What is the appropriate diagnosis and treatment plan for a 51-year-old male presenting with low back pain, initially suspected of UTI, with normal UA results and a mildly elevated WBC count?

Medical Assessment and Treatment Plan for 51-Year-Old Male with Low Back Pain

Diagnosis

The diagnosis is acute nonspecific low back pain (mechanical low back pain). The initial suspicion of UTI is ruled out by the normal urinalysis, and the mildly elevated WBC (10.30) is within acceptable limits and does not indicate infection or serious pathology 1, 2.

Clinical Reasoning

• The normal UA definitively excludes UTI as the cause of symptoms 2, 3
• WBC of 10.30 is minimally elevated and not clinically significant in the absence of other red flags 4
• No red flags are present (no fever, trauma, incontinence, unexplained weight loss, cancer history, steroid use, or severe neurologic deficits) that would warrant imaging or further workup 3, 4
• This presentation represents typical acute nonspecific low back pain, which has a benign course in 90% of patients 2

Treatment Plan

First-line treatment consists of paracetamol for pain control and patient education about the favorable prognosis 1, 4.

Medication Prescription (PhilHealth Konsulta Formulary)

Paracetamol 500mg tablets

• Dosing: 1-2 tablets every 6 hours as needed for pain (maximum 4g/24 hours)
• Dispense: 40 tablets
• Duration: 5-7 days
• Cost: Approximately 40-80 pesos 1, 4

Amoxicillin should NOT be prescribed - there is no indication for antibiotics given the normal UA and absence of infection 2, 3. The antibiotic was inappropriately prescribed based on the ruled-out UTI suspicion.

Non-Pharmacologic Recommendations

• Advice to stay active and avoid prolonged bed rest (no more than 2-3 days if needed) 1, 2, 4
• Apply heat therapy with heating pads for short-term relief 1
• Gradual return to normal activities as tolerated 2, 3
• Activity modification to avoid aggravating movements 5

Patient Education

• Reassurance that acute low back pain typically improves within 4-6 weeks with conservative management 1, 2, 4
• Expected natural history is favorable with 90% of patients recovering without specific intervention 2
• Return if symptoms worsen, develop neurologic deficits (leg weakness, numbness, bowel/bladder dysfunction), or fail to improve after 4-6 weeks 3, 4

Medical Certificate

Diagnosis: Acute nonspecific low back pain

Recommendation: Conservative management with analgesics, heat therapy, and gradual return to activities. Patient may return to work with activity modification (avoid heavy lifting or prolonged sitting/standing). Follow-up if symptoms persist beyond 4-6 weeks or worsen.

Purpose: Return to work with light duty restrictions for 3-5 days, then resume normal activities as tolerated.

Follow-Up

• Reassess only if symptoms persist beyond 4-6 weeks without improvement 1, 4
• No routine imaging is indicated at this time given absence of red flags 1
• If symptoms persist at 4-6 weeks, consider physical therapy or spinal manipulation 1