This case involves a young male patient in Ohio who presented to the emergency room with complaints of back pain that had lasted several days. After a brief physical evaluation, the patient was prescribed a muscle relaxant and discharged without any lab studies or imaging. A few days later, the patient presented to another hospital emergency room with the same complaints of back pain. During this visit, he was quickly diagnosed with musculoskeletal back pain and discharged. The next day, the patient presented to the emergency room a third time with new complaints of nausea, vomiting, and difficulty thinking. The emergency room physician ordered a complete blood count with differential and erythrocyte sedimentation rate (ESR) that showed an elevated white blood cell count, as well as elevated levels of a specific type of white blood cells and elevated ESR. An MRI was ordered and performed, however the treating physician noted that the MRI was non-diagnostic. The doctor claimed that the abnormal lab results could be explained by any number of other conditions, so he wasn’t concerned with the values. The patient was then discharged with a diagnosis of unspecified back pain. No repeat MRI or follow-up was ordered. The patient presented several hours later for another hospital visit, and was promptly discharged. The patient eventually died, with the cause of death being listed as bacterial meningitis.