What is the appropriate emergency department assessment and management plan for a 68‑year‑old Filipino woman with type‑2 diabetes mellitus, dyslipidemia, and osteoporosis who presents with acute right lower back pain of two days' duration, severe cramping radiating to the right shoulder, no trauma, fever, urinary or gastrointestinal symptoms, and right costovertebral angle tenderness?

Emergency Department Assessment and Management

This patient requires urgent evaluation for acute pyelonephritis or nephrolithiasis given the severe right-sided back pain with costovertebral angle tenderness and radiation pattern, particularly in the context of diabetes which increases infection risk and severity. 1

Immediate Assessment Priorities

Critical Red Flag Evaluation

• Rule out serious pathology first: While this patient lacks major red flags (no trauma, no neurologic deficits, no bowel/bladder dysfunction, no saddle anesthesia), the CVA tenderness with radiation to shoulder suggests a renal/urologic rather than musculoskeletal etiology 1
• The severe pain (10/10), cramping quality, and radiation pattern are atypical for simple mechanical low back pain 2
• Her diabetes significantly increases risk for complicated urinary tract infections and diabetic complications 3

Focused History Elements to Clarify

• Urinary symptoms: Dysuria, frequency, urgency, hematuria, or changes in urine color/odor (even if patient denies, ask specifically as diabetics may have atypical presentations) 1
• Fever/chills: May be absent initially in diabetics with infections 3
• Nausea without vomiting: Common in renal colic
• Timing and character: Colicky vs constant pain (colicky suggests stone, constant suggests infection or muscle) 2

Physical Examination Specifics

• Bilateral CVA tenderness comparison: Document severity and laterality
• Abdominal examination: Specifically palpate for suprapubic tenderness, renal masses
• Neurologic examination: Straight leg raise, motor strength L2-S1, reflexes, sensory dermatomes to definitively exclude radiculopathy 1
• Skin examination: Check for herpes zoster rash in thoracolumbar distribution

Diagnostic Testing Required

Laboratory Studies (Obtain Immediately)

• Urinalysis with microscopy: Essential to evaluate for infection (pyuria, bacteriuria, nitrites) or nephrolithiasis (hematuria) 1
• Complete blood count: Leukocytosis suggests infection 1
• Basic metabolic panel: Assess renal function and glucose control in diabetic patient 3
• Blood glucose: Evaluate current diabetic control 3

Imaging Studies

• Non-contrast CT abdomen/pelvis (CT KUB): This is the gold standard for evaluating both nephrolithiasis and complications of pyelonephritis in a diabetic patient with CVA tenderness 1, 4
  • The CVA tenderness with severe pain and diabetic status justifies advanced imaging despite general recommendations to limit imaging in low back pain 4
  • CT is superior to plain radiographs for detecting stones and renal pathology 1
  • Age >50 years and warning signs (CVA tenderness, diabetes) are associated with appropriate advanced imaging use 4

Do NOT order lumbar spine imaging unless urologic workup is negative and neurologic findings develop, as musculoskeletal low back pain is a diagnosis of exclusion here 2, 1

Management Plan

If Pyelonephritis Confirmed (Pyuria + Bacteriuria + CVA Tenderness)

• Admit for IV antibiotics: Diabetic patients with pyelonephritis require admission due to higher risk of complications including emphysematous pyelonephritis and renal abscess 3
• Start broad-spectrum IV antibiotics (e.g., ceftriaxone 1-2g IV daily or fluoroquinolone if local resistance patterns allow)
• IV hydration
• Blood cultures before antibiotics
• Urine culture to guide antibiotic therapy

If Nephrolithiasis Confirmed (Hematuria + Stone on CT)

• Pain management: NSAIDs (ketorolac 30mg IV) are first-line for renal colic if renal function adequate 1
• Opioids: Use judiciously only if NSAIDs contraindicated or inadequate; avoid psychosocial factors driving opioid prescribing 4
• IV hydration
• Antiemetics if needed
• Urology consultation if stone >5mm, signs of obstruction, or solitary kidney
• Outpatient follow-up with urology for stones <5mm without obstruction

If Urologic Workup Negative

• Consider diabetic myonecrosis: Rare but occurs in poorly controlled diabetics with severe muscle pain, though typically affects thigh muscles 3
• MRI lumbar spine: Only if neurologic symptoms develop or pain persists beyond 2-4 weeks 2, 1
• Conservative management:
  • NSAIDs (ibuprofen 400-600mg TID or naproxen 500mg BID) or acetaminophen 1000mg QID 1
  • Muscle relaxants (cyclobenzaprine 5-10mg TID) may provide short-term benefit 1
  • Avoid bed rest: Encourage activity as tolerated 2, 1
  • No role for oral steroids 1
  • Discharge with 48-72 hour follow-up if symptoms not improving 2

Critical Pitfalls to Avoid

• Do not assume musculoskeletal etiology with unilateral CVA tenderness—this is a urologic red flag 1
• Do not discharge without urinalysis in a diabetic patient with back pain and CVA tenderness 3
• Do not prescribe opioids without adequate evaluation as psychosocial factors inappropriately drive opioid prescribing in ED low back pain 4
• Do not order lumbar imaging first—this diverts from the correct diagnostic pathway when renal pathology is suspected 1, 4