain → back, nausea, vomiting, alcohol/gallstones
• Pyelonephritis: flank pain, fever, chills, rigors, dysuria

• Spinal exam: tenderness, deformity, step-offs
• Neurological exam: tone, power, reflexes, sensation, Babinski
• Check for sensory level and saddle anesthesia
• Peripheral pulses (abdominal aortic pathology)

Management

If pain appears muscular with no red flags

• Give Muscadol PO or Perfalgan 1 g IV
• Reassess pain control within 30–60 mins

If red flags are present

• Call for assistance immediately
• Arrange urgent X-ray and MRI spine
• Contact orthopedic team on-call

If pancreatitis suspected

• Keep NPO
• Send amylase, lipase
• Arrange abdominal ultrasound
• Start IV fluids and manage pain

If pyelonephritis suspected

• Send urine R/M + culture, CRP, and PCT
• Start empirical antibiotics
• Arrange imaging (e.g., renal ultrasound or CT KUB)