A 65-year-old woman presented to an emergency
department (ED) with 48 hours of nontraumatic left lower back pain
and general malaise. She was diagnosed with a musculoskeletal
injury and discharged from the ED with muscle relaxants and
antiinflammatory medications. She returned to the ED the following
day with increased back pain described as shooting and burning in
nature. Physical examination was reported as unremarkable, and
basic laboratory tests and an abdominal computed tomography (CT)
study came up normal as well. The patient was unable to ambulate
due to pain and developed nausea related to her narcotic therapy.
She was later admitted for observation and additional analgesics.
The admitting hospitalist evaluated the patient and started her on
intravenous analgesics. He did not document any evidence of
neurologic deficits or an acute abdomen.
The next morning, the hospitalist assuming care
for the patient readily noted a vesicular rash in the exact
distribution of her pain symptoms and correctly diagnosed a herpes
zoster infection (shingles). The patient was treated with
prednisone and acyclovir and was discharged with improved symptoms.
The patient initially reported the rash more than 24 hours prior to
her hospitalization but didn't think it was related to her pain.
She stated, "Nobody actually looked at my skin until the following
morning." The patient had a full recovery but likely underwent
unnecessary testing and delays to appropriate, disease-specific
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