IN THE MATTER OF: DOE, J.
Northgate General Hospital / Emergency Department / Admission Record
1. PATIENT AND ADMISSION
DOE, J. DOB 14/07/1981. MRN 4471-22B. Admitted 02/03/19, 18:42, by ambulance following a motor vehicle accident occurring earlier the same day. Discharged 04/03/19.
2. PRESENTING COMPLAINT
Patient reports acute onset lower back pain, described as sharp and localised to the lumbar region, radiating intermittently to the left posterior thigh. No loss of consciousness reported at scene. Ambulatory on arrival. Denies bladder or bowel disturbance.
3. EXAMINATION
Alert and oriented x3. Vitals within normal limits: BP 128/82, HR 88, RR 16, SpO2 99% on room air. Tenderness on palpation over L4-L5. Range of motion restricted in flexion and extension. Straight leg raise negative bilaterally. Neurovascularly intact distally. No midline step deformity appreciated on inspection or palpation.
4. IMPRESSION
Acute lumbar strain secondary to motor vehicle accident. No evidence of fracture on preliminary imaging. Findings consistent with the reported mechanism of injury.
5. IMAGING PERFORMED
Plain film lumbar spine, AP and lateral projections, obtained in the department at 19:20. Reported by the on-call radiologist as demonstrating no acute bony injury, no vertebral body height loss, and no evidence of listhesis. Soft tissue shadows unremarkable. Further cross-sectional imaging to be arranged on an outpatient basis should symptoms persist beyond six weeks of conservative management.
6. MEDICATION ADMINISTERED
Paracetamol 1g orally at 19:05. Ibuprofen 400mg orally at 19:05. Patient tolerated both without adverse reaction. No opioid analgesia required at any point during the admission. No known drug allergies recorded. Regular medications: none reported by the patient or held on file at this institution.
7. PLAN AND DISPOSITION
Analgesia to continue at home. NSAIDs as required, with food, for a maximum of ten days. Referral to physiotherapy, six sessions. Outpatient follow-up with the primary treating clinician within two weeks. Return precautions discussed with the patient and understood, including new or worsening neurological symptoms, bladder or bowel disturbance, or saddle anaesthesia.
8. ATTESTATION
Signed: Dr. M. Ayres, Emergency Medicine. Countersigned by the attending physician on duty. This record is true and complete to the best of my knowledge and belief. Any subsequent amendment will be recorded as an addendum and dated accordingly. This document forms part of the patient's permanent medical record and may be disclosed in legal proceedings.