72 y.o man CC: back pain + fall
par Pablo Buitron
1. History
1.1. Social
1.1.1. lives in apartment
1.1.2. Good social support
1.2. Medical
1.2.1. Smoking history
1.2.2. DM2
1.3. Family history
2. Present Illness
2.1. LBP
2.1.1. Radiation bilateral
2.1.2. Leg weakness
2.1.3. History of trauma
2.1.4. Severe
2.2. ROS
2.2.1. Urinary retention
2.2.2. Constipation
3. PE/data
3.1. No reflexes lower extremity
3.2. Positive ipsilaterl and contralateral straight leg rise test
3.3. Decrease rectal tone
3.4. Decrease sensation lower extremities
3.5. Weakness in lower extremity
3.6. Suprapubic tenderness and dullness
4. Cauda equina syndrome
4.1. High Probability
4.1.1. disc herniation
4.1.1.1. radiation bilateral
4.1.2. hematoma
4.1.2.1. history of trauma
4.1.3. Prostate cancer
4.2. Moderate Probability
4.3. Low Probability
4.3.1. epidural abscess
4.3.1.1. urinary retention
4.3.1.2. suprapubic tenderness
4.3.2. spinal stroke